Imaging in the evaluation of the patient with suspected acute coronary syndrome

Patients presenting to the emergency department with chest pain have a common problem. Definitive diagnosis at presentation is difficult due to limitations of the initial evaluation, and, thus, the majority of patients are admitted. Recognition of these limitations has driven the investigation of alternative evaluation techniques and protocols to attempt to improve diagnostic sensitivity without increasing overall costs. Acute myocardial perfusion imaging has been a highly valuable technique for risk stratification of intermediate to low-risk patients with chest pain. However, for a variety of reasons, it has not been widely embraced. In the past few years, alternative techniques have been investigated for use in the diagnosis of acute coronary syndromes in the acute setting. Coronary calcium scoring and cardiac magnetic resonance imaging show promise as new tools in the armamentarium for acute coronary syndromes. The challenge now lays in developing a strategy that uses these and future techniques most appropriately to support optimal medical decision making.