Multicenter Study to Rule Out Myocardial Infarction by Cardiac Computed Tomography
Multicenter Study to Rule Out Myocardial Infarction by Cardiac Computed Tomography
The growing availability of cardiac computed tomography (CT)* in emergency departments (EDs)
 across the U.S. expands the opportunities for its clinical application, but also heightens
 the need to define its appropriate use in the evaluation of patients with acute chest pain.
 To address this need, we performed a randomized diagnostic trial (RDT) to determine whether
 integrating cardiac CT, along with the information it provides on coronary artery disease
 (CAD) and left ventricular (LV) function, can improve the efficiency of the management of
 these patients (i.e. shorten length of hospital stay, increase direct discharge rates from
 the ED, decreasing healthcare costs and improving cost effectiveness while being safe).
Patients with acute chest pain and normal or non-diagnostic electrocardiograms (ECGs)
 represent a cohort whose management is notably inefficient and diagnostically challenging.
 Because in less than 30% of EDs diagnostic testing (e.g. nuclear imaging, echocardiography,
 and exercise treadmill ECG) that would allow physicians to rule out the occurrence of
 myocardial ischemia is performed as part of the initial evaluation, most of these patients
 are hospitalized for 24 to 36 hours to exclude the presence of acute coronary syndrome (ACS).
 Of the six million acute chest pain patients admitted each year in the U.S. under these
 conditions, less than 10% of them ultimately receive a diagnosis of ACS at discharge.
 Moreover, inpatient care for negative evaluations imparts an economic burden in excess of $8
 billion annually.

 Since acute myocardial ischemia and necrosis are rare in the absence of coronary artery
 disease, a technology that reliably identifies CAD may allow physicians to discharge chest
 pain patients directly from the ED. Cardiac CT is a safe, high-speed, noninvasive imaging
 technique that accurately detects coronary atherosclerotic plaque and stenosis, and also
 allows physicians to assess global and regional LV function.

 Observational studies have demonstrated that approximately 40% of acute chest pain patients
 have no evidence of atherosclerosis on cardiac CT, and that an additional 30% have no
 evidence of hemodynamically significant (>50%) coronary artery stenosis. Both of these
 criteria are powerful predictors of the absence of both ACS and major adverse cardiovascular
 events (negative predictive value [NPV] of 98%). The specificity of cardiac CT is further
 increased when global and regional LV function is normal. Several studies have demonstrated
 that cardiac CT, with its high NPV, can be effectively used to rule out ACS, but little is
 known about the willingness ability of ED physicians to use this information to augment
 patient management.

 We therefore performed a trial at 9 clinical sites and randomized 1000 patients with acute
 chest pain and normal or non-diagnostic ECGs, to receive either standard ED evaluation (no
 intervention) or a cardiac CT (experimental) in the evaluation of acute chest pain in the
 emergency room. (Rule Out Myocardial Infarction using Computer Assisted Computed Tomography
 [ROMICAT II]).
Inclusion Criteria:

 1. Participant had at least five minutes of chest pain or equivalent (chest tightness;
 pain radiating to left, right, or both arms or shoulders, back, neck, epigastrium,
 jaw/throat; or unexplained shortness of breath, syncope/presyncope, generalized
 weakness, nausea, or vomiting thought to be of cardiac origin) at rest or during
 exercise within 24 hours of ED presentation, warranting further risk stratification,
 as determined by an ED attending.

 2. 2 or more cardiac risk factors (diabetes, hypertension, hyperlipidemia, current smoker
 and family history of coronary artery disease).

 3. Able to provide a written informed consent.

 4. <75 years of age, but >40 years of age.

 5. Able to hold breath for at least 10 seconds.

 6. Sinus rhythm.

 Exclusion Criteria:

 1. New diagnostic ischemic ECG changes (ST-segment elevation or depression > 1 mm or
 T-wave inversion > 4 mm) in more than two anatomically adjacent leads or left bundle
 branch block

 2. Documented or self-reported history of CAD (MI, percutaneous coronary interventions
 [PCIs], coronary artery bypass graft [CABG], known significant coronary stenosis
 [>50%])

 3. Greater than 6 hours since presentation to ED.

 4. BMI >40 kg/m2

 5. Impaired renal function as defined by serum creatinine >1.5 mg/dL*

 6. Elevated troponin-T (> 0.09 ng/ml)

 7. Hemodynamically or clinically unstable condition (BP systolic < 80 mm Hg, atrial or
 ventricular arrhythmias, persistent chest pain despite adequate therapy)

 8. Known allergy to iodinated contrast agent

 9. Currently symptomatic asthma

 10. Documented or self-reported cocaine use within the past 48 hours (acute)

 11. On Metformin therapy and unable or unwilling to discontinue for 48 hours after the CT
 scan

 12. Contraindication to beta blockers (taking daily antiasthmatic medication): This
 exclusion only applies to patients with a heart rate >65 bpm at sites using a non-dual
 source CT scanner

 13. Participant with no telephone or cell phone numbers or no address (preventing
 follow-up)

 14. Participant with positive pregnancy test. Women of childbearing potential, defined as
 <2 years of menopause in the absence of hysterectomy or tube ligation, must have a
 pregnancy test performed within 24 hours before the CT scan.

 15. Participant unwilling to provide a written informed consent.