Cardiac CT for the assessment of chest pain: Imaging techniques and clinical results

Chief complaints and computed tomography results in the emergency department: a three-year retrospective cohort study

BACKGROUND

Computed tomography (CT) is frequently performed in the patients who admitted to the emergency department (ED), discharged but returned to ED within 72 h. It is unknown whether the main complaints of patients assist physicians to use CT effectively. This study aimed to find the association between chief complaints and the CT results.

METHODS

This three-year retrospective cohort study was conducted in the ED of a tertiary medical center. Adult patients who returned to the ED after the index visit were included from 2019 to 2021. Demographics, pre-existing diseases, chief complaints, and CT region were recorded by independent ED physicians. A logistic regression model with an odds ratio (OR) and 95% confidence interval (CI) was used to determine the relationship between chief complaints and positive CT results.

RESULTS

In total, 7,699 patients revisited ED after the index visit; 1,202 (15.6%) received CT. The top chief complaints in patients who received CT were abdominal pain, dizziness, and muscle weakness. Patients with abdominal pain or gastrointestinal symptoms had a significantly higher rate of positive abdominopelvic CT than those without it (OR 2.83, 95% CI 1.98-4.05, p < 0.001), while the central nervous system and cardiopulmonary chief complaints were not associated (or negatively associated) with new positive CT findings.

CONCLUSION

Chief complaints of patients on revisit to the ED are associated with different yields of new findings when CT scans of the chest, abdomen and head are performed. Physicians should consider these differential likelihoods of new positive findings based on these data.

Three-Dimensional Visualization and Imaging of the Entry Tear and Intimal Flap of Aortic Dissection Using CT Virtual Intravascular Endoscopy

AIMS

Conventional computed tomography (CT) approaches provides limited visualization of the entire endoluminal changes of aortic dissection (AD), which is essential for its treatment. As an important supplement, three-dimensional CT virtual intravascular endoscopy (VIE) can show relevant details. This study aims to determine the value of VIE in displaying the entry tear and intimal flap of AD.

METHODS AND RESULTS

Among 127 consecutive symptomatic patients with suspected AD who underwent CT angiography (CTA), 84 subjects were confirmed to have AD and were included in the study. Conventional CT and VIE images were observed and evaluated. From the 92 entry tears revealed via conventional CT, 88 (95.7%) tears appeared on VIE with round (n = 26), slit-shaped (n = 9), or irregular (n = 53) shapes, whereas the intimal flaps were sheetlike (n = 34), tubular (n = 34), wavelike (n = 13), or irregular (n = 7) in shape. The VIE also showed the spatial relationship between the torn flap and adjacent structures. Among 58 entry tears with multiple-line type flap shown on conventional CT, 41 (70.7%) appeared with an irregular shape on VIE, whereas among 30 tears with single-line type flap, 17 (56.7%) appeared as round or slit-shaped on VIE. These results demonstrated a significant difference (P < 0.05). The poor display of tears on VIE was related to the low CT attenuation values in lumen or in neighboring artifacts (P < 0.01).

CONCLUSION

CT VIE presents the complete configurations and details of the intimal tears and flaps of AD better than conventional CT approaches. Accordingly, it should be recommended as a necessary assessment tool for endovascular therapy and as part of strategy planning in pre-surgical patients.

Modern diagnostics for type B aortic dissection

Background

Undifferentiated chest pain is one of the most common complaints in the acute care setting. Type B aortic dissection is an important cause of chest pain and a complex clinical entity, which carries significant morbidity and mortality and requires accurate clinical and radiological evaluation.

Methods

Imaging technologies have become an irreplaceable tool to establish the diagnosis of aortic dissection and to plan treatment strategies. Computed tomography is an important component in this process, replacing catheter-based angiography as the most commonly used preoperative and postoperative imaging modality for the thoracic aorta. The use of functional imaging methods, such as magnetic resonance imaging and echocardiography is evolving. These methods are able to provide the clinically relevant anatomical, hemodynamic and biomechanical information that is necessary for accurate diagnosis, risk stratification and patient selection for treatment.

Conclusion

Advanced image acquisition equipment and expertise are increasingly available in a growing number of institutions and as a consequence, existing strategies for the management of type B dissection are rapidly evolving.

Residents' performance in the interpretation of on-call "triple-rule-out" CT studies in patients with acute chest pain

RATIONALE AND OBJECTIVES

To evaluate the performance of radiology residents in the interpretation of on-call, emergency "triple-rule-out" (TRO) computed tomographic (CT) studies in patients with acute chest pain.

MATERIALS AND METHODS

The study was institutional review board-approved and Health Insurance Portability and Accountability Act compliant. Data from 617 on-call TRO studies were analyzed. Dedicated software enables subspecialty attendings to grade discrepancies in interpretation between preliminary trainee reports and their final interpretation as "unlikely to be significant" (minor discrepancies) or "likely to be significant" for patient management (major discrepancies). The frequency of minor, major and all discrepancies in resident's TRO interpretations was compared to 609 emergent non-electrocardiography (ECG)-synchronized chest CT studies using Pearson χ(2) test.

RESULTS

Minor discrepancies occurred more often in the TRO group (9.1% vs. 3.9%, P < .001), but there was no difference in the frequency of major discrepancies (2.1% vs. 2.8%, P = .55). Minor discrepancies in the TRO group most commonly resulted from missed extrathoracic findings with missed liver lesions being the most frequent. Major discrepancies mostly encompassed cardiac and extracardiac vascular findings but did not result in unnecessary interventions, significant immediate changes in management, or adverse patient outcomes.

CONCLUSIONS

On-call resident interpretation of TRO CT studies in patients with acute chest pain is congruent with final subspecialty attending interpretation in the overwhelming majority of cases. The rate of discrepancies likely to affect patient management in this domain is not different from emergent non-ECG-synchronized chest CT.

A fatal outcome of thoracic aortic aneurysm in a male patient with bicuspid aortic valve

Thoracic aortic aneurysm is often an asymptomatic but potentially lethal disease if its most catastrophic complication – aortic dissection – occurs. Thoracic aortic dissection is associated with a high mortality rate despite ongoing improvement in its management. We report a fatal outcome of thoracic aortic aneurysm in a male patient with bicuspid aortic valve. The patient was qualified for elective surgery of the ascending aorta and aortic valve at the age of 39 but he did not agree to undergo the proposed procedure. Three years later, he experienced acute aortic dissection and died despite a prompt diagnosis and complex management.