Chest pain CT in the Emergency Department: evaluating the coronary arteries even when not specifically asked for?

Abstract

Background

Computed tomography (CT) for excluding acute aortic syndrome (AAS) and pulmonary embolism (PE) simultaneously in patients with chest pain could be used to exclude coronary artery disease (CAD).

Purpose

To evaluate the frequency of further testing for CAD in patients receiving a CT in the emergency department (ED) for simultaneous evaluation for AAS and PE.

Material and Methods

This retrospective study was conducted over a three-year period including all patients with acute chest pain visiting our ED. All patients were included that received an electrocardiography (ECG)-gated CT of the entire chest enquiring simultaneously for AAS and PE. Those patients were followed up for 30 days after their initial ED visit whether they received further testing for CAD.

Results

Within the study period, a total of 157 patients with acute chest pain received a chest pain CT for simultaneous evaluation of both AAS and PE. Image quality was deemed sufficient to evaluate the coronary arteries in 80% of the patients. Thirty-seven patients (24%) underwent additional testing for CAD within 30 days of their ED visit, including catheter coronary angiography (n = 25), cardiac-stress single-photon emission-CT (n = 6), and cardiac magnetic resonance imaging (MRI) (n = 6).

Conclusion

Of patients presenting to the ED with acute chest pain who received a chest pain CT for simultaneous evaluation of AAS and PE, 24% had further imaging for CAD within 30 days of the initial ED visit. Immediate evaluation of the coronary arteries as part of a chest pain CT should be considered here for not delaying diagnosis.

Keywords

Cardiac computed tomography CT aorta

Get full access to this article

View all access options for this article.

References

Hamburger

Spertus

Winchester

. Utility of the Diamond-Forrester classification in stratifying acute chest pain in an academic chest pain center. Crit Pathw Cardiol 2016; 15: 56–59.

Roe

Harrington

Prosper

et al.

Clinical and therapeutic profile of patients presenting with acute coronary syndromes who do not have significant coronary artery disease. The Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) Trial Investigators. Circulation 2000; 102: 1101–1106.

Lee

Goldman

. Evaluation of the patient with acute chest pain. N Engl J Med 2000; 342: 1187–1195.

Morley

Muir

Mirsadraee

et al.

Ten years of imaging for pulmonary embolism: too many scans or the tip of an iceberg?

Clin Radiol 2015; 70: 1370–1375.

Hoffmann

Truong

Schoenfeld

et al.

Coronary CT angiography versus standard evaluation in acute chest pain. N Engl J Med 2012; 367: 299–308.

Iyengar

Morgan-Hughes

Ukoumunne

et al.

Diagnostic accuracy of high-definition CT coronary angiography in high-risk patients. Clin Radiol 2016; 71: 151–158.

Madder

Raff

Hickman

et al.

Comparative diagnostic yield and 3-month outcomes of “triple rule-out” and standard protocol coronary CT angiography in the evaluation of acute chest pain. J Cardiovasc Comput Tomogr 2011; 5: 165–171.

Rogers

Banerji

Siegel

et al.

Usefulness of comprehensive cardiothoracic computed tomography in the evaluation of acute undifferentiated chest discomfort in the emergency department (CAPTURE). Am J Cardiol 2011; 107: 643–650.

Halpern

Levin

Zhang

et al.

Comparison of image quality and arterial enhancement with a dedicated coronary CTA protocol versus a triple rule-out coronary CTA protocol. Acad Radiol 2009; 16: 1039–1048.

10.

Chinnaiyan

Bilolikar

Walsh

et al.

CT dose reduction using prospectively triggered or fast-pitch spiral technique employed in cardiothoracic imaging (the CT dose study). J Cardiovasc Comput Tomogr 2014; 8: 205–214.

11.

Durmus

Rogalla

Lembcke

et al.

Low-dose triple-rule-out using 320-row-detector volume MDCT–less contrast medium and lower radiation exposure. Eur Radiol 2011; 21: 1416–1423.

12.

Rogg

De Neve

Huang

et al.

The triple work-up for emergency department patients with acute chest pain: how often does it occur?

J Emerg Med 2011; 40: 128–134.

13.

Zhang

Zhao

et al.

Diagnostic performance of dual-source CT coronary angiography with and without heart rate control: systematic review and meta-analysis. Clin Radiol 2014; 69: 163–171.

14.

Leschka

Scheffel

Desbiolles

et al.

Image quality and reconstruction intervals of dual-source CT coronary angiography: recommendations for ECG-pulsing windowing. Investigative radiology 2007; 42: 543–549.

15.

Diamond

. A clinically relevant classification of chest discomfort. J Am Coll Cardiol 1983; 1: 574–575.

16.

Taylor

Cerqueira

Hodgson

et al.

ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 Appropriate Use Criteria for Cardiac Computed Tomography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Cardiovasc Comput Tomogr 2010; 4: 407.e1–33.

17.

von Ballmoos

Haring

Juillerat

et al.

Meta-analysis: diagnostic performance of low-radiation-dose coronary computed tomography angiography. Ann Intern Med 2011; 154: 413–420.

18.

Frauenfelder

Appenzeller

Karlo

et al.

Triple rule-out CT in the emergency department: protocols and spectrum of imaging findings. European radiology 2009; 19: 789–799.

19.

Tonino

Fearon

De Bruyne

et al.

Angiographic versus functional severity of coronary artery stenoses in the FAME study fractional flow reserve versus angiography in multivessel evaluation. J Am Coll Cardiol 2010; 55: 2816–2821.

20.

Hinzpeter

Higashigaito

Morsbach

et al.

Coronary artery calcium scoring for ruling-out acute coronary syndrome in chest pain CT. Am J Emerg Med 2017; 35: 1565–1567.