hs-Troponin I Followed by CT Angiography Improves Acute Coronary Syndrome Risk Stratification Accuracy and Work-Up in Acute Chest Pain Patients: Results From ROMICAT II Trial

JACC Cardiovasc Imaging. 2015 Nov;8(11):1272-1281. doi: 10.1016/j.jcmg.2015.06.016. Epub 2015 Oct 14.


Objectives: This study compared diagnostic accuracy of conventional troponin/traditional coronary artery disease (CAD) assessment and highly sensitive troponin (hsTn) I/advanced CAD assessment for acute coronary syndrome (ACS) during the index hospitalization.

Background: hsTnI and advanced assessment of CAD using coronary computed tomography angiography (CTA) are promising candidates to improve the accuracy of emergency department evaluation of patients with suspected ACS.

Methods: We performed an observational cohort study in patients with suspected ACS enrolled in the ROMICAT II (Rule Out Myocardial Infarction/Ischemia using Computer Assisted Tomography) trial and randomized to coronary CTA who also had hsTnI measurement at the time of the emergency department presentation. We assessed coronary CTA for traditional (no CAD, nonobstructive CAD, ≥50% stenosis) and advanced features of CAD (≥50% stenosis, high-risk plaque features: positive remodeling, low <30-Hounsfield units plaque, napkin-ring sign, spotty calcium).

Results: Of 160 patients (mean age: 53 ± 8 years, 40% women) 10.6% were diagnosed with ACS. The ACS rate in patients with hsTnI below the limit of detection (n = 9, 5.6%), intermediate (n = 139, 86.9%), and above the 99th percentile (n = 12, 7.5%) was 0%, 8.6%, and 58.3%, respectively. Absence of ≥50% stenosis and high-risk plaque ruled out ACS in patients with intermediate hsTnI (n = 87, 54.4%; ACS rate 0%), whereas patients with both ≥50% stenosis and high-risk plaque were at high risk (n = 13, 8.1%; ACS rate 69.2%) and patients with either ≥50% stenosis or high-risk plaque were at intermediate risk for ACS (n = 39, 24.4%; ACS rate 7.7%). hsTnI/advanced coronary CTA assessment significantly improved the diagnostic accuracy for ACS as compared to conventional troponin/traditional coronary CTA (area under the curve 0.84, 95% confidence interval [CI]: 0.80 to .88 vs. 0.74, 95% CI: 0.70 to 0.78; p < 0.001).

Conclusions: hsTnI at the time of presentation followed by early advanced coronary CTA assessment improves the risk stratification and diagnostic accuracy for ACS as compared to conventional troponin and traditional coronary CTA assessment. (Multicenter Study to Rule Out Myocardial Infarction/Ischemia by Cardiac Computed Tomography [ROMICAT-II]; NCT01084239).

Keywords: acute coronary syndrome; coronary computed tomography angiography; coronary plaque; emergency department; highly sensitive troponin; risk stratification.

Publication types

  • Comparative Study
  • Multicenter Study
  • Observational Study
  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural

MeSH terms

  • Acute Coronary Syndrome / blood
  • Acute Coronary Syndrome / diagnosis*
  • Acute Coronary Syndrome / diagnostic imaging
  • Adult
  • Angina Pectoris / blood
  • Angina Pectoris / diagnosis*
  • Angina Pectoris / diagnostic imaging
  • Biomarkers / blood
  • Coronary Angiography / methods*
  • Coronary Artery Disease / blood
  • Coronary Artery Disease / diagnosis*
  • Coronary Artery Disease / diagnostic imaging
  • Coronary Stenosis / blood
  • Coronary Stenosis / diagnosis*
  • Coronary Stenosis / diagnostic imaging
  • Coronary Vessels / diagnostic imaging*
  • Emergency Service, Hospital
  • Female
  • Hospitalization
  • Humans
  • Male
  • Middle Aged
  • Plaque, Atherosclerotic
  • Predictive Value of Tests
  • Risk Assessment
  • Risk Factors
  • Severity of Illness Index
  • Tomography, X-Ray Computed*
  • Troponin I / blood*
  • United States
  • Vascular Calcification / blood
  • Vascular Calcification / diagnosis
  • Vascular Calcification / diagnostic imaging


  • Biomarkers
  • Troponin I

Associated data

  • ClinicalTrials.gov/NCT01084239