VERDICT: High Diagnostic Accuracy for Coronary CT in NSTEACS
New data show early coronary CT angiography (CTA) can accurately rule out coronary stenosis in patients presenting with non-ST-segment elevation acute coronary syndrome (NSTEACS), potentially sparing some from subsequent invasive testing and admission.
The negative predictive value (NPV) of CTA to rule out coronary artery stenosis of at least 50% was 90.9% (95% CI, 86.8% – 94.1%).
NPV was not influenced by patient characteristics or clinical-risk profile, and most false-negative results were in patients who had a single stenosis in small side branches with a luminal diameter of 2.5 mm or less.
The positive predictive value of CTA was 87.9%, sensitivity was 96.5%, and specificity was 72.4%.
The analysis, described as the largest CTA study in NSTEACS to date, was published today in the February 11 issue of Journal of the American College of Cardiology.
“The findings of the VERDICT trial suggest that, in patients with NSTEACS, coronary CTA can be conducted within 2 h of clinical diagnosis to quickly identify patients in whom invasive evaluation will be futile,” the authors conclude.
For those found with no significant coronary artery disease (CAD), the strategy could also “reduce the duration of antithrombotic medications and reduce the number of interhospital transportations, which are a major cost in the logistics of handling these patients,” senior author Klaus Kofoed, MD, DmSc, Rigshospitalet, University of Copenhagen, told theheart.org | Medscape Cardiology.
“For the patients where you do find significant coronary artery disease on the CT, I predict that there will be a lot of benefit to be had on the procedural planning of the revascularization,” he said.
Current guidelines favor invasive angiography as the primary diagnostic test for patients with ACS, whereas coronary CTA is reserved for those with chest pain who have an intermediate pretest likelihood of CAD.
The recommendations are based on early moderately sized ACS studies using 64-row CT in low-risk cohorts, whereas VERDICT patients were high risk and most were evaluated using 320-detector CT, Kofoed observed.
The VERDICT investigators previously reported that very early angiography within 12 hours of NSTEACS diagnosis did not improve 5-year clinical outcomes compared with standard angiography within 48 to 72 hours.
The new preplanned analysis included 1023 of the 2147-patient randomized cohort who underwent an additional coronary CTA exam prior to angiography. All patients had at positive troponin or ischemic electrocardiographic changes at baseline, and 67% had at least one stenosis on invasive angiography.
“This is really a big step forward because the tendency was always to think that coronary CTA is really only for patients with a low pretest likelihood. Well here, even in a cohort with high pretest likelihood, coronary CT angiography still performs very accurately,” Stephan Achenbach, MD, Friedrich-Alexander-University Erlangen-Numberg, Germany, told theheart.org | Medscape Cardiology.