Response to Letter Regarding Article, “Coronary Multidetector Computed Tomography in the Assessment of Patients With Acute Chest Pain”
We thank Dr Hamon and colleagues1 for their interest in our work. We agree that our data demonstrate that both the absence of coronary artery plaque or stenosis on noninvasive coronary multidetector computed tomography (MDCT) angiography has high negative predictive value for the subsequent diagnosis of acute coronary syndrome. However, as stated in the paper, we are aware that a subgroup of patients with acute coronary syndrome may not have significant epicardial coronary artery stenoses. Moreover, a late rise in troponin may be observed in some patients even in the absence of coronary artery disease (eg, myocarditis, or coronary ischemia secondary to coronary vasospasm or increased physiological demand). Consequently, we would like to emphasize again that given current knowledge, only the absence of any plaque on MDCT imaging may identify a group of patients (40% of our study population) eligible for early discharge without further investigation. There is no doubt that further risk stratification by serial troponins and by functional imaging such as stress tests will remain important diagnostic tools in patients with lesions of intermediate severity or inadequate image quality on MDCT. Further, we would like to emphasize that statements on the cost-effectiveness of a novel diagnostic tool such as cardiac MDCT in patients with acute chest pain are premature at this point in time, and such statements should not be made on the basis of the observational data provided in our manuscript. Ultimately, only randomized trials can establish whether the use of MDCT effectively and safely reduces hospital admissions in patients with acute chest pain.
Hoffmann U, Nagurney JT, Moselewski F, Pena A, Ferencik M, Chae CU, Cury RC, Butler J, Abbara S, Brown DF, Manini A, Nichols JH, Achenbach S, Brady TJ. Coronary multidetector computed tomography in the assessment of patients with acute chest pain. Circulation. 2006; 114: 2251–2260.