Integrating Multidetector Computed Tomography Into Clinical Practice

Impact of 64-slice cardiac computed tomographic angiography on clinical decision-making in emergency department patients with chest pain of possible myocardial ischemic origin

To examine the impact of contrast enhanced multidetector computed tomography (MDCT) on clinical decision-making in patients who present to the emergency department (ED) with chest pain of possible ischemic origin, we studied 58 consecutive patients (age 56 +/- 10 years, 36% female) with chest pain, intermediate risk, and no ischemic electrocardiographic changes or increased biomarker measurements. After standard ED patient assessment including cardiology consultation, a diagnosis of acute coronary syndrome was made in 41 patients (71%), hospitalization was recommended in 47 (81%), and 32 (55%) were scheduled for an early invasive strategy. Patients underwent 64-slice contrast agent-enhanced MDCT with image reconstruction in multiple formats using retrospective electrocardiographic gating, which revealed normal (no or trivial atheroma) coronary vasculature in 15 patients, nonobstructive atheroma in 20 patients, and obstructive coronary disease (> or =1 luminal narrowing of > or =50%) in 23 patients. After MDCT, the diagnosis of acute coronary syndrome was revised in 18 of 41 patients (44%; 16 normal MDCT/widely patent stents, 2 alternative diagnoses), planned hospitalization canceled in 21 of 47 patients (45%; 13 normal MDCT/patent stent, 8 minor branch vessel disease), and planned early invasive strategy altered in 25 of 58 patients (43%; unnecessary in 20 of 32, advisable in 5 of 26 others). Effect of MDCT on clinical decisions was greater in the 36 patients without known preceding coronary disease. In 32 patients discharged from the ED (11 after initial triage, 21 patients after MDCT), there were no major adverse cardiac events (e.g., death, myocardial infarction, unplanned revascularization) during a 12-month follow-up period. In conclusion, contrast agent-enhanced 64-slice cardiac MDCT was a valuable diagnostic tool in the ED triage of patients with chest pain of possible ischemic origin and decreased the need for hospitalization by almost half in this patient cohort.