Management of acute chest pain: A major role for coronary CT angiography

ACR Appropriateness Criteria® Chest Pain-Possible Acute Coronary Syndrome

Chest pain is a frequent cause for emergency department visits and inpatient evaluation, with particular concern for acute coronary syndrome as an etiology, since cardiovascular disease is the leading cause of death in the United States. Although history-based, electrocardiographic, and laboratory evaluations have shown promise in identifying coronary artery disease, early accurate diagnosis is paramount and there is an important role for imaging examinations to determine the presence and extent of anatomic coronary abnormality and ischemic physiology, to guide management with regard to optimal medical therapy or revascularization, and ultimately to thereby improve patient outcomes. A summary of the various methods for initial imaging evaluation of suspected acute coronary syndrome is outlined in this document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Cardiac Computed Tomography in Certified German Chest Pain Units

OBJECTIVE

The German Cardiac Society runs a nation-wide certification campaign for specialized chest pain units (CPUs). So far, cardiac computed tomography (CT) is not an integral part of such certification. The aim of our study was to analyze whether or not cardiac CT is nevertheless routinely used for further stratification in low-risk patients.

METHODS

For the time interval from January 2010 to April 2011, data were retrieved from the mandatory German CPU registry. Patients with and without cardiac CT during CPU index stay were compared.

RESULTS

Out of 5800 patients, 314 patients (5.4%) underwent cardiac CT during the index CPU stay. Unstable angina pectoris was the most common diagnosis when performing cardiac CT [34.4% vs. 17.7%; odds ratio (OR), 2.44; confidence interval (CI), 1.91-3.11; P < 0.001). Patients undergoing cardiac CT received significantly less often coronary angiography (31.8% vs. 54.8%; OR, 0.39; CI, 0.30-0.49; P < 0.001) or coronary revascularization (15.6% vs. 36.5%; OR, 0.32; CI, 0.23-0.46; P < 0.001). The use of cardiac CT did not prolong the length of stay in the CPU (20:48 vs. 20:25 h, P = 0.21).

CONCLUSIONS

Cardiac CT is underrepresented within the diagnostic work up in certified CPUs in Germany, although its use reduces unnecessary invasive diagnostics. The use of cardiac CT should be reconsidered during the next update of the CPU certification criteria.

Chest pain: coronary CT in the ER

Cardiac CT has developed into a robust clinical tool during the past 15 years. Of the fields in which the potential of cardiac CT has raised more interest is chest pain in acute settings. In fact, the possibility to exclude with high reliability obstructive coronary artery disease (CAD) in patients at low-to-intermediate risk is of great interest both from the clinical standpoint and from the management standpoint. Several other modalities, with or without imaging, have been used during the past decades in the settings of new onset chest pain or in acute chest pain for both diagnostic and prognostic assessment of CAD. Each one has advantages and disadvantages. Most imaging modalities also focus on inducible ischaemia to guide referral to invasive coronary angiography. The advent of cardiac CT has introduced a new practice diagnostic paradigm, being the most accurate non-invasive method for identification and exclusion of CAD. Furthermore, the detection of subclinical CAD and plaque imaging offer the opportunity to improve risk stratification. Moreover, recent advances of the latest generation CT scanners allow combining both anatomical and functional imaging by stress myocardial perfusion. The role of cardiac CT in acute settings is already important and will become progressively more important in the coming years.

Relationships between left atrial pericardial fat and permanent atrial fibrillation: Results of a case-control study

PURPOSE

The goal of this study was to retrospectively investigate the relationships between pericardial fat, left atrium volume (LAV) as measured on multidetector row computed tomography (MDCT) and persistent atrial fibrillation (AF) using a case-control study.

MATERIALS AND METHODS

The study population consisted of 58 patients (19 men, 39 women; mean age, 67.8±10 [SD] years) with persistent AF and 74 control subjects (30 men, 44 women; mean age, 67.8±10.9 [SD] years). The associations between the presence of persistent AF and periatrial pericardial fat volume (PAFV), periatrial pericardial fat thickness (PAFT), and LAV as measured on MDCT were searched for using univariate and multiple linear regression analysis.

RESULTS

On univariate analysis, significant differences were found between patients with AF and control subjects for mean PAFV (54.33cm(3)±23.43 [SD]; range: 12.2-111.1cm(3) vs 42.99cm(3)±20.76 [SD]; range: 7.4-103.9cm(3), respectively) (P=0.01), PAFT at the esophagus (1.87mm±1.65 [SD]; range: 0.1-9.5mm vs 1.12mm±0.77 [SD]; range: 0.1-3.6mm, respectively) (P<0.001) and normalized LAV (78.3cm(3)/m(2)±48.84 [SD]; range: 32.1-319.6cm(3)/m(2) vs 42.1cm(3)/m(2)±25.43 [SD]; range: 15.7-191.4cm(3)/m(2), respectively) (P<0.001). Multiple linear regression analysis revealed that only LAV was an independent predictor (P<0.001) of persistent AF. Also PAFV was significantly associated with LAV (P=0.01).

CONCLUSION

LAV is greater in patients with AF than in control subjects and PAFV is strongly associated with LAV. PAFV and PAFT are not independently associated with AF.