Normal CCTA has been shown to allow safe discharge from the emergency department without further workup, in both academic and community settings, with a negative predictive value for ACS over 95% [1,73-75], with equal or superior diagnostic performance when compared with stress echocardiography or nuclear MPI [76]. High-sensitivity troponin use has increased in Europe and in the United States to stratify patients with suspected ACS [77], but a CCTA strategy has still been found to be useful to avoid unnecessary downstream testing even when patients were first stratified by high-sensitivity troponin [78-80]. In a large multicenter study Chest Pain-Possible Acute Coronary Syndrome comparing CCTA with multiple other modalities used for ACS (stress cardiac MR [CMR], stress echocardiography, stress nuclear MPI, and stress PET), CCTA was found to have the highest diagnostic accuracy in finding patients with a significant coronary artery stenosis [81]. CT Coronary Calcium CT Coronary Calcium The role of the calcium score as a standalone test in the acute setting has not been established [94]. Limited studies have been performed demonstrating that the absence of coronary artery calcium (CAC) has a high negative predictive value for ACS among lower-risk patients with chest pain [95]. Several studies have suggested that in young patients with chest pain, a calcium score of zero is not a reliable test to exclude CAD, and adverse events have been shown to occur in up to 6% of acute chest pain patients without coronary artery calcium [96]. The ability of a zero calcium score to allow safe discharge of low-risk acute chest pain patients continues to be actively studied [97-100]. CT Chest CT Chest Nongated chest CT, although useful for evaluating noncardiac thoracic pathology, does not currently have a role in the evaluation of possible ACS, although perfusion defects can be seen on contrast-enhanced nongated chest CT in patients with ACS [101,102].
Chest Pain Possible Acute Coronary Syndrome PCAs. Normal CCTA has been shown to allow safe discharge from the emergency department without further workup, in both academic and community settings, with a negative predictive value for ACS over 95% [1,73-75], with equal or superior diagnostic performance when compared with stress echocardiography or nuclear MPI [76]. High-sensitivity troponin use has increased in Europe and in the United States to stratify patients with suspected ACS [77], but a CCTA strategy has still been found to be useful to avoid unnecessary downstream testing even when patients were first stratified by high-sensitivity troponin [78-80]. In a large multicenter study Chest Pain-Possible Acute Coronary Syndrome comparing CCTA with multiple other modalities used for ACS (stress cardiac MR [CMR], stress echocardiography, stress nuclear MPI, and stress PET), CCTA was found to have the highest diagnostic accuracy in finding patients with a significant coronary artery stenosis [81]. CT Coronary Calcium CT Coronary Calcium The role of the calcium score as a standalone test in the acute setting has not been established [94]. Limited studies have been performed demonstrating that the absence of coronary artery calcium (CAC) has a high negative predictive value for ACS among lower-risk patients with chest pain [95]. Several studies have suggested that in young patients with chest pain, a calcium score of zero is not a reliable test to exclude CAD, and adverse events have been shown to occur in up to 6% of acute chest pain patients without coronary artery calcium [96]. The ability of a zero calcium score to allow safe discharge of low-risk acute chest pain patients continues to be actively studied [97-100]. CT Chest CT Chest Nongated chest CT, although useful for evaluating noncardiac thoracic pathology, does not currently have a role in the evaluation of possible ACS, although perfusion defects can be seen on contrast-enhanced nongated chest CT in patients with ACS [101,102].