ACUTE CHEST PAINACUTE CHEST PAIN

Imaging Diagnostic DepartmentTokuda Hospital Sofia

G.KirovaG.Kirova

CChallengehallenge

Chest pain accounts for 25% of ED consultations Number one among all specific chief complaints in the ED 10% of all severe non-surgical patients Low admitment threshold for pts with chest pain

• High rate of missed diagnosis of ACS (2-4%)• Up to 5% of patients are discharged inappropriately• Unnecessary hospitalization in more than 35% Acad Emerg Med 2008;15:9

Lifethreatening Acute Coronary

Syndrome Pulmonary embolism Aortic dissection Tension

pneumothorax Esophageal rupture

Others Noncoronary heart

disease Pleuritis/Pneumonia Pneumothorax Pericarditis GERB Gastritis Osteochondritis/Tietze

sy

?? ??

Diagnostic algorithmDiagnostic algorithm First line examinations

ECG Biochemical markers (cardiac enzimes) EchoCG CXR

Second line examinations Stress EchoCG Nuclear Medicine (Thallium, Technetium-

99m Sestamibi) MRI

American College of Radiology Appropriateness Criteria,2000

MDCT?MDCT?

Fast High spatial resolution High temporal resolution ECG gating Evaluation of left and right

cavities Simultaneous visualization of

all chest structures

Ideal diagnostic test?Ideal diagnostic test?

GoalGoal

This review describes the potential value of an acute chest pain CT protocol and the considerable challenges that remain prior to its implementation for routine clinical use.

Selection of patients Parameters of MDCT acquisition Analysis of data Preliminary clinical findings

Patients selectionPatients selection

(-) Pts with a very low likelihood of acute coronary artery disease

(-) Pts with very high likelihood of CAD (CAD history, ST elevation or depression, positive cardiac markers) – catheter angiography, “the time is life”

(+) Non-risk pts with intermediate pre-scan probability of coronary artery disease (non-segment elevation and +/- stress test results) - MDCTnegative MDCTA would allow pts to be discharged and a non-cardiac causes of the presenting chest pain to be concerned

American College of Cardiology/American Guidelines

ACS with MI and ST elevationACS with MI without ST elevationUnstable angina pectoris

Patients preparationPatients preparation

No contrast allergies Normal renal function Normal sinus rhythm Targeted heart rate less than 65 b/min Ability to lie flat

Beta-blockers ??? and nitrates ??? to lower the heart beat and to dilate the coronaries

ECG gating Oxygen inhaled

What is different?What is different?

PE Ao CA

"Triple Rule-Out“"Triple Rule-Out“alternative protocolalternative protocol

Calcium scoring - to exclude patients with excessive calcifications

From lung apexes to diaphragm

Large axial FOV DLP:

1400 -1500 mGy.cm (23-24 mSv) with multiphase imaging

+Ca scoring (1-2 mSv)

Analysis of imagesAnalysis of images

Automatically reconstructed at systolic and diastolic phase Calcium score, plaque characterization Free-motion coronary arteries images Analysis of myocardial enhancement, myocardial

perfusion Quantitative assessment of the ventricular output Analysis of pulmonary vessels Analysis of aorta Analysis of lung parenchyma

http://radiographics.rsnajnls.org/content/vol26/issue4/images/large/g06jl23c12a.jpeg

CORONARY VISUALIZATION CORONARY VISUALIZATION FIRST PRIORITY! FIRST PRIORITY!

(Di Carli, J Nucl Cardiol 2004; 11: 719-32)

Coronary CalcificationCoronary Calcification

No CalcificationMild-Moderate Calcification

Severe Calcification

Left Main LADLCX

PA

Ao

LAD

PA

Ao

PA

Ao

Calcium scoring is best suited to asymptomatic patients at intermediate risk of coronary artery disease for general risk stratification

MDCT Sensit Specif

Leber JACC 2005 73% 97%

Mollet Circ 2005 99% 92%

Raff JACC 2005 86% 95%

Ropers AJC 2006 95% 93%

Fine AJC 2006 95% 96%

Leschka EHJ 2006 94% 97%

If patient has a negative scan, there is a high degree of certainty that he/she can be safely discharged

Stress Echo 85% 95%

SPECT 90% 88%

Evaluation of the severity of the occlusive diseaseEvaluation of the severity of the occlusive disease

Limitations: Evaluation of patients with severe coronary

calcifications Metal implants and related artifacts Motion blurring Overestimation of grade of the stenosis

Leber et al, Limitations of Anatomic Approaches, JACC 2005;46: 147-154

By-pass grafting

Feuchtner GM et al; Diagnostic performance of 64-slice CT in evaluation of coronary by-pass grafs; AJR 2007:189:574-580

Myocardial bridging

Anomalous origin

Noncoronary cardiogenic diseases

Endocarditis Valvular involvement Paravalvular abscessus or

pseudoaneurysm Exclusion of coronary disease

LA appendage thrombus

ASD’s with septal aneurysm

Pulmonary Embolism

Acute vs Chronic PE Findings

Clinical Validity of a Negative Computed Tomography Scan in Patients with Suspected Pulmonary EmbolismA Systematic ReviewQuiroz et al; JAMA 2005

CT Angiography for Diagnosis of Pulmonary Embolism: State of the Art U. Joseph Schoepf, MD and Philip Costello, MD

Radiology 2004;230:329-337

http://radiology.rsnajnls.org/content/vol230/issue2/images/large/r04fe01g08x.jpeg

Vascular diseases

aortic dissection intramural haematoma aortic wall ulcerations aortic aneurysm arterial wall disease, arteriitis vascular anomalies

Radiology 2003;228:430-435 Thoracic Involvement of Type A Aortic Dissection and Intramural Hematoma: Diagnostic Accuracy— Comparison of Emergency Helical CT and Surgical Findings1

Satoru Yoshida, M D, Hidenari Akiba, MD, M itsuharu Tamakawa, MD et al;

.)© R S N A , 2 0 0 6

Radiology 2006;238:841-852S u s p e c t e d A o r t ic D is s e c t io n a n d O th e r A o r t ic D is o r d e r s : M u l t i– D e te c t o r R o w C T in 3 7 3 C a s e s in t h e E m e r g e n c y S e t t in gRobert G. Hayter, BS , James T. Rhea, MD, Andrew Small, MD, Faranak S . Tafazoli, MD and Robert A. Novelline, MD

http://radiology.rsnajnls.org/misc/terms.shtml

Imaging of Aortic Dessection by Helical Computed TomographyЕuropean Radiology 2005

Think extracardiac!

Lung parenchyma Lung parenchyma granulomatous diseases

(Tb, sarcoidosis) Infection (pneumonia,

abscesses) emphysema atelectasis tumours /nodules

…Do not forget

Pleural diseases Pleural diseases

effusion effusion adhesions

adhesions plaques and

calcifications plaques and calcifications

Tumours pneumothorax

…or Mediastinum Chest wall Diaphragm

How to evaluate extracardiac findings: key points for findingskey points for everybody

read carefully the request and reports of prior imaging studies

always correlate the extracardiac findings with patient history, symptoms and signs

realize the limits of FOV decide whether the findings are important enough to be

in a report if yes, suggest possible further tests make sure life -threatening diseases get noticed!

know your limits therefore, co-operation between specialties is essential

ResultsResults

Heart Heart 2007;93:1325-13262007;93:1325-1326

CT angiography: front line for acute coronary syndrome now?SK Senevirante, F Bamberg, U Hoffmann

Preliminary data suggest that cardiac CTA has the potential to redefine the diagnostic and management strategies in pts with acute chest pain in the ED

CCirculation 2007;115:1762-1768irculation 2007;115:1762-1768

Usefulness of 64-slice CTA for diagnosisng ACS and predicting clinical outcome in ED pts with chest pain of uncertain originR Rubinshtein, DA Holon, T Gaspar et al

AJR AJR 2005;185:533-5402005;185:533-540

Multidetector CT: can it provide a global evaluation of the patient presenting to the emergency department with chest pain?Ch. S. White; D.Kuo; M Kelemen et al

Miller J; Coronary evaluation using MDCTA using 64 detectors: a multicenter international trial; AHA Scientific Sessions 2007 Late-Breaking Clinical Trials News Release, Orlando 2007

291 pts from an original cohort of 405 pts Comparison between MDCT and CA Per pt analysis for detection of 50% stenoses

201 consecutive low- to moderate risk pts 30 days follow-up Noncoronary disease in 2 (14%) of 197 pts CAD in 68pts

10 with severe disease (>70% stenosis) 12 with moderate disease (50-70% stenosis) 46 with mild disease (

Diagnostic performance and predictive value of 64-slice MDCT CA for the detection of >50% stenosis on quantitative coronary angiography

Prevalence of disease % n TP TN FP FN k Sensit.%

Specif.%

PPV %

NPV%

All pts 85 104 88 12 4 0 0,84 100 75 96 100

High risk 85 71 60 8 3 0 0,82 100 73 95 100

Low risk 85 33 28 4 1 0 0,87 100 80 93 100

Vessel-based analysis

All vessels 35 416 141 214 58 3 0,70 98 79 71 99

RCA 48 104 48 39 15 2 0,68 96 72 76 95

LM 3 104 3 98 3 0 0,65 100 97 50 100

LAD 47 104 49 32 23 0 0,57 100 58 68 100

CX 39 104 40 46 17 1 0,66 98 73 70 98

Segment-based analysis

All segments

13 1525 183 1205 122 15 0,68 92 91 60 99

Proximal 14 416 58 312 44 2 0,65 97 88 57 99

Mid 23 302 67 199 34 2 0,71 97 85 66 99

Distal 9 327 24 286 11 6 0,71 80 96 69 98

Side branch

8 480 34 408 33 5 0,60 87 92 51 99

•64 MDCTA comparing with invasive coronary angiography in a high-risk acute chest pain population with non-ST elevation ACS•Patients with high prevalence of coronary artery calcifications•Patient per patient basis•All segments included

MDCTA safely excludes significant CAD (NPV 100%)Specificity 75%

Diagnostic Accuracy of CTA to Detect ≥50% Stenosis

(Di Carli et al, Circulation 2007)

Per SegmentPer SegmentN=18,296N=18,296

Per PatientPer PatientN=1,650N=1,650

21 Studies21 Studies

8392

67

97

0

20

40

60

80

100

Sens Spec PPV NPV

93

7784 87

0

20

40

60

80

100

Sens Spec PPV NPV

Coronary Multidetector Computed Tomography in the Assessment of Patients With Acute Chest PainU.Hoffmann, JT Nagurney, F Moselewski et al.

Circulation 2006;114:2251-2260

ROMICAT (Rule-out Myocardial Infarction using Computer Assisted Tomography) as a prospective observational cohort study of consecutive adult pts with \acute chest pain

pts 103, CT 3,7+/-2,3h after presentation in ED

in 40% no coronary plaques

5 months follow-up Absence of significant

CA stenosis (73 of 103pts) and nonsignificant CA stenosis (41 of 103 pts) accurately predicted the absence of ACS

http://circ.ahajournals.org/content/vol114/issue21/images/large/11FF4.jpeg

Additional promise of CTA – prognostic benefits

Negative CT – “clean bill” for several years – decrease of subsequent testing in repeated presenters

Detection of new non-obstructive disease – Initiation of secondary prevention

G Pundziute et al; Prognostic value of MSCT coronary angiography in patients with known or suspected coronary artery disease; J Am Coll Cardiol 2007;49:62-70

CTA vs Standard of Care (SOC) in Chest Pain

(Goldstein JACC 2007; 49: 863-71)

Triple rule-out protocolpros and cons

For: elegant, simple diagnostic method single contrast injection robust (compare dw. MRI) fast (compare dw. MRI or NM) gated images much better than in a non-

gated study extracardiac findings financially acceptable

Triple rule-out protocolpros and cons

Against: hardware requirements: 64-slice CT mandatory adequate software needed high radiation dose (up to 25mSv) premedication usually needed poor cooperation challenging (breath hold, movement

artifacts) adverse effects of contrast media (incl. nephrotoxicity) analysis often time consuming and difficult increased workload; 365/7/24 service demanding turf battles?

Conclusions

Absence of CAD enables early and safe discharge from the ED, enormous improvement of ED throughput

Risk assessment and prognostic benefits – warrant period, preventive therapy

The comprehensive protocol appears to diagnose a small number of cases of non-coronary disease that might be missed if only a dedicated coronary CTA protocol is used

The adoption of this protocol will almost certainly lead to increased use of MDCT in the ED. This must be weighed against the potential decrease in other imaging studies currently used for evaluating ED chest pain

Major technical and labour issues as well as considerations related to radiation and economics remain to be resolved prior to routine adoption of MDCT for the evaluation of chest pain in the emergency department

The full potential of cardiac CT remains to be explored

Imaging Diagnostic DepartmentCardiology DepartmentEmergency Department

Slide 1Slide 2Slide 3Diagnostic algorithmMDCT?Goal Patients selection Patients preparationWhat is different?"Triple Rule-Out“ alternative protocolAnalysis of imagesSlide 12Slide 13Slide 14Slide 15Slide 16Slide 17 Evaluation of the severity of the occlusive diseaseSlide 19Myocardial bridgingSlide 21Noncoronary cardiogenic diseasesEndocarditisPulmonary EmbolismSlide 25Slide 26Vascular diseases Slide 28Slide 29Slide 30Imaging of Aortic Dessection by Helical Computed Tomography Еuropean Radiology 2005Slide 32Think extracardiac!…Do not forget …orHow to evaluate extracardiac findings: key points for findings key points for everybodyResultsPreliminary data suggest that cardiac CTA has the potential to redefine the diagnostic and management strategies in pts with acute chest pain in the EDMiller J; Coronary evaluation using MDCTA using 64 detectors: a multicenter international trial; AHA Scientific Sessions 2007 Late-Breaking Clinical Trials News Release, Orlando 2007Slide 40Diagnostic Accuracy of CTA to Detect 50% StenosisCoronary Multidetector Computed Tomography in the Assessment of Patients With Acute Chest Pain U.Hoffmann, JT Nagurney, F Moselewski et al. Circulation 2006;114:2251-2260Additional promise of CTA – prognostic benefitsSlide 44Triple rule-out protocol pros and consКадър 46ConclusionsSlide 48