The diagnostic accuracy of 64-slice computed tomography coronary angiography compared with stress nuclear imaging in emergency department low-risk chest pain patients

Study objective: We compared the accuracy of multidetector computed tomography (CT) coronary angiography with stress nuclear imaging for the detection of an acute coronary syndrome or 30-day major adverse cardiac events in low-risk chest pain patients. Methods: This was a prospective study of the diagnostic accuracy of myocardial perfusion imaging and multidetector CT in low-risk chest pain patients. The target condition was an acute coronary syndrome (confirmed >70% coronary stenosis on coronary artery catheterization) or major adverse cardiac events within 30 days. Patients were low risk by Reilly/Goldman criteria and had negative serial ECGs and cardiac markers. All had both rest/stress sestamibi nuclear imaging and multidetector CT. Patients with abnormal stress nuclear imaging results (reversible perfusion defects) or multidetector CT results (stenosis >50% or calcium score >400) were considered for cardiac catheterization, and those with discordant results had a greater than 30-day reevaluation (including ECG) by a cardiologist. All were followed up for evidence of major adverse cardiac events within 30 days by review of hospital records and structured telephone interview. Primary outcomes were the accuracy of multidetector CT and myocardial perfusion imaging for the detection of an acute coronary syndrome and 30-day major adverse cardiac events. Results: Of the 92 patients, 7 (8%) were excluded because of uninterpretable multidetector CT scans. Of the remaining 85 study patients (49 +/- 11 years, 53% men), 7 (8%) were found to have the target condition, with all having significant coronary stenosis (88% +/- 9%) and none having myocardial infarction or major adverse cardiac events during 30 days. Stress nuclear imaging results were negative in 72 (85%) patients, and multidetector CT results were negative in 73 (86%) patients. The sensitivity of stress nuclear imaging was 71% (95% confidence interval [CI] 36% to 92%), and multidetector CT was 86% (95% CI 49% to 97%), and the specificity was 90% (95% CI 81% to 95%) and 92% (95% CI 84% to 96%), respectively. The negative predictive value of stress nuclear imaging and multidetector CT was 97% (95% CI 90% to 99%) and 99% (95% CI 93% to 100%), respectively, and the positive predictive value was 38% (95% CI 18% to 64%) and 50% (95% CI 25% to 75%), respectively. Conclusion: The accuracy of multidetector CT is at least as good as that of stress nuclear imaging for the detection and exclusion of an acute coronary syndrome in low-risk chest pain patients.