MDCT pp 263-268 | Cite as

Coronary CTA in Acute Chest Pain

  • Ian S. Rogers
  • Udo Hoffmann


It has been estimated that over 5 million patients present to emergency departments (EDs) in the United States with acute chest pain each year [1], Although rapid triage of these patients is crucial for optimizing treatment and improving prognosis, an effective strategy for diagnosis remains elusive in a majority of these patients. The current strategies for triage of the large subset of patients who present with acute chest pain but have normal or unchanged electrocardiograms (ECG) and negative initial cardiac enzymes provide inadequate risk stratification. This stems from the fact that the predictive value of symptom history [2] as well single variables such as patient age, sex, cardiac risk factors, and biochemical markers for adverse outcomes is limited [3, 4]. Moreover, symptoms of chest pain from cardiac etiologies are often similar to those from non-cardiac etiologies, further complicating accurate diagnosis [5].


Chest Pain Acute Coronary Syndrome Positive Predictive Value Acute Chest Pain Regional Left Ventricular Function 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    McCaig LF, Burt CW (2004) National Hospital Ambulatory Medical Care Survey: (2002 emergency department summary. Adv Data 340:1–34PubMedGoogle Scholar
  2. 2.
    Swap CJ, Nagurney JT (2005) Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA 294:2623–2629CrossRefPubMedGoogle Scholar
  3. 3.
    Ornato JP (2003) Management of patients with unstable angina and non-ST-segment elevation myocardial infarction: update ACC/AHA guidelines. Am J Emerg Med 21:346–351CrossRefPubMedGoogle Scholar
  4. 4.
    Limkakeng A Jr, Gibler WB, Pollack C et al (2001) Combination of Goldman risk and initial cardiac troponin I for emergency department chest pain patient risk stratification. Acad Emerg Med 8:696–702CrossRefPubMedGoogle Scholar
  5. 5.
    McCarthy BD, Beshansky JR, D’Agostino RB (1993) Missed diagnoses of acute myocardial infarction in the emergency department: results from a multicenter study. Ann Emerg Med 22:579–582CrossRefPubMedGoogle Scholar
  6. 6.
    Pope JH, Aufderheide TP, Ruthazer R et al (2000) Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med 342:1163–1170CrossRefPubMedGoogle Scholar
  7. 7.
    Lee TH, Rouan GW, Weisberg MC et al (1987) Clinical characteristics and natural history of patients with acute myocardial infarction sent home from the emergency room. Am J Cardiol 60:219–224CrossRefPubMedGoogle Scholar
  8. 8.
    Gibbons RJ, Chatterjee K, Daley J et al (1999) ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable an gina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina). Circulation 99:2829–2848PubMedGoogle Scholar
  9. 9.
    Tosteson AN, Goldman L, Udvarhelyi IS, Lee TH (1996) Cost-effectiveness of a coronary care unit versus an intermediate care unit for emergency department patients with chest pain. Circulation 94:143–150PubMedGoogle Scholar
  10. 10.
    Lee TH, Goldman L (2000) Evaluation of the patient with acute chest pain. N Engl J Med 342:1187–1195CrossRefPubMedGoogle Scholar
  11. 11.
    Goldman L, Cook EF, Johnson PA et al (1996) Prediction of the need for intensive care in patients who come to emergency departments with acute chest pain. N Engl J Med 334:1498–1504CrossRefPubMedGoogle Scholar
  12. 12.
    Kaul P, Newby LK, Fu Y et al (2004) International differences in evolution of early discharge after acute myocardial infarction. Lancet 363:511–517CrossRefPubMedGoogle Scholar
  13. 13.
    Leschka S, Alkadhi H, Plass A et al (2005) Accuracy of MSCT coronary angiography with 64-slice technology: first experience. Eur Heart J 26:1482–1487CrossRefPubMedGoogle Scholar
  14. 14.
    Mollet NR, Cademartiri F, van Mieghem CA et al (2005) High-resolution spiral computed tomography coronary angiography in patients referred for diagnostic conventional coronary angiography. Circulation 112:2318–2323CrossRefPubMedGoogle Scholar
  15. 15.
    Leber AW, Knez A, von Ziegler F et al (2005) Quantification of obstructive and nonobstructive coronary lesions by 64-slice computed tomography: a comparative study with quantitative coronary angiography and intravascular ultrasound. J Am Coll Cardiol 46:147–154CrossRefPubMedGoogle Scholar
  16. 16.
    Roe MT, Harrington RA, Prosper DM et al (2000) Clinical and therapeutic profile of patients presenting with acute coronary syndromes who do not have significant coronary artery disease: the Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) Trial Investigators. Circulation 102:1101–1106PubMedGoogle Scholar
  17. 17.
    Hoffmann U, Nagurney JT, Moselewski F et al (2006) Coronary multidetector computed tomography in the assessment of patients with acute chest pain. Circulation 114(21):2251–2260CrossRefPubMedGoogle Scholar
  18. 18.
    Rixe J, Achenbach S, Ropers D et al (2006) Assessment of coronary artery stent restenosis by 64-slice multi-detector computed tomography. Eur Heart J 27(21):2567–2572CrossRefPubMedGoogle Scholar
  19. 19.
    Cademartiri F, Schuijf JD, Pugliese F et al (2007) Usefulness of 64-slice multislice computed tomography coronary angiography to assess in-stent restenosis. J Am Coll Cardiol 49(22):2204–2210CrossRefPubMedGoogle Scholar
  20. 20.
    Malagutti P, Nieman K, Meijboom W et al (2007) Use of 64-slice CT in symptomatic patients after coronary bypass surgery: evaluation of grafts and coronary arteries. Eur Heart J 28(15):1879–1885CrossRefPubMedGoogle Scholar
  21. 21.
    Berman DS, Hachamovitch R, Shaw LJ et al (2006) Roles of nuclear cardiology, cardiac computed tomography, and cardiac magnetic resonance: Noninvasive risk stratification and a conceptual framework for the selection of noninvasive imaging tests in patients with known or suspected coronary artery disease. J Nucl Med 47(7):1107–1118PubMedGoogle Scholar
  22. 22.
    Hendel RC, Patel MR, Kramer CM et al (2006) ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR (2006 appropriateness criteria for cardiac computed tomography and cardiac magneticresonance imaging: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology. J Am Coll Cardiol 48(7):1475–1497CrossRefPubMedGoogle Scholar
  23. 23.
    Hoffmann U, Nagurney JT, Moselewski F et al (2006) Coronary multidetector computed tomography in the assessment of patients with acute chest pain. Circulation 114:2251–2260CrossRefPubMedGoogle Scholar
  24. 24.
    Wallentin L, Lagerqvist B, Husted S et al (2000) Outcome at 1 year after an invasive compared with a non-invasive strategy in unstable coronary-artery disease: the FRICS II invasive randomised trial. FRISC II Investigators. Fast revascularisation during instability in coronary artery disease. Lancet 356:9–16CrossRefPubMedGoogle Scholar
  25. 25.
    Wallentin L (2002) Non-ST-elevation acute coronary syndrome: fuel for the invasive strategy. Lancet 360:738–739CrossRefPubMedGoogle Scholar
  26. 26.
    Roe MT, Harrington RA, Prosper DM et al (2000) Clinical and therapeutic profile of patients presenting with acute coronary syndromes who do not have significant coronary artery disease. The Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) Trial Investigators. Circulation 102:1101–1106PubMedGoogle Scholar
  27. 27.
    Ambrose JA, Tannenbaum MA, Alexopoulos D et al (1988) Angiographic progression of coronary artery disease and the development of myocardial infarction. J Am Coll Cardiol 12:56–62PubMedCrossRefGoogle Scholar
  28. 28.
    Falk E, Shah PK, Fuster V (1995) Coronary plaque disruption. Circulation 92:657–671PubMedGoogle Scholar
  29. 29.
    Nakamura M, Nishikawa H, Mukai S et al (2001) Impact of coronary artery remodeling on clinical presentation of coronary artery disease: an intravascular ultrasound study. J Am Coll Cardiol 37:63–69CrossRefPubMedGoogle Scholar
  30. 30.
    Ehara S, Kobayashi Y, Yoshiyama M et al (2004) Spotty calcification typifies the culprit plaque in patients with acute myocardial inarction: an in travascular ultrasound study. Circulation 110:3424–3429CrossRefPubMedGoogle Scholar
  31. 31.
    Maehara A, Mintz GS, Bui AB et al (2002) Morphologic and angio graphic features of coronary plaque rupture detected by intravascular ultrasound. J Am Coll Cardiol 40:904–910CrossRefPubMedGoogle Scholar
  32. 32.
    Hoffmann U, Moselewski F, Nieman K et al (2006) Noninvasive assessment of plaque morphology and composition in culprit and stable lesions in acute coronary syndrome and stable lesions in stable angina by multidetector computed tomography. J Am Coll Cardiol 47(8):1655–1662CrossRefPubMedGoogle Scholar
  33. 33.
    Goldstein JA, Gallagher MJ, O’Neill WW et al (2007) A randomized controlled trial of multi-slice coronary computed tomography for evaluation of acute chest pain. J Am Coll Cardiol 49(8):863–871CrossRefPubMedGoogle Scholar
  34. 34.
    Rubinshtein R, Halon DA, Gaspar T et al (2007) Impact of 64-slice cardiac computed tomographic angiography on clinical decision-making in emergency department patients with chest pain of possible myocardial ischemic origin. Am J Cardiol 100:1522–1526CrossRefPubMedGoogle Scholar
  35. 35.
    Kontos MC, Arrowood JA, Jesse RL et al (1998) Comparison between 2-dimensional echocardiography and myocardial perfusion imaging in the emergency department in patients with possible myocardial is chemia. Am Heart J 136(4 Pt 1):724–733CrossRefPubMedGoogle Scholar
  36. 36.
    Sabia PJ, Powers ER, Jayaweera AR et al (1992) Functional significance of collateral blood flow in patients with recent acute myocardial infarction. A study using myocardial contrast echocardiography. Circulation. 85(6):2080–2089PubMedGoogle Scholar
  37. 37.
    Kwong RY, Schussheim AE, Rekhraj S et al (2003) Detecting acute coronary syndrome in the emergency department with cardiac magnetic resonance imaging. Circulation 107:531–537CrossRefPubMedGoogle Scholar
  38. 38.
    Fischbach R, Juergens KU, Ozgun M et al (2007) Assessment of regional left ventricular function with multidetector-row computed tomography versus magnetic resonance imaging. Eur Radiol 17:1009–1017CrossRefPubMedGoogle Scholar
  39. 39.
    Rogers IS, Seneviratne SK, Bamberg F et al (2007) Resting regional left ventricular function as assessed using cardiac 64-slice computed tomography to predict acute coronary syndrome in patients with acute chest pain. Circulation 116(Suppl II):II–562Google Scholar
  40. 40.
    Nikolaou K, Sanz J, Poon M et al (2005) Assessment of myocardial perfusion and viability from routine contrast-enhanced 16-detector-row computed tomography of the heart: preliminary results. Eur Radiol 15:864–871CrossRefPubMedGoogle Scholar
  41. 41.
    Rogers IS, Cury RC, Shapiro MD et al (2007) Evaluation of cardiac multidetector computed tomography reconstruction modalities for the detection of perfusion defects in patients presenting with acute ST Segment elevation myocardial infarction. J Cardiovasc Comput Tomogr 1(1 Supp):S31Google Scholar
  42. 42.
    Lardo AC, Cordeiro MA, Silva C et al (2006) Contrast-enhanced multidetector computed tomography viability imaging after myocardial infarction: characterization of myocyte death, microvascular obstruction, and chronic scar. Circulation 113:394–404CrossRefPubMedGoogle Scholar
  43. 43.
    Gerber BL, Belge B, Legros GJ et al (2006) Characterization of acute and chronic myocardial infarcts by multidetector computed tomography: comparison with contrast-enhanced magnetic resonance. Circulation 113:823–833CrossRefPubMedGoogle Scholar
  44. 44.
    Kruip MJ et al (2006) A simple diagnostic strategy in hospitalized patients with clinically suspected pulmonary embolism. J Intern Med 260(5):459–466CrossRefPubMedGoogle Scholar
  45. 45.
    Yoshida S, Akiba H, Tamakawa M et al (2003) Thoracic involvement of type A aortic dissection and intramural hematoma: diagnostic accuracy—comparison of emergency helical CT and surgical findings. Radiology 228(2):430–435CrossRefPubMedGoogle Scholar
  46. 46.
    White CS, Kuo D, Kelemen M et al (2005) Chest pain evaluation in the emergency department: can MD-CT provide a comprehensive evaluation? AJR Am J Roentgenol 185(2):533–540PubMedGoogle Scholar
  47. 47.
    Raptopoulos VD, Boiselle PB, Michailidis N et al (2006) MDCT angiography of acute chest pain: evaluation of ECG-gated and nongated techniques. AJR Am J Roentgenol 186(6 Suppl 2):S346–356CrossRefGoogle Scholar
  48. 48.
    Shapiro MD, Dodd J, Wittram C et al (2007) A novel imaging protocol to visualize the coronary artery tree, thoracic aorta, and pulmonary artery vasculature with a single contrast bolus and twenty second sean duration using ECG-gated 64-slice MDCT. Meeting: RSNA 2007, November 27, 2007, Chicago, Abstract SS G19–03Google Scholar
  49. 49.
    Johnson TR, Nikolaou K, Becker A et al (2007) Dual-source CT for chest pain assessment. Eur Radiol [Epub ahead of print]Google Scholar
  50. 50.
    Schertler T, Scheffel H, Frauenfelder T et al (2007) Dual-source computed tomography in patients with acute chest pain: feasibility and image quality. Eur Radiol 17(12):3179–3188CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Italia 2008

Authors and Affiliations

  • Ian S. Rogers
    • 1
    • 2
    • 3
  • Udo Hoffmann
    • 2
  1. 1.Division of CardiologyMassachusetts General Hospital Harvard Medical SchoolBostonUSA
  2. 2.Department of RadiologyMassachusetts General Hospital Harvard Medical SchoolBostonUSA
  3. 3.School of Public HealthBostonUSA

Personalised recommendations