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Published on: August 28, 2018
Clinical assessment of chest pain and guidelines for imaging
J Gruettner1, T Henzler, T Sueselbeck
11st Department of Medicine (Cardiology), University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany. joachim.gruettner@umm.de
Insights
Standardized cardiac diagnostics help emergency facilities assess chest pain patients. Advanced imaging like cardiac CT angiography (CCTA) aids in ruling out coronary artery disease and other serious conditions.
Area of Science:
- Cardiology
- Emergency Medicine
- Diagnostic Imaging
Background:
- Risk assessment for patients with diffuse chest pain is a significant challenge in emergency settings.
- International cardiological societies provide standardized recommendations for assessing cardiac risk criteria.
Purpose of the Study:
- To outline standardized diagnostic approaches for chest pain patients in emergency facilities.
- To highlight the role of basic cardiac diagnostics, advanced imaging, and differential diagnosis in managing acute coronary syndrome and related conditions.
Main Methods:
- Standardized assessment including case history (cardiac risk factors), physical examination (vital parameters), ECG (ST segment analysis), and laboratory markers (troponin levels).
- Percutaneous catheterization for high-risk patients.
- Non-invasive diagnostic methods for intermediate/low-risk patients: stress testing (physical/pharmacological) with scintigraphy, echocardiography, or magnetic resonance imaging.
- Cardiac CT angiography (CCTA) for non-invasive coronary imaging.
- Thoracic CT for differential diagnoses like pulmonary embolism and aortic dissection, potentially with CCTA for triple rule-out.
Main Results:
- Basic diagnostics are paramount for stratifying cardiac risk.
- Timely percutaneous catheterization is indicated for high-risk patients.
- Non-invasive methods can safely discharge intermediate/low-risk patients after excluding coronary syndrome.
- Cardiac CT angiography (CCTA) effectively rules out coronary heart disease in intermediate/low-risk patients.
- Thoracic CT is the preferred method for diagnosing pulmonary embolism and aortic dissection.
Conclusions:
- A standardized diagnostic pathway improves emergency care for chest pain patients.
- Non-invasive imaging, particularly CCTA, plays a crucial role in risk stratification and diagnosis.
- Comprehensive evaluation including differential diagnoses is essential for optimal patient management.
Abstract:
For many emergency facilities, risk assessment of patients with diffuse chest pain still poses a major challenge. In their currently valid recommendations, the international cardiological societies have defined a standardized assessment of the prognostically relevant cardiac risk criteria. Here the classic sequence of basic cardiac diagnostics including case history (cardiac risk factors), physical examination (haemodynamic and respiratory vital parameters), ECG (ST segment analysis) and laboratory risk markers (troponin levels) is paramount. The focus is, on the one hand, on timely indication for percutaneous catheterization, especially in patients at high cardiac risk with or without ST-segment elevation in the ECG, and, on the other hand, on the possibility of safely discharging patients with intermediate or low cardiac risk after non-invasive exclusion of a coronary syndrome. For patients in the intermediate or low risk group, physical or pharmacological stress testing in combination with scintigraphy, echocardiography or magnetic resonance imaging is recommended in addition to basic diagnostics. Moreover, the importance of non-invasive coronary imaging, primarily cardiac CT angiography (CCTA), is increasing. Current data show that in intermediate or low risk patients this method is suitable to reliably rule out coronary heart disease. In addition, attention is paid to the major differential diagnoses of acute coronary syndrome, particularly pulmonary embolism and aortic dissection. Here the diagnostic method of choice is thoracic CT, possibly also in combination with CCTA aiming at a triple rule-out.
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