BACKGROUND In patients with non-ST-segment elevation acute coronary syndrome (NSTEACS), coronary pathology may range from structurally normal vessels to severe coronary artery disease. OBJECTIVES The purpose of this study was to test if coronary computed tomography angiography (CTA) may be used to exclude coronary artery stenosis $50% in patients with NSTEACS. METHODS The VERDICT (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography in Patients With Acute Coronary Syndromes) trial (NCT02061891) evaluated the outcome of patients with confirmed NSTEACS randomized 1:1 to very early (within 12 h) or standard (48 to 72 h) invasive coronary angiography (ICA). As an observational component of the trial, a clinically blinded coronary CTA was conducted prior to ICA in both groups. The primary endpoint was the ability of coronary CTA to rule out coronary artery stenosis ($50% stenosis) in the entire population, expressed as the negative predictive value (NPV), using ICA as the reference standard. RESULTS Coronary CTA was conducted in 1,023 patients-very early, 2.5 h (interquartile range [IQR]: 1.8 to 4.2 h), n = 583; and standard, 59.9 h (IQR: 38.9 to 86.7 h); n = 440 after the diagnosis of NSTEACS was made. A coronary stenosis $50% was found by coronary CTA in 68.9% and by ICA in 67.4% of the patients. Per-patient NPV of coronary CTA was 90.9% (95% confidence interval [CI]: 86.8% to 94.1%) and the positive predictive value, sensitivity, and specificity were 87.9% (95% CI: 85.3% to 90.1%), 96.5% (95% CI: 94.9% to 97.8%) and 72.4% (95% CI: 67.2% to 77.1%), respectively. NPV was not influenced by patient characteristics or clinical risk profile and was similar in the very early and the standard strategy group. CONCLUSIONS Coronary CTA has a high diagnostic accuracy to rule out clinically significant coronary artery disease in patients with NSTEACS. (C) 2020 by the American College of Cardiology Foundation.

Objective To prospectively validate the CT-Valve score, a new risk score designed to identify patients with valvular heart disease at a low risk of coronary artery disease (CAD) who could benefit from multislice CT (MSCT) first instead of coronary angiography (CAG).Methods This was a prospective cohort study of patients referred for valve surgery in the Capital Region of Denmark and Odense University Hospital from the 1 February 2015 to the 1 February 2017. MSCT was implemented for patients with a CT-Valve score ≤7 at the referring physician’s discretion. Patients with a history of CAD or chronic kidney disease were excluded. The primary outcome was the proportion of patients needing reevaluation with CAG after MSCT and risk of CAD among the patients determined to be low to intermediate risk.Results In total, 1149 patients were included. The median score was 9 (IQR 3) and 339 (30%) had a score ≤7. MSCT was used for 117 patients. Of these 29 (25%) were reevaluated and 9 (7.7%) had CAD. Of the 222 patients with a score ≤7 that did not receive an MSCT, 14 (6%) had significant CAD. The estimated total cost of evaluation among patients with a score ≤7 before implementation was €132 093 compared with €79 073 after, a 40% reduction. Similarly, estimated total radiation before and after was 608 mSv and 362 mSv, a 41% reduction. Follow-up at a median of 32 months (18–48) showed no ischaemic events for patients receiving only MSCT.Conclusion The CT-Valve score is a valid method for determining risk of CAD among patients with valvular heart disease. Using a score ≤7 as a cut-off for the use of MSCT is safe and cost-effective.

Ruptured bronchial artery aneurysm (BAA) is a rare but potentially life-threatening condition. In this case report, a 73-year-old man was admitted to hospital due to acute onset of retrosternal chest pain radiating to the back. A CT and a selective bronchial artery angiography revealed a ruptured BAA, which was initially coiled, and haemostasis was secured with a microvascular plug. The post-operative course was without complications, and the patient was discharged after two days.

ObjectiveCoronary artery disease (CAD) is frequent in patients with newly diagnosed heart failure (HF). Multislice CT (MSCT) is a non-invasive alternative to coronary angiography (CAG) suggested for patients with a low-to-intermediate risk of CAD. No established definition of such patients exists. Our purpose was to develop a simple score to identify as large a group as possible with a suitable pretest risk of CAD.MethodsRetrospective study of patients in Denmark undergoing CAG due to newly diagnosed HF from 2010 to 2014. All Danish patients were registered in two databases according to geographical location. We used data from one registry and multiple logistic regression with backwards elimination to find predictors of CAD and used the derived OR to develop a clinical risk score called the CT-HF score, which was subsequently validated in the other database.ResultsThe main cohort consisted of 2171 patients and the validation cohort consisted of 2795 patients with 24% and 27% of patients having significant CAD, respectively. Among significant predictor, the strongest was extracardiac arteriopathy (OR 2.84). Other significant factors were male sex, smoking, hyperlipidaemia, diabetes mellitus, angina and age. A proposed cut-off of 9 points identified 61% of patients with a 15% risk of having CAD, resulting in an estimated savings of 15% of the cost and 21% of the radiation.ConclusionsA simple score based on clinical risk factors could identify HF patients with a low risk of CAD; these patients may have benefitted from MSCT as a gatekeeper for CAG.

BackgroundHigh-sensitivity cardiac troponin T (hs-cTnT) is a good prognostic marker for mortality. However, it is uncertain if hs-cTnT can be used to detect sub-clinical cardiac disease. MethodPilot study in patients without known heart disease and elevated hs-cTnT measured at presentation to the emergency department. Hs-cTnT was measure with Roche Diagnostics. Echocardiography was used to assess structural heart disease and the participants underwent computed tomography angiography for assessment of coronary artery disease and agatston score. ResultsTen patients were included in the final cohort. Median age was 68 years IQR (57-78) and 80% were female (n=8). Six patients had a history of chronic obstructive lung disease and five patients had history of hypertension. The median level of hs-cTnT was 26ng/L and values ranged from 19ng/L to 495ng/L. The median calcium score was 12. Three patients had signs of coronary artery disease. All patients had normal left ventricular ejection fraction with a median LVEF at 54.5%. Two patients were noted to have increased left ventricular mass index (LVMI). ConclusionThe majority of patients with hs-cTnT above the 99th percentile did not have structural heart disease or ischaemic coronary disease. However, 30% of the patient did have signs of coronary disease and might benefit from preventive medical treatment. Measuring hs-cTnT in the absence of acute illness might be a better approach for evaluation for sub-clinical cardiac disease.

Background: Differences in prevalence and prognostic information of cardiac troponin T (cTnT) and I (cTnI) concentrations in patients without acute coronary syndrome (ACS) are insufficiently investigated. High-sensitivity assays (hs-cTn) have led to an increased interest in hs-cTn for risk stratification. Here, we compare hs-cTnT and hs-cTnI in prediction of mortality patients without ACS. Method and results: Patients aged > 18 years, consecutively admitted to an emergency department (ED) were included. Blood was collected at admission and later analyzed with high-sensitivity assays for cTnT (Roche) and cTnI (Siemens). Troponin concentrations were reported as normal or increased according to the clinical cut-off value of 99th percentile as defined by the manufacturer. The primary outcome was all-cause mortality. Of the 822 participants (median, 65 years [48-77]; 428 female [52%]), 239 patients died. Median follow-up time was 3.0 years [2.1-3.0]. Elevation of hs-cTn was observed in 40% (n = 345) for hs-cTnT and 8% (n = 64) for hs-cTnI, p < 0.001. The relationship between elevated hs-cTn and mortality was strong for both hs-cTnT and hs-cTnI [HR 6.0 (95% CI: 2.9-12.6) vs. 5.1 (95% CI: 1.9-13.6)]. There was no difference in prognostic accuracy for short-term mortality (30 days) betwee(n) hs-cTnT and hs-cTnI. However, the prognostic accuracy for longterm mortality (1080 days) was superior for hs-cTnT than for hs-cTnI [area under the receivers operating curve (AUC) 0.81 vs 0.74, p < 0.001]. Conclusion: Both hs-cTnI and hs-cTnT were predictive for all-cause mortality. Notably, hs-cTnT measurement showed superior prognostic performance in predicting long-term all-cause mortality compared with hs-cTnI. (c) 2018 Elsevier B.V. All rights reserved.

Background: The optimal timing of invasive coronary angiography (ICA) and revascularization in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) is not well defined. We tested the hypothesis, that a strategy of very early invasive coronary angiography (ICA) and possible revascularization within 12 hours of diagnosis, is superior to an invasive strategy performed within 48-72 hours in terms of clinical outcomes. Methods: Patients admitted with clinical suspicion of NSTE-ACS in the Capital Region of Copenhagen, Denmark were screened for inclusion in the VERDICT trial (ClinicalTrials.gov NCT02061891). Patients with ECG changes indicating new ischemia and/or elevated troponin, in whom ICA was clinically indicated and deemed logistically feasible within 12 hours, were randomized 1:1 to ICA within 12 hours or standard invasive care within 48-72 hours. The primary endpoint was a combination of all-cause death, non-fatal recurrent myocardial infarction, hospital admission for refractory my...

Background: The optimal timing of invasive coronary angiography (ICA) and revascularization in patients with non-ST-segment elevation acute coronary syndrome is not well defined. We tested the hypothesis that a strategy of very early ICA and possible revascularization within 12 hours of diagnosis is superior to an invasive strategy performed within 48 to 72 hours in terms of clinical outcomes. Methods: Patients admitted with clinical suspicion of non-ST-segment elevation acute coronary syndrome in the Capital Region of Copenhagen, Denmark, were screened for inclusion in the VERDICT trial (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography) ( ClinicalTrials.gov NCT02061891). Patients with ECG changes indicating new ischemia or elevated troponin, in whom ICA was clinically indicated and deemed logistically feasible within 12 hours, were randomized 1:1 to ICA within 12 hours or standard invasive care within 48 to 72 hours. The primary end point was a combination of all-cause death, nonfatal recurrent myocardial infarction, hospital admission for refractory myocardial ischemia, or hospital admission for heart failure. Results: A total of 2147 patients were randomized; 1075 patients allocated to very early invasive evaluation had ICA performed at a median of 4.7 hours after randomization, whereas 1072 patients assigned to standard invasive care had ICA performed 61.6 hours after randomization. Among patients with significant coronary artery disease identified by ICA, coronary revascularization was performed in 88.4% (very early ICA) and 83.1% (standard invasive care). Within a median follow-up time of 4.3 (interquartile range, 4.1–4.4) years, the primary end point occurred in 296 (27.5%) of participants in the very early ICA group and 316 (29.5%) in the standard care group (hazard ratio, 0.92; 95% CI, 0.78–1.08). Among patients with a GRACE risk score (Global Registry of Acute Coronary Events) >140, a very early invasive treatment strategy improved the primary outcome compared with the standard invasive treatment (hazard ratio, 0.81; 95% CI, 0.67–1.01; P value for interaction=0.023). Conclusions: A strategy of very early invasive coronary evaluation does not improve overall long-term clinical outcome compared with an invasive strategy conducted within 2 to 3 days in patients with non-ST-segment elevation acute coronary syndrome. However, in patients with the highest risk, very early invasive therapy improves long-term outcomes. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02061891.

Background Multislice computed tomography (MSCT) is a non-invasive, less expensive, low-radiation alternative to coronary angiography (CAG) prior to valvular heart surgery. MSCT has a high negative predictive value for coronary artery disease (CAD) but previous studies of patients with valvular disease have shown that MSCT, as the primary evaluation technique, lead to re-evaluation with CAG in about a third of cases and it is therefore not recommended. If a subgroup of patients with low- to intermediate risk of CAD could be identified and examined with MSCT, it could be cost-effective, reduce radiation and the risk of complications associated with CAG. Methods The study cohort was derived from a national registry of patients undergoing CAG prior to valvular heart surgery. Using logistic regression, we identified significant risk factors for CAD and developed a risk score (CT-valve score). The score was validated on a similar cohort of patients from another registry. Results The study cohort consisted of 2221 patients, 521 (23.5%) had CAD. The validation cohort consisted of 2575 patients, 771 (29.9%) had CAD. The identified risk factors were male sex, age, smoking, hyperlipidemia, hypertension, aortic valve disease, extracardiac arteriopathy, ejection fraction <30% and diabetes mellitus. CT-valve score could identify a third of the population with a risk about 10%. Conclusion A score based on risk factors of CAD can identify patients that might benefit from using MSCT as a gatekeeper to CAG prior to heart valve surgery.

Background Cardiac troponin T and I are important diagnostic and prognostic markers in patients with acute coronary syndrome (ACS). Troponin elevations in various non-ACS scenarios have been documented, but few studies have been conducted on the general hospitalized population, none compared the diagnostic performance of troponin I and T. Methods and results Patients aged >18 years (n = 1097), consecutively admitted to a district hospital, were included in the study. Blood samples were collected at admission and analysed with three different troponin assays. Serum was available in 92.2%, giving a study population of 1012 patients (mean age 61.6 years, 510 (50.4%) female). ACS was diagnosed among 125 (12.4%) of the patients. Remaining patients were admitted with a broad spectrum of medical and surgical conditions. Of the total population, sc-cTnI was above the 99th percentile in 93 (9.2%), hs-cTnI was above the 99th percentile in 80 (7.9%) and hs-cTnT was above the 99th percentile in 400 (39.5%) of the patients (p < 0.001 for all differences). Hs-cTnT was stronger correlated with estimated glomerular filtration rate (r [2] = 0.13 vs r [2] = 0.06) and haemoglobin (r [2] = 0.1 vs r2 = 0.02) than with hs-cTnI, none were correlated with C-reactive protein (r [2] = 0.04 vs r [2] = 0.02). The correlation between ln(hs-cTnT) and ln(hs-cTnI) was better in ACS patients than in non-ACS patients (r [2] = 0.79 vs r [2] = 0.47, p < 0.001). Conclusion Hs-cTnT was elevated above the 99th percentile in more than one third of the non-ACS patients, while hs-cTnI and sc-cTnI were elevated in approximately one tenth. The correlation between hs-cTnT and hs-cTnI concentrations was significantly stronger in ACS patients than in non-ACS patients.

Background Serum YKL-40 is an inflammatory biomarker associated with disease activity and mortality in diseases characterized by inflammation such as coronary artery disease (CAD). Exercise has a positive effect on CAD, possibly mediated by a decreased inflammatory activity. This study aimed to compare serial measurements of serum YKL-40 before and after exercise in patients with stable CAD versus controls.Materials and methods Eleven patients with stable CAD verified by coronary angiography (> 70% stenosis) and 11 patients with a computer tomography angiography with no stenosis or calcification (calcium score= 0) (controls) performed a standard clinical maximal exercise test. Serum YKL-40 was measured before exercise, immediately after exercise, and every hour for 6 h.Results Cardiovascular risk factors were more prevalent among the CAD patients compared with the controls. CAD patients had higher serum concentration of YKL-40 at baseline compared with controls, median (interquartile range) 94 (52-151) versus 57 (45-79) mu g/l. Serum YKL-40 decreased stepwise after exercise, with a median decrease of 16 (13-39) mu g/l for the CAD patients and 13 (10-22) mu g/l for the controls from baseline to the lowest value. Thereafter, values increased again toward baseline level. Time after exercise was a significant factor for decrease in serum YKL-40 (P< 0.0001), but no difference in YKL-40 decrease over time could be demonstrated between the groups (P= 0.12).Conclusion Serum YKL-40 is elevated in patients with documented CAD compared with controls, and it decreases stepwise after exercise in both groups, indicating an anti-inflammatory effect of exercise independent of the presence of coronary atherosclerosis. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

Background: The European Society of Cardiology (ESC) guideline on non-ST-elevation acute coronary syndrome (N-STE ACS) proposed a new ACS rule-out protocol. Objectives: To evaluate this new tool, which uses diagnostic levels of high-sensitivity troponin T (hs-TnT; > 14 ng/L) in a slightly modified version and compare this to a recently proposed approach using undetectable levels of hs-TnT to rule out patients. Methods: There were 534 consecutive patients with suspected ACS included. Protocol 1: symptom duration, hs-TnT at 0 and 6-9 h, Global Registry of Acute Coronary Events (GRACE) score, and symptom status at 6-9 h. Protocol 2: a single blood sample of hs-TnT. The primary endpoint was a discharge diagnosis of ACS by blinded adjudication. Secondary endpoints were ACS re-admission < 30 days and 1-year mortality. Results: Protocol 1 classified 434/534 (81%) patients, with 27.9% being ruled out. All myocardial infarctions were correctly ruled in, but 15 cases of unstable angina were missed, resulting in a sensitivity and negative predictive value of 87.3% (79.6-92.5%) and 87.6% (80.4-92.9%), respectively. Protocol 2 ruled out 17.5% of the population, yielding a sensitivity and negative predictive value of 94.1% (88.2-97.6%) and 90.8% (81.9-96.2%), respectively. Both protocols correctly ruled in 2/3 patients with ACS re-admission < 30 days and 55/56 1-year fatalities. Conclusion: The present study confirms the diagnostic value of a modified version of the ESC rule-out protocol (Protocol 1) in N-STE ACS patients, but also suggests that a simpler protocol using undetectable levels of hs-TnT (Protocol 2) could provide a similar or even superior sensitivity. (C) 2015 Elsevier Inc.

Background The usual primary evaluation in patients with acute non-traumatic chest pain is investigation for signs of ischemic heart disease in a coronary care unit. Frequently, standard chest radiograph (CXR) is obtained in order to rule out differential diagnoses and complications. A high prevalence of lung disease may be suspected, even if acute coronary syndrome (ACS) is ruled out, since both symptoms and risk factors for lung disease and heart disease are overlapping. Aim To investigate the occurrence of radiologic signs of lung disease in patients admitted with non-traumatic chest pain, and to evaluate whether such findings subsequently led to further pulmonary examination. Methods 244 randomly selected patients under evaluation for ACS were included in this observational study. Demographic, clinical and successive follow up data were extracted from charts. Patient CXRs were scored independently by 2 trained investigators. Results 136 patients were discharged with no definitive diagnosis of heart disease. Radiologic signs of lung disease on CXR (new opacity, fibrosis, hyperinflation and coarse bronchovascular markings) were detected in 84 of these patients. Twenty-six patients previously had a known pulmonary condition and received treatment. Of the remaining 58 patients (69%), who were eligible for further evaluation, only a minority were referred to pulmonary examination. Conclusions In the setting of acute non-traumatic chest pain and a primary suspicion of ACS, a routine standard chest radiograph may be recommended, since it holds the potential of early recognition of lung disease in many patients.

Background Acute non-traumatic chest pain is a common clinical presentation, often resulting in examination for acute coronary syndrome (ACS). A standard chest radiograph (CXR) is usually obtained to rule out differential diagnoses. Recent studies indicate, that this screening procedure is limited by a low diagnostic yield, and that current decision rules based solely on clinical information are not adequate in determining which patients to examine. Aim To evaluate if upfront routine CXR in patients suspected for ACS identifies a substantial number of findings requiring acute intervention, and whether such findings are better predicted, using a decision algorithm including both clinical information and biochemical markers. Methods Patients admitted for ACS were randomly selected and included in this observational study. Clinical and laboratory data were extracted from charts. CXRs were scored independently by 2 trained investigators. Results Out of 244 included patients, 85 patients (35%) revealed radiologic findings, indicating need for acute intervention, i.e., any sign of pulmonary congestion (n=56), or a new infiltrate (n=29). Patients with findings requiring acute intervention had higher respiratory frequencies (p < 0.001) and higher levels of NT-pro-BNP (p < 0.001), leukocytes (p = 0.009) and hsCRP (p < 0.001), compared to patients with no acute findings on CXR. Conclusion Routine CXR is still relevant in chest pain patients suspected for ACS, as it identifies conditions requiring acute intervention. Combined use of clinical and laboratory information in a formal decision algorithm may assist in determining, which subgroup most likely benefits from an early CXR.

Purpose: With the advent of high-sensitivity cardiac troponins (hscTn), detectable levels have become the norm and clinical challenge lies within distinction of normal and abnormal. We therefore sought to describe diagnostic and prognostic implications of the clinical introduction of hscTn. Methods: Myocardial infarction (MI) adjudication was based on hsTnT (Roche Diagnostics) and clinical setting. The 99% upper reference limit (URL) of 30 ng/L (10% CV) in the 4th generation TnT assay corresponds to 50 ng/L URL in the hsTnT assay. First, we used a 50 ng/L cut off (+dynamic changes) after the introduction of hsTnT in order to parallel MI diagnosis with the 4th generation assay. MI was then re-adjudicated by hsTnT levels >99% URL (>14 ng/L) with an absolute (abs.) change as rise/fall >50% of URL (>7 ng/L). We then compared hsTnT with a contemporary sensitivity TnI assay (sTnI) (Siemens Vista), with a 15 ng/L detection limit, a 45 ng/L 99% URL and significant abs. change of 20 ng/L. Results: In 335 chest pain patients with at least 2 values, 46 (13.7%) had MI by the 50 ng/l cut off. Re-adjudicating MI resulted in a 67% increase with 69 (20.6%) MI, 74% of the additional MI were type II. STnI only identified 51 of re-defined MI with modest 73.9% sensitivity (sens.) but high 95.9% specificity, yielding only 4.1% false positives, which was doubled (7.9%) with hsTnT. In 586 patients with at least 1 hsTnT value, 105 (17.9%) had undetectable levels (< 3 ng/L) at admission, ruling out all 1 year mortality [n = 81 (13.8%)] and all MI [n = 85 (14.5%)] with 100% sens. and NPV. 313 (53.4%) patients had hsTnT levels <14 ng/L, which predicted mortality with 96.3% sens. and 99% NPV, missing 3 events, and MI with 98.8% sens. and 99.7% NPV, missing 1 case. In 553 patients with at least 1 sTnI value, 376 (68%) had undetectable levels (< 15 ng/L) at admission, ruling out 1 year mortality [n = 73 (13.2%)] with 78.1% sens. and 95.7% NPV, missing 16 events. 430 (77.8%) had sTnI levels <45 ng/L, which predicted mortality with 58.9% sens. and 93% NPV, missing 30 events. MI at admission was ruled out with 86.7% sens. and 97.1% NPV by sTnI <15 ng/L, missing 11 cases, and with 75.9% sens. and 95.3% NPV by sTnI <45 ng/L, missing 20 cases. Conclusion: The advent of hscTn will substantially increase MI incidence, primarily type II. Fewer chest pain patients will have undetectable cTn but constitute a new very low risk population with absolute rule out of MI and 1 year all cause mortality. This implies higher rates of false positives with non-ischemic disease burden and diagnostic work up for MI is more important than ever.