CT Rule-Out for Chest Pain

The multitude of patients arriving in emergency departments with chest pain symptoms poses an almost unsolvable problem for triaging physicians. Identifying patients with bona fide ischemia, and differentiating them from patients with a pulmonary embolus or a dissecting aneurysm, is a recurring clinical dilemma.

The development of the 64-slice multidetector CT provides a new technology for the evaluation of emergency department patients with chest pain. It also may have an important role in ruling out many patients seen in the outpatient clinic with chest pain symptoms. In the emergency department, however, perplexing symptoms continue to burden staff with the need to conduct expensive and labor-intensive procedures to make certain that their patients will not be reassured, only to die in the parking lot. The need to prevent a disaster often leads to unnecessary hospitalization and can result in expensive testing and coronary angiography. Although acute coronary syndrome is in the forefront of the diagnostic possibilities facing the emergency physician, lurking in the background are the other two deadly diagnoses: pulmonary embolism and dissecting aneurysm. It may be comforting to think that with one test, we can deal with all three high-risk diagnostic possibilities.

It appears that “fast CT” goes a long way in confirming or ruling out these three entities. A number of important clinical studies are underway that compare CT with standard diagnostic techniques, including stress echocardiography, nuclear imaging, and coronary angiography. Results so far have been very encouraging, but we will need more clinical data to support these initial studies. The fast CT is relatively easy to perform, with few contraindications, although it does require dye injection and some considerable radiation. Regular sinus rhythm at a moderate heart rate is also a requirement. Currently, the cost of the procedure is in the $1,000-$1,500 range, which is comparable to costs for other cardiac tests.

The ideal candidates for CT imaging and the “triple rule-out” will be those patients with low probability of ischemic disease who have chest pain symptoms of uncertain cause. These patients may represent approximately a quarter of all patients seen in the emergency department with chest pain. Current CT technology will have marginal importance in patients with known coronary artery disease. For them, more definitive imaging will be needed to describe and evaluate anatomic abnormalities. The ability to measure definitive changes in coronary anatomy still requires further refinement in CT imaging. Future developments may overcome this limitation. Assessment of the functional importance of anatomic lesions also will depend on stress nuclear or echocardiography imaging.

CT has an important role in defining coronary anomalies, and it may provide easy access to the imaging of coronary stents and bypass grafts. However, for confirmation of the presence of noncritical coronary artery disease, pulmonary embolism, and dissecting aneurysm, fast CT may well be the diagnostic technique of choice that can provide the answer to the triple rule-out.

The multitude of patients arriving in emergency departments with chest pain symptoms poses an almost unsolvable problem for triaging physicians. Identifying patients with bona fide ischemia, and differentiating them from patients with a pulmonary embolus or a dissecting aneurysm, is a recurring clinical dilemma.

The development of the 64-slice multidetector CT provides a new technology for the evaluation of emergency department patients with chest pain. It also may have an important role in ruling out many patients seen in the outpatient clinic with chest pain symptoms. In the emergency department, however, perplexing symptoms continue to burden staff with the need to conduct expensive and labor-intensive procedures to make certain that their patients will not be reassured, only to die in the parking lot. The need to prevent a disaster often leads to unnecessary hospitalization and can result in expensive testing and coronary angiography. Although acute coronary syndrome is in the forefront of the diagnostic possibilities facing the emergency physician, lurking in the background are the other two deadly diagnoses: pulmonary embolism and dissecting aneurysm. It may be comforting to think that with one test, we can deal with all three high-risk diagnostic possibilities.

It appears that “fast CT” goes a long way in confirming or ruling out these three entities. A number of important clinical studies are underway that compare CT with standard diagnostic techniques, including stress echocardiography, nuclear imaging, and coronary angiography. Results so far have been very encouraging, but we will need more clinical data to support these initial studies. The fast CT is relatively easy to perform, with few contraindications, although it does require dye injection and some considerable radiation. Regular sinus rhythm at a moderate heart rate is also a requirement. Currently, the cost of the procedure is in the $1,000-$1,500 range, which is comparable to costs for other cardiac tests.

The ideal candidates for CT imaging and the “triple rule-out” will be those patients with low probability of ischemic disease who have chest pain symptoms of uncertain cause. These patients may represent approximately a quarter of all patients seen in the emergency department with chest pain. Current CT technology will have marginal importance in patients with known coronary artery disease. For them, more definitive imaging will be needed to describe and evaluate anatomic abnormalities. The ability to measure definitive changes in coronary anatomy still requires further refinement in CT imaging. Future developments may overcome this limitation. Assessment of the functional importance of anatomic lesions also will depend on stress nuclear or echocardiography imaging.

CT has an important role in defining coronary anomalies, and it may provide easy access to the imaging of coronary stents and bypass grafts. However, for confirmation of the presence of noncritical coronary artery disease, pulmonary embolism, and dissecting aneurysm, fast CT may well be the diagnostic technique of choice that can provide the answer to the triple rule-out.

The multitude of patients arriving in emergency departments with chest pain symptoms poses an almost unsolvable problem for triaging physicians. Identifying patients with bona fide ischemia, and differentiating them from patients with a pulmonary embolus or a dissecting aneurysm, is a recurring clinical dilemma.

The development of the 64-slice multidetector CT provides a new technology for the evaluation of emergency department patients with chest pain. It also may have an important role in ruling out many patients seen in the outpatient clinic with chest pain symptoms. In the emergency department, however, perplexing symptoms continue to burden staff with the need to conduct expensive and labor-intensive procedures to make certain that their patients will not be reassured, only to die in the parking lot. The need to prevent a disaster often leads to unnecessary hospitalization and can result in expensive testing and coronary angiography. Although acute coronary syndrome is in the forefront of the diagnostic possibilities facing the emergency physician, lurking in the background are the other two deadly diagnoses: pulmonary embolism and dissecting aneurysm. It may be comforting to think that with one test, we can deal with all three high-risk diagnostic possibilities.

It appears that “fast CT” goes a long way in confirming or ruling out these three entities. A number of important clinical studies are underway that compare CT with standard diagnostic techniques, including stress echocardiography, nuclear imaging, and coronary angiography. Results so far have been very encouraging, but we will need more clinical data to support these initial studies. The fast CT is relatively easy to perform, with few contraindications, although it does require dye injection and some considerable radiation. Regular sinus rhythm at a moderate heart rate is also a requirement. Currently, the cost of the procedure is in the $1,000-$1,500 range, which is comparable to costs for other cardiac tests.

The ideal candidates for CT imaging and the “triple rule-out” will be those patients with low probability of ischemic disease who have chest pain symptoms of uncertain cause. These patients may represent approximately a quarter of all patients seen in the emergency department with chest pain. Current CT technology will have marginal importance in patients with known coronary artery disease. For them, more definitive imaging will be needed to describe and evaluate anatomic abnormalities. The ability to measure definitive changes in coronary anatomy still requires further refinement in CT imaging. Future developments may overcome this limitation. Assessment of the functional importance of anatomic lesions also will depend on stress nuclear or echocardiography imaging.

CT has an important role in defining coronary anomalies, and it may provide easy access to the imaging of coronary stents and bypass grafts. However, for confirmation of the presence of noncritical coronary artery disease, pulmonary embolism, and dissecting aneurysm, fast CT may well be the diagnostic technique of choice that can provide the answer to the triple rule-out.