Chest pain CT in the emergency department: Watch out for the myocardium

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Kai Higashigaito1, Ricarda Hinzpeter1, Stephan Baumueller1

  • 1Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Switzerland.

European Journal of Radiology Open
|November 21, 2018
PubMed

Insights

Hypodense myocardium (HM) is frequently found in chest pain CT scans, even when acute myocardial infarction (MI) is not suspected. This finding highlights the importance of analyzing myocardial regions for hypodensity in all chest pain CTs.

Area of Science:

  • Radiology
  • Cardiology
  • Emergency Medicine

Background:

  • Hypodense myocardium (HM) is a CT imaging finding that can indicate myocardial infarction (MI).
  • Chest pain CT scans are commonly performed in emergency departments (EDs) to evaluate acute chest pain.
  • The diagnostic utility of HM in chest pain CTs, particularly when acute coronary syndrome is not initially suspected, requires further evaluation.

Purpose of the Study:

  • To determine the frequency and clinical significance of hypodense myocardium (HM) detected in emergency department (ED) chest pain CT examinations.
  • To assess the prevalence of HM in chest pain CTs performed with and without coronary artery imaging.
  • To evaluate the association of HM with acute myocardial infarction (MI) and previous MI.

Main Methods:

  • Retrospective analysis of 300 consecutive ECG-gated chest pain CT examinations in patients presenting to the ED.
  • Patients underwent chest pain CT with coronary artery imaging (n=121) or without (n=179) after excluding ST-elevation MI.
  • Myocardial segments were assessed for HM, with attenuation values compared to normal myocardium.

Main Results:

  • Hypodense myocardium (HM) was identified in 9% of patients (27/300).
  • HM was detected in 7% of chest pain CTs without coronary imaging (12/179) and 12% with coronary imaging (15/121).
  • In 55.6% of patients with HM, the final diagnosis was acute MI; previous MI was noted in 44.4%. Chest pain CT without coronary imaging detected HM in 66.6% of acute MI cases.

Conclusions:

  • Hypodense myocardium (HM) is frequently encountered in chest pain CTs within the ED, often indicating acute MI.
  • HM is detectable even in chest pain CTs performed without coronary artery imaging, suggesting its utility when MI is not initially suspected.
  • Continuous analysis of myocardial regions for hypodense areas is recommended in all chest pain CT examinations, regardless of initial suspicion for MI.
Abstract

Keywords:
AAC/AHA, American College of Cardiology / American Heart AssociationAAS, acute aortic syndromeACS, acute coronary syndromeAcute chest painBPM, beats per minuteCAD, coronary artery diseaseCI, confidence intervalCT, computed tomographyCX, circumflex arteryCardiacComputed tomographyECG, electrocardiographyED, emergency departmentEmergency departmentHU, hounsfield unitICC, intraclass correlation coefficientsLAD, left anterior descending arteryMH, hypodense myocardiumMI, myocardial infarctionNPV, negative predictive valueNSTEMI, non-ST elevation myocardial infarctionPE, pulmonary embolismPPV, positive predictive valueRCA, right coronary arteryROI, region of interest

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