Chest Pain in the Emergency Department: Role of Multidetector CT

Abstract

The development of newer generations of multidetector computed tomographic (CT) scanners capable of enabling accurate assessment of the coronary arteries in conjunction with the increasing placement of CT scanners near the emergency department has raised interest in using CT to provide a comprehensive imaging evaluation of patients presenting with acute chest pain. In this article, the authors review the challenges surrounding the current clinical and imaging work-up of chest pain in the emergency room and provide a framework for understanding the potential role of CT.

Is Computed Tomography Coronary Angiography the Most Accurate and Effective Noninvasive Imaging Tool to Evaluate Patients With Acute Chest Pain in the Emergency Department?

“…10 Despite the passing of several years since the dissemination of 64-slice CT machines, there are still few published reports of CTA in ED patients; many of these studies have small numbers of patients, often fewer than 100. [11][12][13][14][15][16] Additionally, none of the trials have been multicenter investigations, although several such studies are underway. Furthermore, few trials have been adequately randomized or controlled to eliminate either selection or treatment bias.…”

“…This is extremely important when attempting to define which cohort of patients is best suited for this new technology. Although some trials focused on low-risk patients, 13 20 Additionally, many studies excluded patients with known CAD, 13,15,17,19 thereby limiting applicability for many ED patients.…”

“…The most definitive and probably useful measure for the value of CCTA in ED patients would be a final diagnosis of an ACS, based on biomarkers and ECG findings. However, this end point was used in few trials, 13,20 and the actual frequency of ACS in several studies was zero, probably because of the low-risk cohort. 13,17,21 In 1 of the larger trials of CCTA in the ED, Hollander et al 17 examined more than 500 low-risk patients (low TIMI score and nonischemic ECG) and demonstrated that 84% of patients could be discharged after CCTA, with no cardiac events in the 30-day follow-up period.…”

“…11,13,14,22 However, combined end points may be misleading because they may not truly reflect the ability of CCTA to risk-stratify potential patients with ACS. One of the key concerns with much of the CCTA/ACS literature is the use or incorporation of an anatomic end point, based on ICA.…”

“…Uninterpretable areas on 64-slice CCTA may lead to the inability to evaluate 6% to 11% of patients with chest pain. 9,11,13,21,33 Prominent calcification, even when limited in scope, may cause a "blooming" artifact, preventing accurate interpretation of that segment (Figure 2). Excessive cardiac motion, potentially related to excessive heart rate, may cause a motion artifact, with degradation of imaging quality and "banding" 34 ( Figure 1).…”