Myocardial Late Contrast Enhancement CT in Troponin-Positive Acute Chest Pain Syndrome

Abstract

cute chest pain or anginal equivalents associated with mild troponin rise remain a diagnostic challenge, particularly in patients at low to intermediate risk for acute coronary syndrome. Coronary CT angiography can be used to safely triage these patients (1,2). In previous large multicenter trials with participants with acute chest pain at low to intermediate pretest risk of acute coronary syndrome, coronary CT angiography was associated with higher detection of coronary artery disease (CAD) (3), shorter length of stay (3,4), and higher rate of discharge (3,4) compared with the standard of care, without an increase in major adverse events at 28 days (4) and at a longer follow-up (5). Acute aortic syndrome, pulmonary embolism, and CAD can be simultaneously ruled out with use of a triple-rule-out (TRO) CT protocol (6,7). However, a TRO CT study cannot help identify nonvascular causes of acute myocardial injury (8). In patients with troponin-positive acute chest pain and unobstructed coronary arteries, cardiac MRI was found to provide a diagnosis in 74%-95% (9-12), identifying myocarditis, takotsubo cardiomyopathy, and myocardial infarction with nonobstructed coronary arteries as the most frequent causes of symptoms and alteration in cardiac biologic markers (10-12). Cardiac MRI was found to change the Background: Acute chest pain with mild troponin rise and inconclusive diagnosis after clinical evaluation represents a diagnostic challenge. Triple-rule-out (TRO) CT may exclude coronary artery disease (CAD), as well as acute aortic syndrome and pulmonary embolism, but cannot help identify other causes of myocardial injury.Purpose: To investigate the diagnostic value of a comprehensive CT protocol including both an angiographic and a late contrast enhancement (LCE) scan in participants with troponin-positive acute chest pain. Materials and Methods:In this prospective study, consecutive patients with troponin-positive acute chest pain or anginal equivalent and inconclusive diagnosis after clinical evaluation (symptoms, markers, electrocardiography, and echocardiography) who underwent TRO CT between June 2018 and September 2020 were enrolled. TRO CT was performed to evaluate the presence of obstructive CAD (stenosis 50%), acute aortic syndrome, and pulmonary embolism. If the findings on the TRO CT scan were negative, an LCE CT scan was acquired after 10 minutes to assess the presence and pattern of scar and quantify the myocardial extracellular volume fraction. CT-based diagnoses were compared with diagnoses obtained with reference standard methods, including invasive coronary angiography, cardiac MRI, and endomyocardial biopsy.Results: Eighty-four patients (median age, 69 years [interquartile range, 50-77 years]; 45 men) were enrolled. TRO CT helped identify obstructive CAD in 35 participants (42%), acute aortic syndrome in one (1.2%), and pulmonary embolism in six (7.1%). LCE CT scans were acquired in the remaining 42 participants. The following diagnoses were reached with use of LCE CT: myocarditis (22 of 42 partici...

Advanced cardiac imaging in the spectrum of COVID-19 related cardiovascular involvement

“…However, Stefanini et al found out that 39% of COVID-19 patients with STEMI had negative invasive coronary angiography (ICA) probably for the higher prevalence of type-2 MI in patients during the acute phase of COVID-19. These data further supported the use of CCTA in COVID-19 patients [47], also having the advantage to simultaneously rule-out coronary artery disease (CAD) and pulmonary embolism (PE) using a triple rule-out scanning protocol [23,24] and to refine risk stratification of COVID-19 patients with the quantification of coronary artery calcium score (CAC) [7,9,10,16,25,48].…”

“…CT assessment offers the additional advantage of COVID-19 pneumonia severity assessment [1] and to reveal subclinical CV risk factors such as liver steatosis [49], myosteatosis [50], and epicardial fat volume and attenuation [11,51]. Finally, CT may offer the opportunity to characterize myocardial scar and extracellular volume fraction (ECV) with the addition of a late contrast enhancement scan [23,24,52,53]. This may be particularly useful and effective especially in the emergency setting [23], providing a full range of diagnosis with a single examination requiring few minutes, without the need of CMR [24] (Fig.…”

“…CT has a pivotal rule in ruling-out coronary artery disease and pulmonary embolism. Vascular evaluation may be coupled with the assessment of pneumonia severity and to myocardial tissue characterization, excluding myocardial scars [23,24]. Additionally, CT may provide quantitative information about subclinical comorbidities or COVID-19 related complications capable of improving risk stratification of COVID-19 patients [7,9,10,[25][26][27] (Fig.…”

Symptomatic Young Adults with ST-Segment Elevation—Acute Coronary Syndrome or Myocarditis: The Three-Factor Diagnostic Model

“…Additionally, CT (computed tomography) is increasingly enumerated beside MRI as an alternative imaging tool for estimation of myocardial oedema or myocardial fibrosis, particularly in those with contraindications to the latter. Several studies have demonstrated that, similarly to MRI, in CT imaging the late contrast enhancement may visualise the difference between the normal and damaged myocardium [26,27].…”

“…Both diseases might be presented with increased levels of cardiac serum enzymes and inflammatory biomarkers [4,32,33]. However, a TnT level within normal limits does not exclude the diagnosis of myocarditis but may constitute a prognostic factor of a better outcome [27,34,35]. Serum cardiac biomarkers are routinely measured in patients presenting with chest pain in ED.…”