The diagnosis and treatment of acute coronary syndrome remain a challenge for clinicians in many clinical settings, especially in patients with previous low-to-intermediate risk. Due to its high specificity and sensitivity for detecting significant coronary artery stenoses, cardiac computed tomography angiography (CCTA) tends to be used more frequently in the emergency room (ER) in the last years. This technique has been associated with a higher rate of safe discharge in patients with chest pain, less time spent in the ER, and decreased costs related to further investigations. In cases positive for coronary artery stenosis, CCTA can accurately evaluate the indication for percutaneous coronary angioplasty and can offer relevant information related to the characteristics of the coronary plaques, being able to detect vulnerable coronary plaques. The aim of this manuscript is to highlight the possibility of using CCTA in the ER in the assessment of patients with chest pain and to show the benefits of the procedure regarding safety, costs, accuracy, and time.
Computed tomography (CT) in cardiac examination is a powerful imaging tool that has developed rapidly during the last decade and continues to increase its potential by bringing novel technologies. Due to its noninvasive character, cardiac CT became a largely used method in detecting coronary diseases or functional issues at the expense of conventional coronary angiography. The accuracy of images has also increased, especially since new generation dual-source multi-slice detectors were developed. Although there are continuous improvements that serve to gain better-quality images, thus increasing their diagnostic accuracy, there is an inconvenient that became a serious topic for debate in the current literature: exposure to higher doses of radiation during cardiac CT examinations. Fortunately, physicians and manufacturers are taking into consideration the need to apply new strategies for radiation dose-reduction. Thus, this objective can be achieved by using patient-tailored dose-reduction strategies and by modulating the technical features of the CT scanners in order to gather highquality images with minimal radiation exposure. The aim of this manuscript was to review the current literature data on dose-reduction strategies that are used for cardiovascular computed tomography scans.
Given the higher amount of detail it offers, the use of magnetic resonance (MR) in the field of cardiology has increased, thus leading to a decrease in the use of invasive and irradiating methods for diagnosing various cardiovascular disorders. The only precautions for MR imaging are metallic implants and advanced-stage chronic kidney disease. For the acquisition of clear and dynamic myocardial images, methods such as spin echo imaging for anatomical description, steady-state free precession imaging for the assessment of ventricular cavity size and function, flow velocity encoding for blood flow measurements, radiofrequency tagging for dynamics, and even spectroscopy for metabolism evaluation are used. Cardiac magnetic resonance (CMR) is considered the gold standard imaging method for the anatomical characterization of the heart and obtaining information related to myocardial dynamics. In case of ischemic events, CMR is used for a detailed description of the necrotic area and the complications, and for tracking the ventricular remodeling. By administrating a contrast agent (gadolinium), the difference between sub-endothelial and transmural infarctions can be distinguished, highlighting even microvascular lesions responsible for the extension of the necrosis. The assessment of the dynamics of ventricular remodeling and viability through late gadolinium enhancement (LGE) technology highlights the area of fibrosis and the occurrence of late complications.
We present the case of a 34-year-old male patient, hypertensive, smoker, and diabetic, who was admitted from the Emergency Unit where he presented for typical angina pectoris with several days onset, heightened on the day of admission. In the context of typical signs and symptoms for acute coronary syndrome, the physical examination revealed arterial hypertension (blood pressure value of 140/70 mmHg) with high additional cardiovascular risk. The laboratory tests revealed elevated levels of serum biomarkers characterizing renal function (urea 58 mg/dL, creatinine 1.15 mg/dL), mild anemia (hemoglobin 9.6-11 g/dL), and a positive troponin level, while all other cardiac enzyme levels were in normal ranges. An electrocardiogram was performed, which revealed normal sinus rhythm, with a frequency of 65 beats per minute, left axis deviation, hyperacute T waves in leads V1 to V4, and right bundle branch block (Panel A). In order to assess the presence of possible coronary artery lesions in this patient with a high cardiovascular risk due to multiple comorbidities, an invasive coronary angiography was performed. The examination was well-tolerated, without any complications. Upon coronary angiography, no thrombotic lesion was revealed, and one non-significant lesion was described on the anterior descending artery (40%), without indication for revascularization. However, at this level, an unusual persistence of the iodinated contrast agent was revealed (Panel B). In order to certify the real origin of the chest pain that appeared recently in a young patient with multiple comorbidities (type 2 diabetes mellitus, high blood pressure, obesity, dyslipidemia), an optical coherence tomography (OCT) examination was performed to evaluate in detail the coronary system and to detect a possible vulnerable plaque responsible for the symptoms. The OCT examination described a 2 cm long vulnerable plaque with inflammatory cells and spontaneous dissecIoana Rodean • Str. 22 Decembrie 1989 nr. 76,
For a better assessment of ischemic heart diseases, myocardial viability should be quantified. Current studies underline the importance and the evolution of several techniques and methods used in the evaluation of myocardial viability. Taking into account these considerations, the aim of this manuscript was to present the recent points of view regarding myocardial viability and its clinical significance in patients with ischemic cardiomyopathies and left ventricular dysfunction. On the other hand, the manuscript points out the role of magnetic resonance imaging (MRI), one of the most useful noninvasive imaging techniques, in the assessment of myocardial viability. By comparing the advantages and disadvantages of cardiac MRI, its usefulness can be better appreciated by the clinician. In the following years, it is considered that MRI will be an indispensable imaging tool in the assessment of ischemic heart disease, guiding interventions for revascularization and long-term risk stratification in patients with stable angina or myocardial infarction.
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