Stanford School of Medicine
Cardiovascular Institute–

Coronary Artery Disease - Diagnosis, Treatment and Prevention

This Strategic Research Area is co-chaired by Stephen Fortmann, MD, Geoff Rubin, MD, and Alan Yeung, MD. The members are:

Assimes, Themistocles MD
Lee , David P MD
Brenner, Jacob
McConnell, Michael V MD, MSEE
Chawla, Ajay MD/PhD
Popp, Richard L MD
Clusin, William T. MD, PhD
Rubin, Geoff MD
Fahrig, Rebecca PhD
Robinson, Thomas MD, MPH
Fearon, William F MD
Schillinger, Erika MD
Fortmann, Stephen MD
Schreiber, Donald MD, CM
Haskell, William L PhD
Stertzer, Simon MD FACC FAHA
Herfkens, Robert J MD
Wang, Shan X PhD
Hlatky, Mark A MD
Yang, Phillip MD
Knowles, Joshua MD
Yock, Paul MD
Lamendola, Cindy A MSN, ANP
Yeung, Alan MD

– fostering new research discoveries based on problems arising in the clinical setting

With 2007 Institute seed funding, the Coronary Artery Disease group has proposed an Emergency Department research study addressing the difficulties of risk stratification and early triage in patients presenting with chest pain and possible acute coronary syndrome. Current utilization of various clinical risk stratification tools cannot identify the majority of these patients that may be safely discharged from the Emergency Department.

 

Risk Stratification of ED Patients with Chest Pain and Suspected Acute Coronary Syndrome
using 64 Detector Row Computed Tomography, principal investigator Donald Schreiber, MD, CM, will enroll those patients with atypical symptoms, normal initial cardiac markers and non-diagnostic electrocardiograms. Although the majority of these patients do not have acute coronary syndrome, further diagnostic testing such as serial cardiac marker evaluation and functional cardiac studies is often required. The high medicolegal risk and the potential for adverse cardiac events including death drive the decision to admit these patients for further evaluation.

The rate of missed diagnosis of acute coronary syndrome in these ED patients is unacceptably high at 2%-4%. The burden and cost of these unnecessary admissions have led to the introduction of alternative approaches including dedicated chest pain units and rapid rule-out protocols for low-moderate risk patients, requiring a 12-24 hour stay consume an inordinate amount of hospital resources.

Improving diagnostic accuracy
and management of emergency department patients with chest pain

Multi-detector row CT (MDCT) angiography has shown diagnostic accuracy for the detection of coronary artery stenosis in selected patients undergoing cardiac catheterization (Sensitivity 91%-100%). MDCT with 64 detector rows could help quantify and characterize the extent of coronary plaque when compared to intravascular ultrasound. The negative predictive value of MDCT may be used to help rule out acute coronary syndrome in low-moderate risk patients evaluated for possible acute coronary syndrome in the Emergency Department.

A management study is proposed that combines the very high negative predictive value of  MDCT with clinical assessment to evaluate the safety and efficacy of discharging patients from the Emergency Department. This study would also determine if the detection of significant coronary artery stenosis and plaque by MDCT would improve patient care, reduce cost and improve the efficacy in the management of Emergency Department patients with chest pain.

 

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