Role of MDCT Angio in Management of Acute Chest Pain

Dr. Muhammad Bin ZulfiqarPGR IV FCPS Services Institute of Medical

Sciences / Hospitalradiombz@gmail.com

Objectives

• To look for MDCT Utility in Cardiac Emergency.• Its role to characterize ACS.• Effect on hospital stay and expenditure.• To look for future cardiac risk factors.• To stop inadvertent interventions.

Usual Presentations

• The most clinically relevant conditions– coronary artery disease presenting as acute coronary

syndrome– pulmonary embolism– Acute aortic syndrome– Other Causes of Chest pain• Pneumonia• Pleurisy• musculoskeletal

Truong et al. Coronary CT Angiography Versus Standard Emergency Department Evaluation for Acute Chest Pain and Diabetic Patients: Is There Benefit With Early Coronary CT Angiography? J Am Heart Assoc. 2016;5:e003137Bastarrika et al. Cardiac CT of Acute Chest Pain. AJR 2009; 193:397–409Helpren E.J. Triple-Rule-Out CT Angiography for Evaluation of Acute Chest Pain and Possible Acute Coronary Syndrome. Radiology: Volume 252: Number 2—August 2009

Definition of ACS

• Constellation of clinical symptoms that are compatible with acute myocardial ischemia– STEMI – NSTEMI– Unstable Angina (UA)

J Am Coll Cardiol. 2007 Aug 14;50(7)

Classic Initial Approach

• Detailed patient history • Physical examination• ECG• Measurement of cardiac biomarkers.

Bastarrika et al. Cardiac CT of Acute Chest Pain. AJR 2009; 193:397–409

Thrombosis in Myocardial Infarction (TIMI) risk score

One point to each the following risk factors: 1. Age greater than 65 years2. known coronary artery disease (documented

previous coronary artery stenosis > 50%)3. Severe angina (more than two episodes of

chest pain in the preceding 24 hours)4. St segment changes (persistent depression

or transient elevation) on admission ECG

Bastarrika et al. Cardiac CT of Acute Chest Pain. AJR 2009; 193:397–409

Thrombosis in Myocardial Infarction (TIMI) risk score

5. Elevated serum markers of myocardial ischemia (troponins)

6. Use of aspirin in the 7 days before presentation

7. Three or more conventional risk factors for coronary artery disease – (family history, diabetes mellitus, hypertension,

hypercholesterolemia, smoking).

Bastarrika et al. Cardiac CT of Acute Chest Pain. AJR 2009; 193:397–409

Risk Factor Stratification

• High risk (TIMI score, 5–7) – usually are referred without delay for urgent

coronary angiography and intervention• Intermediate risk (TIMI score, 3–4)• Low risk (TIMI score, 0–2) – Admitted for observation and undergo serial ECG

and cardiac biomarker testing followed by stress testing.

Thrombosis in Myocardial Infarction (TIMI) risk scoreBastarrika et al. Cardiac CT of Acute Chest Pain. AJR 2009; 193:397–409

MDCT Techniques / Protocols

• CT coronary angiogram• "Triple rule-out” coronary CT angiography• CT perfusion

Truong et al. Coronary CT Angiography Versus Standard Emergency Department Evaluation for Acute Chest Pain and Diabetic Patients: Is There Benefit With Early Coronary CT Angiography? J Am Heart Assoc. 2016;5:e003137Bastarrika et al. Cardiac CT of Acute Chest Pain. AJR 2009; 193:397–409Helpren E.J. Triple-Rule-Out CT Angiography for Evaluation of Acute Chest Pain and Possible Acute Coronary Syndrome. Radiology: Volume 252: Number 2—August 2009

Patient Selection Criteria

• Low to moderate risk of ACS• Non ACS diagnosis• Negative biomarkers – Troponin-I– Myoglobin

• Normal ECG or non specific changes• No history to suggest extensive coronary

calcium Helpren E.J. Triple-Rule-Out CT Angiography for Evaluation of Acute Chest Pain and Possible Acute Coronary Syndrome. Radiology: Volume 252: Number 2—August 2009

Careful consideration / Exclusion

• Abnormal renal function tests.• Patients with stents and bypass• H / O allergy to tolerate CT• Abnormal cardiac rythems.

Helpren E.J. Triple-Rule-Out CT Angiography for Evaluation of Acute Chest Pain and Possible Acute Coronary Syndrome. Radiology: Volume 252: Number 2—August 2009

Reconstruction Techniques

• Multiplanar Reformation. • Curved Multiplanar Reformation• Maximum Intensity Projection• Volume Rendering

Helpren E.J. Triple-Rule-Out CT Angiography for Evaluation of Acute Chest Pain and Possible Acute Coronary Syndrome. Radiology: Volume 252: Number 2—August 2009

Case 1

• 52-year-old woman with acute atypical chest pain.

• Study allowed to noninvasively rule-out pulmonary embolism, acute aortic syndrome, and coronary artery disease with single scan

• Contrast-enhanced retrospectively ECG-gated thoracic CT angiogram done which showed normal findings.

Case 1

• Volume-rendered images show (Right) pulmonary vasculature (Left) aorta

Case 1

• Volume rendered images show coronary arteries

Case 1

• Curved multiplanar reformatted image shows left anterior descending coronary artery, right coronary artery, and circumflex artery.

Case 2

• 50-year-old man with acute chest pain, family history of coronary artery disease, intermediate cardiovascular risk, and normal initial cardiac biomarker and ECG results referred for CT imaging

Case 2

• (Right) Curved MPR and (Left) volume rendered images show calcified plaques causing nonsignificant stenosis in mid segment of artery. Arrowhead indicates intramyocardial course in distal segment.

Case 3

• 40-year-old woman with acute chest pain and dyspnea.

Case 3

• Right. Axial contrast-enhanced image shows bilateral central pulmonary emboli (arrowheads).

• Left. Axial reformatted volume-rendered color-mapped image shows pulmonary hypo perfused areas (arrowheads) mainly at upper lobes.

Case 3

• Right and Left, Axial CT image at midheart level (right) and right ventricular end-diastolic volumetric analysis (left) show right ventricular (RV) enlargement and septal flattening indicating right ventricular pressure overload.

Case 4

• 53-year-old woman with acute chest pain radiating to back and dyspnoea.

• Thoracic CT angiography suggested.

Case 4• Contrast-enhanced axial

CT image shows dissection flap involving descending aorta

Case 4

• Volume-rendered image shows origination of dissection (arrowhead) distal to left subclavian artery and extension into abdominal aorta.

Case 5

• 43-year-old man with intermediate cardiovascular risk and acute chest pain.

• Thoracic CT angiography done

Case 5

• Curved MPR (Right) and volume-rendered (Left) images of left anterior descending coronary artery show intense vascular remodeling of entire vessel with significant stenosis caused by predominantly noncalcified plaque (arrow) involving mid and distal segments.

Case 6

• 61-year-old man with chest pain. • Thoracic CT angiography done

Case 6

• Right. Multiplanar reformatted coronal image shows left central pulmonary artery embolism (arrowhead) extending to segmental lingula and left inferior lower lobe branches.

• Left Reformatted coronal volume-rendered color-mapped image shows corresponding perfusion defects. Arrowhead indicates embolism.

Case 7

• 46-year-old man admitted in emergency department because of acute chest pain.

• Thoracic CT angiography done

Case 7

• Right. Unenhanced thoracic CT image shows intramural hematoma involving descending thoracic aorta (arrow).

• Left. Contrast-enhanced thoracic CT image shows absence of aortic dissection.

Case 8

• 58-year-old man admitted in emergency department because of acute chest pain radiating to back.

• Suspicion was aortic dissection.• Thoracic CT angiography done

Case 8

• Right Contrast-enhanced axial CT image shows involvement of ascending and descending aorta (arrows).

• Left Contrast-enhanced axial CT image shows flap with whirl-like complex structure at aortic arch.

Case 9

• 24-year-old woman with history of Marfan syndrome who presented with acute onset of chest pain radiating into the neck. Clinical suspicion was high for aortic dissection with possible extension into coronary arteries or great arteries in the neck.

• Thoracic CT angiography done on TRO Extended Protocol

Case 9

• Right. Coronal maximum intensity projection (MIP) image demonstrates enhancement of aorta, pulmonary arteries, and great vessels extending from the aortic arch with no dissection.

• Left Oblique MIP image demonstrates normal aortic arch and descending thoracic aorta.

Case 9

• Right Oblique coronal MIP image demonstrates normal left ventricular outflow tract extending into proximal part of aortic arch. However, there is air in tissues of the neck surrounding great vessels (arrows). Left Coronal MIP image through the trachea demonstrates extensive free air in soft tissue planes.

Case 10

• 37-year-old woman with no relevant cardiac history presented with sudden onset of chest pain while at work.

• Thoracic TRO angiography done.

Case 10

• MIP images of (right) left anterior descending artery in long axis of the aortic root and (left) left anterior descending artery in orthogonal obliquity in the short axis of the aortic root.

• 75% stenosis of the left anterior descending artery (arrow).

Raff G.L. et.al. SCCT guidelines on the use of coronary computed tomographic angiography for patients presenting with acute chest pain to the emergency department: A Report of the Society of Cardiovascular Compute Tomography Guidelines Committee. J o u rnal of Ca r d i o v a s c u l a r Computed Tomography 8 ( 2 0 1 4 ) 2 5 4e2 7 1

Markedly elevated calcium score

• (Right) Axial image at a slightly lower level demonstrates calcification in the LAD, circumflex, and RCA. Mild calcification is also identified in the posterior mitral annulus (arrowhead). (Left) Calcium in the three major coronary arteries is color-coded. The mitral annular calcification is labeled in pink and is not included in the calcium score. The total Agatston calcium of 2726.1 is markedly elevated, suggesting increased risk for a coronary event.

Pitfalls In MDCT Cardiac Imaging

• Image quality suffers from fast heart rate– Requires premedication with β-blockers

• Arrhythmias, ectopy, or ECG artifacts result in degradation of image quality– ECG-gating critical to coronary imaging

• Radiation dose to patient• Provides anatomic information, and debates

about physiologic data

Chinnaiyan KM, et al. Cardiol Clin. 2009 Nov;27(4):587-96.

Take Home Message

• Provides excellent spatial resolution provides superior information of anatomy

• Provides functional information through blood perfused volume and stress protocols

• Ability for plaque analysis• Appropriate use of Triple-Rule-Out Protocol can

explore other differential diagnoses for chest pain• MDCT imaging protocols incorporated into ACS

workup demonstrates savings in time to diagnosis, costs while providing good patient outcomes

THANK YOU