Coronary CT Angiography Enhances Evaluation of Acute Chest Pain with Ambiguous Troponins

Overview

In patients presenting with acute chest pain and inconclusive high-sensitivity troponin levels, coronary computed tomography angiography (CCTA) improves diagnostic accuracy for non-ST-segment elevation acute coronary syndrome (NSTE-ACS). CCTA serves as a non-invasive gatekeeper to invasive coronary angiography, reducing unnecessary procedures and identifying significant coronary artery disease.

Background

Acute chest pain is a frequent emergency department presentation with a broad differential diagnosis ranging from benign to life-threatening conditions such as NSTE-ACS. Current diagnostic protocols rely on clinical assessment, ECG, and high-sensitivity troponin measurements using rule-in and rule-out algorithms. However, 20–30% of patients fall into an inconclusive category where NSTE-ACS cannot be definitively excluded. Invasive coronary angiography is the reference standard for detecting obstructive coronary artery disease but carries procedural risks. CCTA has emerged as a promising non-invasive alternative to improve diagnostic evaluation in this challenging patient subset.

Data Highlights

The study enrolled patients aged 30–80 years presenting with acute chest pain and inconclusively elevated hs-troponins who did not meet rule-in or rule-out criteria for NSTE-ACS. Exclusion criteria included prior coronary artery disease, recent coronary imaging, clinical instability, and contraindications to CCTA. Patients underwent CCTA within one week of presentation, including coronary artery calcium scoring and contrast-enhanced imaging. Findings were categorized by clinical significance, and significant CAD was defined as ≥50% stenosis. The primary outcome was the diagnostic accuracy of CCTA for detecting type 1 NSTE-ACS.

Key Findings

• CCTA identified obstructive coronary artery disease (≥50% stenosis) in patients with inconclusive hs-troponin results, aiding diagnosis of NSTE-ACS.
• Use of CCTA reduced the need for invasive coronary angiography by serving as a gatekeeper in this patient population.
• Significant coronary findings with prognostic implications (e.g., left main or proximal LAD disease) were detected and reported to clinicians for management.
• CCTA also revealed important non-coronary cardiac and non-cardiac findings warranting further follow-up.
• Blinded reading and standardized reporting using CAD-RADS ensured consistent interpretation of coronary findings.

Clinical Implications

Incorporating CCTA into the diagnostic pathway for patients with acute chest pain and ambiguous hs-troponin levels can improve identification of obstructive coronary artery disease and NSTE-ACS. This approach may reduce unnecessary invasive procedures and facilitate timely management of high-risk coronary lesions. Clinicians should consider CCTA as a valuable non-invasive tool in the evaluation of this challenging patient group.

Conclusion

CCTA enhances the diagnostic evaluation of patients with acute chest pain and inconclusive high-sensitivity troponin results by accurately detecting obstructive coronary artery disease and guiding clinical decision-making. Its use may optimize patient management and reduce reliance on invasive angiography.

References

1. COURSE Study Investigators 2021 -- Coronary CT Angiography for Improved Assessment of Patients with Acute Chest Pain and Inconclusively Elevated High-Sensitivity Troponins