Cardiac CT in emergency department patients with acute chest pain
Udo Hoffmann1, Antonio J Pena, Ricardo C Cury
1Department of Radiology, Massachusetts General Hospital, 165 Charles River Plaza, Suite 400, Boston, MA 02114, USA. uhoffman@partners.org
Insights
Current chest pain triage is inefficient, leading to unnecessary hospital admissions. Multidetector computed tomography (CT) shows promise for accurately assessing coronary artery disease and improving patient management.
Area of Science:
- Cardiology
- Radiology
- Emergency Medicine
Background:
- Inefficient triage of chest pain patients with normal initial tests leads to millions of unnecessary hospital admissions annually in the US.
- Standard work-up lacks information on coronary artery disease presence and extent, contributing to diagnostic uncertainty and high costs.
- Missed acute coronary syndromes carry fatal consequences and significant malpractice costs.
Purpose of the Study:
- To evaluate the role of multidetector computed tomography (CT) in risk stratification for patients with chest pain.
- To assess the accuracy of multidetector CT in detecting coronary artery stenosis and characterizing atherosclerotic plaque.
- To explore the potential of multidetector CT in improving triage and cost-effectiveness for acute chest pain management.
Main Methods:
- Review of current strategies for chest pain triage and diagnostic limitations.
- Analysis of data on selective coronary angiography for acute coronary syndrome diagnosis.
- Evaluation of preliminary findings on 16- and 64-section multidetector CT for coronary artery stenosis and plaque detection.
Main Results:
- Selective coronary angiography detects significant stenosis in 80%-94% of acute coronary syndrome patients.
- Multidetector CT demonstrates high diagnostic accuracy for significant coronary artery stenosis in stable angina.
- Preliminary data suggest multidetector CT can quantify and characterize coronary plaque, correlating well with intravascular ultrasonography.
Conclusions:
- Multidetector CT offers accurate information on coronary artery disease presence.
- Further large blinded observational studies are needed to identify CT characteristics for acute coronary syndrome diagnosis.
- Randomized controlled trials are warranted to determine if multidetector CT improves triage, reduces costs, or increases cost-effectiveness.
Abstract:
Current strategies for the triage of patients who have chest pain but normal initial cardiac enzyme levels and nondiagnostic electrocardiograms do not permit efficient risk stratification. The potentially fatal consequences and high malpractice costs of missed acute coronary syndromes lead every year to the unnecessary hospital admission of about 2.8 million patients who present with acute chest pain in emergency departments in the United States. Most of these patients are at very low risk for an acute coronary syndrome. However, the standard clinical work-up does not provide information about the presence and extent of coronary artery disease. In most patients (80%-94%) with an acute coronary syndrome, a significant coronary artery stenosis can be detected with selective coronary angiography. High levels of diagnostic accuracy also have been established for the detection of significant coronary artery stenosis with the use of 16- and 64-section multidetector computed tomography (CT) in patients with stable angina. Preliminary data indicate that multidetector CT also can help quantify and characterize coronary atherosclerotic plaque and that the CT findings are in good agreement with those at intravascular ultrasonography. Although multidetector CT provides accurate information about the presence of coronary artery disease, large blinded observational studies are warranted to identify CT characteristics with high accuracy for diagnosis of acute coronary syndromes. Such information would enable the conduct of randomized controlled trials to determine whether the detection of coronary stenosis and plaque with multidetector CT improves triage and reduces the costs or increases the cost-effectiveness of management of acute chest pain.
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