Utility of nonspecific resting electrocardiographic features for detection of coronary artery stenosis by Computed Tomography in acute chest pain patients: from the ROMICAT trial

  • Quynh A. Truong
  • Dahlia Banerji
  • Leon M. Ptaszek
  • Carolyn Taylor
  • Joao D. Fontes
  • Matthias Kriegel
  • Thomas Irlbeck
  • John T. Nagurney
  • Udo Hoffmann
Original Paper


Twelve-lead surface electrocardiography (ECG) and computed tomography (CT) are used to evaluate for myocardial ischemia and coronary artery disease (CAD), respectively. We aimed to determine features on resting ECG that predict coronary artery stenosis by cardiac CT. In 309 acute chest pain patients, we compared the initial triage resting ECG to contrast-enhanced 64-slice cardiac CT angiography. We assessed for 6 quantitative (QT interval, QTc interval, QTc > 440 ms, gender-specific QTc, QT dispersion and QRS duration) and 4 qualitative ECG parameters (ST depression >0.05 to ≤0.1 mV, T wave inversion ≥0.1 mV, T wave flattening, and any T wave abnormalities) and for the presence of coronary stenosis by CT (>50% luminal narrowing). Specificities of these ECG parameters were excellent (83.6–97.0%) while sensitivities were poor (12.2–29.3%). For coronary stenosis detection, the ECG features with the greatest performance were the presence of ST depression (positive likelihood ratio [LR+] 4.09) and T wave inversion (LR+ 4.58). In multivariable analyses, the risk for coronary stenosis increased by 33–41% for every 20 ms prolongation of the QTc interval after adjusting for age, gender, and cardiac risk factors or adjustment for Framingham risk score. Similarly, there was an increase of fourfold with the presence of ST depression >0.05 to ≤0.1 mV or T wave inversion ≥0.1 mV. In acute chest pain patients, resting ECG features of QTc interval prolongation, mild ST depression, and T wave inversion are independently associated with the presence of CT coronary stenosis and their presence suggests an increase risk of CAD.


Electrocardiography Coronary artery stenosis Computed tomography Acute chest pain Emergency department 



Computed tomography




Coronary artery disease


Body mass index


Positive predictive value


Negative predictive value



This work was supported by the NIH R01HL080053, and in part supported by Siemens Medical Solutions and General Electrics Healthcare. Dr. Truong received support from NIH grants L30HL093896 and 1K23HL098370.

Conflict of interests

No conflicts of interest to be disclosed.


  1. 1.
    Veglio M, Borra M, Stevens LK, Fuller JH, Perin PC (1999) The relation between QTc interval prolongation and diabetic complications. The EURODIAB IDDM Complication Study Group. Diabetologia 42:68–75PubMedCrossRefGoogle Scholar
  2. 2.
    Veglio M, Bruno G, Borra M, Macchia G, Bargero G, D’Errico N, Pagano GF, Cavallo-Perin P (2002) Prevalence of increased QT interval duration and dispersion in type 2 diabetic patients and its relationship with coronary heart disease: a population-based cohort. J Intern Med 251:317–324PubMedCrossRefGoogle Scholar
  3. 3.
    Elhendy A, Hammill SC, Mahoney DW, Pellikka PA (2005) Relation of QRS duration on the surface 12-lead electrocardiogram with mortality in patients with known or suspected coronary artery disease. Am J Cardiol 96:1082–1088PubMedCrossRefGoogle Scholar
  4. 4.
    Festa A, D’Agostino R Jr, Rautaharju P, O’Leary DH, Rewers M, Mykkanen L, Haffner SM (1999) Is QT interval a marker of subclinical atherosclerosis in nondiabetic subjects? The Insulin Resistance Atherosclerosis Study (IRAS). Stroke 30:1566–1571PubMedCrossRefGoogle Scholar
  5. 5.
    Möhlenkamp S, Schmermund A, Lehmann N, Roggenbuck U, Dragano N, Stang A, Moebus S, Beck EM, Schluter C, Sack S, Meinertz T, Taylor A, Jockel KH, Erbel R (2008) Subclinical coronary atherosclerosis and resting ECG abnormalities in an unselected general population. Atherosclerosis 196:786–794PubMedCrossRefGoogle Scholar
  6. 6.
    Lancellotti P, Gerard PL, Kulbertus HE, Pierard LA (2002) Persistent negative T waves in the infarct-related leads as an independent predictor of poor long-term prognosis after acute myocardial infarction. Am J Cardiol 90:833–837PubMedCrossRefGoogle Scholar
  7. 7.
    Hayden GE, Brady WJ, Perron AD, Somers MP, Mattu A (2002) Electrocardiographic T-wave inversion: differential diagnosis in the chest pain patient. Am J Emerg Med 20:252–262PubMedCrossRefGoogle Scholar
  8. 8.
    Pan NH, Yang HY, Hsieh MH, Chen YJ (2008) Coronary calcium score from multislice computed tomography correlates with QT dispersion and left ventricular wall thickness. Heart Vessels 23:155–160PubMedCrossRefGoogle Scholar
  9. 9.
    Alexander KP, Newby LK, Armstrong PW, Cannon CP, Gibler WB, Rich MW, Van de Werf F, White HD, Weaver WD, Naylor MD, Gore JM, Krumholz HM, Ohman EM (2007) Acute coronary care in the elderly, part II: ST-segment-elevation myocardial infarction: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation 115:2570–2589PubMedCrossRefGoogle Scholar
  10. 10.
    Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE 2nd, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B (2007) ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol 50:e1–e157PubMedCrossRefGoogle Scholar
  11. 11.
    Straus SM, Kors JA, De Bruin ML, van der Hooft CS, Hofman A, Heeringa J, Deckers JW, Kingma JH, Sturkenboom MC, Stricker BH, Witteman JC (2006) Prolonged QTc interval and risk of sudden cardiac death in a population of older adults. J Am Coll Cardiol 47:362–367PubMedCrossRefGoogle Scholar
  12. 12.
    Lin KB, Shofer FS, McCusker C, Meshberg E, Hollander JE (2008) Predictive value of T-wave abnormalities at the time of emergency department presentation in patients with potential acute coronary syndromes. Acad Emerg Med 15:537–543PubMedCrossRefGoogle Scholar
  13. 13.
    Turnipseed SD, Trythall WS, Diercks DB, Laurin EG, Kirk JD, Smith DS, Main DN, Amsterdam EA (2009) Frequency of acute coronary syndrome in patients with normal electrocardiogram performed during presence or absence of chest pain. Acad Emerg Med 16:495–499PubMedCrossRefGoogle Scholar
  14. 14.
    Wong TW, Huang XH, Liu W, Ng K, Ng KS (2004) New electrocardiographic criteria for identifying the culprit artery in inferior wall acute myocardial infarction-usefulness of T-wave amplitude ratio in leads II/III and T-wave polarity in the right V5 lead. Am J Cardiol 94:1168–1171PubMedCrossRefGoogle Scholar
  15. 15.
    Snider RL, Pai RK, Kusumoto FM (2004) The importance of the evolution of ST-T wave changes for differentiating acute pericarditis from myocardial ischemia. Cardiol Rev 12:138–140PubMedCrossRefGoogle Scholar
  16. 16.
    Budoff MJ, Dowe D, Jollis JG, Gitter M, Sutherland J, Halamert E, Scherer M, Bellinger R, Martin A, Benton R, Delago A, Min JK (2008) Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial. J Am Coll Cardiol 52:1724–1732PubMedCrossRefGoogle Scholar
  17. 17.
    Miller JM, Rochitte CE, Dewey M, Arbab-Zadeh A, Niinuma H, Gottlieb I, Paul N, Clouse ME, Shapiro EP, Hoe J, Lardo AC, Bush DE, de Roos A, Cox C, Brinker J, Lima JA (2008) Diagnostic performance of coronary angiography by 64-row CT. N Engl J Med 359:2324–2336PubMedCrossRefGoogle Scholar
  18. 18.
    Mowatt G, Cook JA, Hillis GS, Walker S, Fraser C, Jia X, Waugh N (2008) 64-Slice computed tomography angiography in the diagnosis and assessment of coronary artery disease: systematic review and meta-analysis. Heart 94:1386–1393PubMedCrossRefGoogle Scholar
  19. 19.
    Hoffmann U, Bamberg F, Chae CU, Nichols JH, Rogers IS, Seneviratne SK, Truong QA, Cury RC, Abbara S, Shapiro MD, Moloo J, Butler J, Ferencik M, Lee H, Jang IK, Parry BA, Brown DF, Udelson JE, Achenbach S, Brady TJ, Nagurney JT (2009) Coronary computed tomography angiography for early triage of patients with acute chest pain: the ROMICAT (Rule Out Myocardial Infarction using Computer Assisted Tomography) trial. J Am Coll Cardiol 53:1642–1650PubMedCrossRefGoogle Scholar
  20. 20.
    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 (2006) Coronary multidetector computed tomography in the assessment of patients with acute chest pain. Circulation 114:2251–2260PubMedCrossRefGoogle Scholar
  21. 21.
    Miller JM, Dewey M, Vavere AL, Rochitte CE, Niinuma H, Arbab-Zadeh A, Paul N, Hoe J, de Roos A, Yoshioka K, Lemos PA, Bush DE, Lardo AC, Texter J, Brinker J, Cox C, Clouse ME, Lima JA (2009) Coronary CT angiography using 64 detector rows: methods and design of the multi-centre trial CORE-64. Eur Radiol 19:816–828PubMedCrossRefGoogle Scholar
  22. 22.
    Kramer B, Brill M, Bruhn A, Kubler W (1986) Relationship between the degree of coronary artery disease and of left ventricular function and the duration of the QT-interval in ECG. Eur Heart J 7:14–24PubMedGoogle Scholar
  23. 23.
    Chugh SS, Reinier K, Singh T, Uy-Evanado A, Socoteanu C, Peters D, Mariani R, Gunson K, Jui J (2009) Determinants of prolonged QT interval and their contribution to sudden death risk in coronary artery disease: the Oregon Sudden Unexpected Death Study. Circulation 119:663–670PubMedCrossRefGoogle Scholar
  24. 24.
    Michaelides AP, Liakos CI, Raftopoulos LG, Antoniades C, Vyssoulis G, Andrikopoulos G, Ioakeimides N, Tsioufis C, Soulis D, Stefanadis C (2009) Electrocardiographic criteria for detecting coronary artery disease in hypertensive patients with ST-segment changes during exercise testing. J Electrocardiol 42:405–409PubMedCrossRefGoogle Scholar
  25. 25.
    Lin FY, Saba S, Weinsaft JW, Wong FJ, Szulc M, Kligfeld P, Okin PM, Berman DS, Shaw LJ, Min JK (2009) Relation of plaque characteristics defined by coronary computed tomographic angiography to ST-segment depression and impaired functional capacity during exercise treadmill testing in patients suspected of having coronary heart disease. Am J Cardiol 103:50–58PubMedCrossRefGoogle Scholar
  26. 26.
    Capewell S, O’Flaherty M, Ford ES, Critchley JA (2009) Potential reductions in United States coronary heart disease mortality by treating more patients. Am J Cardiol 103:1703–1709PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, B.V. 2011

Authors and Affiliations

  • Quynh A. Truong
    • 1
    • 2
  • Dahlia Banerji
    • 1
  • Leon M. Ptaszek
    • 2
  • Carolyn Taylor
    • 1
  • Joao D. Fontes
    • 1
  • Matthias Kriegel
    • 1
  • Thomas Irlbeck
    • 1
  • John T. Nagurney
    • 3
  • Udo Hoffmann
    • 1
  1. 1.Cardiac MR PET CT ProgramMassachusetts General Hospital and Harvard Medical SchoolBostonUSA
  2. 2.Division of CardiologyMassachusetts General Hospital, Harvard Medical SchoolBostonUSA
  3. 3.Department of Emergency MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonUSA

Personalised recommendations