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Observational Study
. 2025 Feb;35(2):789-797.
doi: 10.1007/s00330-024-10930-1. Epub 2024 Aug 16.

Coronary computed tomography angiography improves assessment of patients with acute chest pain and inconclusively elevated high-sensitivity troponins

Murat Arslan  1   2 , Jeroen Schaap  3 , Bart van Gorsel  3 , Anton Aubanell  4 , Ricardo P J Budde  5   4 , Alexander Hirsch  5   4 , Martijn W Smulders  6 , Casper Mihl  7 , Peter Damman  8 , Olga Sliwicka  9 , Jesse Habets  10 , Eric A Dubois  5   11 , Admir Dedic  5   12
Affiliations
Observational Study

Coronary computed tomography angiography improves assessment of patients with acute chest pain and inconclusively elevated high-sensitivity troponins

Murat Arslan et al. Eur Radiol. 2025 Feb.

Abstract

Objectives: To determine whether coronary computed tomography angiography (CCTA) can improve the diagnostic work-up of patients with acute chest pain and inconclusively high-sensitivity troponins (hs-troponin).

Methods: We conducted a prospective, blinded, observational, multicentre study. Patients aged 30-80 years presenting to the emergency department with acute chest pain and inconclusively elevated hs-troponins were included and underwent CCTA. The primary outcome was the diagnostic accuracy of ≥ 50% stenosis on CCTA to identify patients with type-1 non-ST-segment elevation acute coronary syndrome (NSTE-ACS).

Results: A total of 106 patients (mean age 65 ± 10, 29% women) were enrolled of whom 20 patients (19%) had an adjudicated diagnosis of type-1 NSTE-ACS. In 45 patients, CCTA revealed non-obstructive coronary artery disease (CAD) or no CAD. Sensitivity, specificity, negative predictive value (NPV), positive predictive value and area-under-the-curve (AUC) of ≥ 50% stenosis on CCTA to identify patients with type 1 NSTE-ACS, was 95% (95% confidence interval: 74-100), 56% (45-68), 98% (87-100), 35% (29-41) and 0.83 (0.73-0.94), respectively. When only coronary segments with a diameter ≥ 2 mm were considered for the adjudication of type 1 NSTE-ACS, the sensitivity and NPV increased to 100%. In 8 patients, CCTA enabled the detection of clinically relevant non-coronary findings.

Conclusion: The absence of ≥ 50% coronary artery stenosis on CCTA can be used to rule out type 1 NSTE-ACS in acute chest pain patients with inconclusively elevated hs-troponins. Additionally, CCTA can help improve the diagnostic work-up by detecting other relevant conditions that cause acute chest pain and inconclusively elevated hs-troponins.

Clinical relevance statement: Coronary CTA (CCTA) can safely rule out type 1 non-ST-segment elevation acute coronary syndrome (NSTE-ACS) in patients presenting to the ED with acute chest pain and inconclusively elevated hs-troponins, while also detecting other relevant non-coronary conditions.

Trial registration: Clinicaltrials.gov (NCT03129659). Registered on 26 April 2017 KEY POINTS: Acute chest discomfort is a common presenting complaint in the emergency department. CCTA achieved very high negative predictive values for type 1 NSTE-ACS in this population. CCTA can serve as an adjunct for evaluating equivocal ACS and evaluates for other pathology.

Keywords: Acute coronary syndrome; Computed tomography angiography; Non-ST elevated myocardial infarction; Troponin.

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Conflict of interest statement

Compliance with ethical standards. Guarantor: The scientific guarantor of this publication is Eric A. Dubois. Conflict of interest: The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article. Statistics and biometry: No complex statistical methods were necessary for this paper. Informed consent: Written informed consent was obtained from all subjects (patients) in this study. Ethical approval: Institutional Review Board approval was obtained. Study subjects or cohorts overlap: NA Methodology: Prospective Observational Multicentre study

Figures

Fig. 1
Fig. 1
Study population. Inconclusively refers to patients who do not meet the criteria for rule-out or rule-in of the European Society of Cardiology 0-h/1-h algorithm using high-sensitivity cardiac troponins. 0-h/1-h algorithm cut-off levels shown (in ng/L) are specific to the hs-cTnT assay (elecsys; Roche). *Only applicable if chest pain onset > 3 h. #‘0-h/3-h’ algorithm is only used as a substitute in cases where the standard ‘0-h/1-h’ algorithm is not feasible. 0 h, 1 h and 3 h refer to the time (in hours) from the first blood draw. CCTA, coronary computed tomography angiography; hs-cTnT, high-sensitivity cardiac Troponin T; NSTE-ACS, non-ST-segment elevation acute coronary syndrome; ∆, delta
Fig. 2
Fig. 2
Curved multiplanar reconstructions of the three main coronary artery branches of a patient included in the COURSE trial showing no signs of coronary artery disease. Exemplary case showcasing the use of CCTA as a gatekeeper for patients with inconclusively elevated high-sensitivity troponin levels in the emergency department: an elderly patient, an active smoker, was admitted to the emergency department with typical angina. The electrocardiogram showed a previously known right bundle branch block. The first and second hs-troponin T measurements according to the European Society of Cardiology 0-h/1-h algorithm were 13 ng/L and 11 ng/L, respectively. The patient was assigned to the ‘inconclusively’ category and admitted to the Cardiology ward to undergo invasive coronary angiography. The patient was included in the COURSE trial and underwent CCTA, which showed no coronary artery disease, virtually eliminating the need for invasive coronary angiography. LAD, left anterior descending artery; LCX, left circumflex artery; RCA, right coronary artery
Fig. 3
Fig. 3
Predictive value of CCTA for type 1 NSTE-ACS. The receiver-operating-characteristic curve shows the predictive value of CCTA for type 1 non-ST-segment elevation acute coronary syndrome. CCTA, coronary computed tomography angiography
Fig. 4
Fig. 4
Predictive value of CCTA for type 1 NSTE-ACS, if only coronary segments with a diameter ≥ 2 mm are considered. The receiver-operating-characteristic curve shows the predictive value of CCTA for type 1 non-ST-segment elevation acute coronary syndrome if only coronary segments with a diameter ≥ 2 mm are considered. CCTA, coronary computed tomography angiography
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