Limited Axial Interpretation of Coronary CT Angiography in the Emergency Department Setting

PURPOSE

Incorporating coronary CT angiographic (CCTA) imaging into emergency department (ED) workflows has been limited by the need for 24/7 real-time postprocessing. The aim of this study was to determine whether interpretation of transaxial CCTA images alone (limited axial interpretation [LI]) is noninferior to interpretation of combined transaxial and multiplanar reformation images (full interpretation [FI]) in assessing patients with acute chest pain in the ED.

METHODS

CCTA examinations from 74 patients were evaluated by two radiologists, one without dedicated CCTA training and one with basic CCTA experience. Each examination was evaluated three times in separate sessions, once by LI and twice by FI, in random order. Nineteen coronary artery segments were rated as having significant stenoses (≥50%) or not. Interreader agreement was assessed using Cohen's κ statistic. The primary analysis was whether the accuracy of LI for detecting significant stenosis was noninferior to that of FI at the patient level (margin = -10%). Secondary analyses included similar analyses of sensitivity and specificity, at both the patient and vessel levels.

RESULTS

Interreader agreement for significant stenosis was good for both LI and FI (κ = 0.72 vs 0.70, P = .74). Average accuracy for significant stenosis at the patient level was 90.5% for LI and 91.9% for FI, with a difference of -1.4%. The accuracy of LI was noninferior to FI, because the confidence interval did not include the noninferiority margin. Noninferiority was also found for patient-level sensitivity and for accuracy, sensitivity, and specificity at the vessel level.

CONCLUSIONS

LI of the coronary arteries using transaxial CCTA images may be sufficient for the detection of significant coronary artery disease in the ED setting.

Incidence, Pattern, Causes, and Outcome of Acute Chest Pain Among Patients Presenting in the Emergency Department of a Tertiary Care Hospital in North India

BACKGROUND

Acute chest pain is a common presentation in emergency departments worldwide. Differentiating between cardiac and non-cardiac chest pain is crucial for patient management and resource allocation.

METHODS

This study analyzed 714 patients presenting with acute chest pain in a tertiary care hospital in North India. We investigated demographic characteristics, chief complaints, risk factors, ECG findings, and final diagnoses to identify patterns associated with cardiac (CCP) and non-cardiac chest pain (NCCP).

RESULTS

CCP was diagnosed in 53.7% (n=383) and NCCP in 46.3% (n=331). Significant predictors of CCP included age (OR=1.05, p<0.001), smoking (OR=2.22, p<0.001), diabetes (OR=1.57, p=0.003), hypertension (OR=1.82, p<0.001), and family history of ischemic heart disease (IHD) (OR=1.42, p=0.01). Central chest pain was more common in CCP (60% vs. 40%, p<0.001), as were abnormal ECG findings such as ST-segment depression (35% vs. 10%, p<0.001) and elevation (29% vs. 6%, p<0.001). Normal ECG was more prevalent in NCCP (60%, p<0.001).

CONCLUSION

Traditional cardiovascular risk factors remain strongly associated with CCP. Smoking has a particularly high odds ratio, suggesting the need for targeted interventions. ECG findings significantly aid in differentiating CCP from NCCP. This study underscores the importance of a comprehensive approach in evaluating acute chest pain to ensure accurate diagnosis and effective treatment.

Prehospital Targeting of 1-Year Mortality in Acute Chest Pain by Cardiac Biomarkers

The identification and appropriate management of patients at risk of suffering from acute chest pain (ACP) in prehospital care are not straightforward. This task could benefit, as occurs in emergency departments (EDs), from cardiac enzyme assessment. The aim of the present work was to derive and validate a scoring system based on troponin T (cTnT), N-terminal pro B-type natriuretic peptide (NT-proBNP), and D-dimer to predict 1-year mortality in patients with ACP. This was a prospective, multicenter, ambulance-based cohort study of adult patients with a prehospital ACP diagnosis who were evacuated by ambulance to the ED between October 2019 and July 2021. The primary outcome was 365-day cumulative mortality. A total of 496 patients fulfilled the inclusion criteria. The mortality rate was 12.1% (60 patients). The scores derived from cTnT, NT-proBNP, and D-dimer presented an AUC of 0.802 (95% CI: 0718-0.886) for 365-day mortality. This AUC was superior to that of each individual cardiac enzyme. Our study provides promising evidence for the predictive value of a risk score based on cTnT, NT-proBNP, and D-dimer for the prediction of 1-year mortality in patients with ACP. The implementation of this score has the potential to benefit emergency medical service care and facilitate the on-scene decision-making process.

Magnetocardiography at rest predicts cardiac death in patients with acute chest pain

Introduction

Sudden cardiac arrest is a major cause of morbidity and mortality worldwide and remains a major public health problem for which better non-invasive prediction tools are needed. Primary preventive therapies, such as implantable cardioverter defibrillators, are not personalized and not predictive. Most of these devices do not deliver life-saving therapy during their lifetime. The individual relationship between fatal arrhythmias and cardiac function abnormalities in predicting cardiac death risk has rarely been explored.

Methods

We retrospectively analyzed the measurements at rest for 191 patients with acute chest pain (ACP) magnetocardiographically. Our recently introduced analyses are able to detect inhomogeneities of the depolarization and repolarization. Moreover, electrically silent phenomena-intracellular ionic currents as well as vortex currents-can be measured and quantified. All included ACP patients were recruited in 2009 at Yonsei University Hospital and were followed up until 2022.

Results

During half of the follow-up period (6.5 years), 11 patients died. Out of all the included nine clinical, eight magnetocardiographical, and nine newly introduced magnetoionographical parameters we tested in this study, three parameters revealed themselves to be outstanding at predicting death: heart rate-corrected QT (QTc) prolongation, depression of repolarization current IKr + IKs, and serum creatinine (all significant in Cox regression, p < 0.05). They clearly predicted cardiac death over the 6.5 years duration (sensitivity 90.9%, specificity 85.6%, negative predictive accuracy 99.4%). Cardiac death risk was more than ninefold higher in patients with low repolarization reserve and QTc prolongation in comparison with the remaining patients with ACP (p < 0.001). The non-parametric Kaplan-Meier statistics estimated significantly lower survival functions from their lifetime data (p < 0.001).

Discussion

To the best of our knowledge, these are the first data linking magnetocardiographical and magnetoionographical parameters and subsequent significant fatal events in people, suggesting structural and functional components to clinical life-threatening ventricular arrhythmogenesis. The findings support investigation of new prevention strategies and herald those new non-invasive techniques as complementary risk stratification tools.

Cocaine-Induced Ascending Aortic Thrombus

Aortic thrombosis without coexisting atherosclerosis is uncommon. Sometimes, aneurysms or dissections can predispose to thrombus in the abdominal or thoracic aorta. However, ascending aortic thrombus in a non-aneurysmal, non-atherosclerotic aorta is a rare occurrence. Although arterial thrombosis has been linked with its use, cocaine-associated thrombus of the ascending aorta has been rarely described. We report a young man with regular use of cocaine presenting with constant, burning, left-sided chest pain. He was found to have a large thrombus in a structurally normal ascending aorta. Medical management with therapeutic anticoagulation was started. Despite an interruption of anticoagulation treatment for two months due to non-compliance, the man survived. This unique case highlights the importance of various vascular complications associated with cocaine use, their early recognition, and their treatment.

Independent Predictors of Repeat Emergency Room Presentations: Insights from a Cohort of 1066 Consecutive Patients with Non-Cardiac Chest Pain Generating 4770 Repeat Presentations

BACKGROUND AND IMPORTANCE

Chest pain (CP) is one of the most frequent presentations to the emergency department (ED), a large proportion of which is non-cardiac chest pain (NCCP). Repeat attendances to ED are common and impose considerable burden to overstretched departments.

OBJECTIVE

Our aim was to determine drivers for repeat ED presentations using NCCP as the primary cause of index presentation.

DESIGN, SETTING AND PARTICIPANTS

This was a retrospective cohort study of 1066 consecutive presentations with NCCP to a major urban hospital ED in North England. Index of Multiple Deprivation (IMD), a postcode-derived validated index of deprivation, was computed. Charlson comorbidity index (CCI) was determined by reference to known comorbidity variables. Repeat presentation to ED to any national hospital was determined by a national linked database (population 53.5 million). Independent predictors of ED representation were computed using logistic regression analysis.

RESULTS

Median age was 43 (IQR 28-59), and 50.8% were male. Furthermore, 27.8%, 8.1% and 3.8% suffered from chronic obstructive pulmonary disease (COPD), hypertension and diabetes mellitus, respectively. The most frequent diagnoses, using ICD-10 coding, were non-cardiac chest pain (55.1%), followed by respiratory conditions (14.7%). One-year incidence of adjudicated myocardial infarction, urgent or emergency coronary revascularisation and all-cause death was 0.6%, 2% and 5.3%, respectively. There was a total of 4770 ED repeat presentations 1 year prior to or following index presentation with NCCP in this cohort. Independent (multivariate) predictors for frequent re-presentation (defined as ≥2 representations) were a history of COPD (OR [odds ratio] 2.06, p = 0.001), previous MI (OR3.6, p = 0.020) and a Charlson comorbidity index ≥1 (OR 1.51, p = 0.030). The frequency of previous MI was low as only 3% had sustained a previous MI.

CONCLUSIONS

This analysis indicates that COPD and complex health care needs (represented by high CCI), but not socio-economic deprivation, should be health policy targets for lessening repeat ED presentations. What is already known on this topic: Repeat presentations with non-ischaemic chest pain are common, placing a considerable burden on emergency departments.

WHAT THIS STUDY ADDS

COPD and complex health care needs, denoted by Charlson comorbidity index, are implicated as drivers for repeat presentation to accident and emergency department. Socio-economic deprivation was not an independent predictor of re-presentation. How might this study affect research, practice, or policy: Community-based support for COPD and complex health care needs may reduce frequency of ED attendance.

Concurrent Pacemaker Lead Perforation and Subacute Coronary Stent Thrombosis: A Case Report

Stent thrombosis and lead perforation are important differentials for patients presenting with chest pain following recent coronary stent insertion and pacemaker insertion. In this report, we describe an unusual case of a 78-year-old male who presented with sharp chest pain one week after admission for posterior ST-elevation myocardial infarction (STEMI) and subsequent Mobitz type II block, for which he received primary percutaneous coronary intervention (PPCI) to the left circumflex artery (LCx) and dual chamber permanent pacemaker (PPM) insertion. Computed tomography (CT) chest and CT coronary angiogram (CTCA), respectively, showed he had concurrent lead perforation and stent thrombosis. On balance, the cause of chest pain was likely lead perforation. This diagnosis was reached by having a high index of suspicion for both of these important post-procedure complications and investigating appropriately.

Diagnosis of an Acute Anterior Wall Infarction in Dual-Energy CT

Due to its high morbidity and mortality, myocardial infarction is the leading cause of death worldwide. Against this background, rapid diagnosis is of immense importance. Especially in case of an atypical course, the correct diagnosis may be delayed and thus lead to increased mortality rates. In this report, we present a complex case of acute coronary syndrome. A triple-rule-out CT examination was performed in dual-energy CT (DECT) mode. While pulmonary artery embolism and aortic dissection could be ruled out with conventional CT series, the presence of anterior wall infarction was only detectable on DECT reconstructions. Subsequently, adequate and rapid therapy was then initiated leading to survival of the patient.

Clinical applications of cardiac computed tomography: a consensus paper of the European Association of Cardiovascular Imaging-part I

Cardiac computed tomography (CT) was introduced in the late 1990's. Since then, an increasing body of evidence on its clinical applications has rapidly emerged. From an initial emphasis on its technical efficiency and diagnostic accuracy, research around cardiac CT has now evolved towards outcomes-based studies that provide information on prognosis, safety, and cost. Thanks to the strong and compelling data generated by large, randomized control trials, the scientific societies have endorsed cardiac CT as pivotal diagnostic test for the management of appropriately selected patients with acute and chronic coronary syndrome. This consensus document endorsed by the European Association of Cardiovascular Imaging is divided into two parts and aims to provide a summary of the current evidence and to give updated indications on the appropriate use of cardiac CT in different clinical scenarios. This first part focuses on the most established applications of cardiac CT from primary prevention in asymptomatic patients, to the evaluation of patients with chronic coronary syndrome, acute chest pain, and previous coronary revascularization.

Coronary Calcium to Rule Out Obstructive Coronary Artery Disease in Patients With Acute Chest Pain

OBJECTIVES

This study aimed to evaluate the ability of coronary artery calcium (CAC) as an initial diagnostic tool to rule out obstructive coronary artery disease (CAD) in a very large registry of patients presenting to the emergency department (ED) with acute chest pain (CP) who were at low to intermediate risk for acute coronary syndrome (ACS).

BACKGROUND

It is not yet well established whether CAC can be used to rule out obstructive CAD in the ED setting.

METHODS

We included patients from the Baptist Health South Florida Chest Pain Registry presenting to the ED with CP at low to intermediate risk for ACS (Thrombolysis In Myocardial Infarction risk score ≤2, normal/nondiagnostic electrocardiography, and troponin levels) who underwent CAC and coronary computed tomography angiography (CCTA) procedures for evaluation of ACS. To assess the diagnostic accuracy of CAC testing to diagnose obstructive CAD and identify the need for coronary revascularization during hospitalization, we estimated sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV).

RESULTS

Our study included 5,192 patients (mean age: 53.5 ± 10.8 years; 46% male; 62% Hispanic). Overall, 2,902 patients (56%) had CAC = 0, of which 135 (4.6%) had CAD (114 [3.9%] nonobstructive and 21 [0.7%] obstructive). Among those with CAC >0, 23% had obstructive CAD. Sensitivity, specificity, PPV, and NPV of CAC testing to diagnose obstructive CAD were 96.2%, 62.4%, 22.4%, and 99.3%, respectively. The NPV for identifying those who needed revascularization was 99.6%. Among patients with CAC = 0, 11 patients (0.4%) underwent revascularization, and the number needed to test with CCTA to detect 1 patient who required revascularization was 264.

CONCLUSIONS

In a large population presenting to ED with CP at low to intermediate risk, CAC = 0 was common. CAC = 0 ruled out obstructive CAD and revascularization in more than 99% of the patients, and <5% with CAC = 0 had any CAD. Integrating CAC testing very early in CP evaluation may be effective in appropriate triage of patients by identifying individuals who can safely defer additional testing and more invasive procedures.

When Blades broke my heart

Takotsubo cardiomyopathy (TCM) was first described about 30 years ago. It has been attributed to the sudden catecholamine surge in relation to severe stress, which can cause multi-vessel coronary spasms and myocardial apical ballooning. Football supporters are prone to develop severe stress due to sudden changes in match results. This case presents a football supporter of Sheffield United (the Blades) who was admitted to the hospital with cardiac sounding chest pain following a last minute goal by the opposing team. The necessary investigations were carried out including coronary angiogram and echocardiogram. He was diagnosed with TCM following a left ventricular angiogram demonstrating the typical appearance of the octopus pot.

Current Role of Computed Tomography in the Evaluation of Acute Coronary Syndrome

This review article provides an overview regarding the role of computed tomography (CT) in the evaluation of acute chest pain (ACP) in the emergency department (ED), focusing on characteristic CT findings.

Epipericardial Fat Necrosis: A Case Report and a Review of the Literature

Epipericardial fat necrosis (EFN), also known as pericardial or mediastinal fat necrosis, has until lately been considered an unusual cause of acute chest pain. Due to increased use of computed tomography (CT) and other imaging techniques, EFN is now believed to be an under-diagnosed cause of acute chest pain. We here present a patient with a short history of acute, left-sided pleuritic chest pain and dyspnoea, with total resolution of symptoms upon few days with nonsteroidal anti-inflammatory drugs (NSAIDs) treatment. Chest X-ray showed a paracardial opacity with ipsilateral pleural effusion, echocardiography revealed features of EFN, and CT scan demonstrated the cardinal lesion of EFN—an ovoid, fat-containing paracardial mass with surrounding inflammatory stranding. There was a near to full radiological resolution in 3 weeks.

Diaphragmatic Rupture and Gastric Perforation in a Patient with COVID-19 Pneumonia

We describe the case of a young female patient admitted to our emergency department during the Italian COVID-19 epidemic, for fever and dry cough associated with symptoms of gastric reflux over the previous 5 days. Lung ultrasound showed diffuse bilateral B lines with irregular pleural thickening, and consolidation with air bronchogram and slight pleural effusion in the lower left lobe. Chest HRCT and abdominal CT scanning with contrast revealed diaphragmatic rupture with gastric perforation, and atelectasis of the left pulmonary lobe with unilateral pleural effusion, diffuse ground-glass opacities and multiple small consolidations in both lobes. A nasopharyngeal swab for 2019-nCoV was positive. A diagnosis of diaphragmatic rupture and gastric perforation in COVID-19 pneumonia was made. The patient was immediately hospitalized and surgically treated. Treatment for COVID-19 and empiric antibiotic therapy were promptly started.

Challenges in the diagnosis of Boerhaave syndrome: A case report

RATIONALE

Acute chest pain remains one of the most challenging complaints of patients presenting to emergency departments (EDs). The diverse etiologies of chest pain frequently lead to diagnostic and therapeutic challenges. Esophageal perforation is a rare but potentially life-threatening disease. It results in delayed diagnosis and an estimated mortality risk of 20% to 40%. Prompt diagnosis and immediate therapeutic interventions are key factors for a good prognosis.

PATIENT CONCERNS

Case 1 involved a 66-year-old man who presented to the ED with acute chest pain radiating to the back and hematemesis. Emergent contrast thoracic computerized tomography (CT) indicated the presence of a massive pneumothorax with pleural effusion. The continuous drainage of a dark-red bloody fluid following emergent thoracic intubation led to the discovery that the patient had experienced severe vomiting after whiskey consumption before admission to the hospital. Re-evaluation of the CT indicated spontaneous pneumomediastinum, whereas barium esophagography confirmed the presence of an esophageal perforation. Case 2 involved an 18-year-old Vietnamese man admitted to our ED with acute chest pain and swelling of the neck after vomiting due to beer consumption. A chest x-ray indicated diffuse subcutaneous emphysema of the neck and upper thorax. Contrast CT indicated pneumomediastinum with extensive emphysema and air in the paraspinal region and spinal canal.

DIAGNOSES

Both of the 2 cases were diagnosed as spontaneous perforation of the esophagus (Boerhaave syndrome [BS]).

INTERVENTIONS

Case 1 received surgical interventions, whereas case 2 decided not to avail our medical services.

OUTCOMES

Case 1 was discharged after a good recovery. Case 2 lost to follow-up.

LESSONS

We recommend all physicians in the ED to raise their index of suspicion for BS when dealing with patients having acute chest pain, dyspnea, confirmed pneumothorax, or newly-developed pleural effusion.

Clinical Use of CT-Derived Fractional Flow Reserve in the Emergency Department

OBJECTIVES

This study sought to examine the feasibility, safety, clinical outcomes, and costs associated with computed tomography-derived fractional flow reserve (FFR_CT) in acute chest pain (ACP) patients in a coronary computed tomography angiography (CTA)-based triage program.

BACKGROUND

FFR_CT is useful in determining lesion-specific ischemia in patients with stable ischemic heart disease, but its utility in ACP has not been studied.

METHODS

ACP patients with no known coronary artery disease undergoing coronary CTA and coronary CTA with FFR_CT were studied. FFR_CT ≤0.80 was considered positive for hemodynamically significant stenosis.

RESULTS

Among 555 patients, 297 underwent coronary CTA and FFR_CT (196 negative, 101 positive), whereas 258 had coronary CTA only. The rejection rate for FFR_CT was 1.6%. At 90 days, there was no difference in major adverse cardiac events (including death, nonfatal myocardial infarction, and unexpected revascularization after the index visit) between the coronary CTA and FFR_CT groups (4.3% vs. 2.7%; p = 0.310). Diagnostic failure, defined as discordance between the coronary CTA or FFR_CT results with invasive findings, did not differ between the groups (1.9% vs. 1.68%; p = NS). No deaths or myocardial infarction occurred with negative FFR_CT when revascularization was deferred. Negative FFR_CT was associated with higher nonobstructive disease on invasive coronary angiography (56.5%) than positive FFR_CT (8.0%) and coronary CTA (22.9%) (p < 0.001). There was no difference in overall costs between the coronary CTA and FFR_CT groups ($8,582 vs. $8,048; p = 0.550).

CONCLUSIONS

In ACP, FFR_CT is feasible, with no difference in major adverse cardiac events and costs compared with coronary CTA alone. Deferral of revascularization is safe with negative FFR_CT, which is associated with higher nonobstructive disease on invasive angiography.

Coronary CT angiography in acute chest pain

Coronary computed tomographic angiography has become a reliable diagnostic tool in the evaluation of patients with chest pain. Studies have shown this modality to be accurate and safe when compared with conventional methods of assessing patients with chest pain. We review the recent developments with coronary computed tomographic angiography and devote particular attention toward its application to triage patients in the emergency department.

Impact of Coronary Calcification on Clinical Management in Patients With Acute Chest Pain

BACKGROUND

Coronary artery calcification (CAC) may impair diagnostic assessment of coronary computed tomography angiography (CTA). We determined whether CAC affects efficiency of coronary CTA in patients with suspected acute coronary syndrome (ACS).

METHODS AND RESULTS

This is a pooled analysis of ACRIN-PA (American College of Radiology Imaging Network-Pennsylvania) 4005 and the ROMICAT-II trial (Rule Out Myocardial Infarction/Ischemia Using Computer Assisted Tomography) comparing an initial coronary CTA strategy to standard of care in acute chest pain patients. In the CTA arms, we investigated appropriateness of downstream testing, cost, and diagnostic yield to identify patients with obstructive coronary artery disease on subsequent invasive coronary angiography across CAC score strata (Agatston score: 0, >0-10, >10-100, >100-400, >400). Out of 1234 patients (mean age 51±8.8 years), 80 (6.5%) had obstructive coronary artery disease (≥70% stenosis) and 68 (5.5%) had ACS. Prevalence of obstructive coronary artery disease (1%-64%), ACS (1%-44%), downstream testing (4%-72%), and total (2337-8484 US$) and diagnostic cost (2310-6678 US$) increased across CAC strata (P<0.001). As the increase in testing and cost were lower than the increase of ACS rate in patients with CAC>400, cost to diagnose one ACS was lowest in this group (19 283 US$ versus 464 399 US$) as compared with patients without CAC. The diagnostic yield of invasive coronary angiography was highest in patients with CAC>400 (87% versus 38%).

CONCLUSIONS

Downstream testing, total, and diagnostic cost increased with increasing CAC, but were found to be appropriate because obstructive coronary artery disease and ACS were more prevalent in patients with high CAC. In patients with acute chest pain undergoing coronary CTA, cost-efficient testing and excellent diagnostic yield can be achieved even with high CAC burden.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifiers: NCT01084239 and NCT00933400.

Left Ventricular Pseudoaneurysm Dissecting into the Anterior Chest Wall: A Rare Cause of Sudden Onset Excruciating Chest Pain

Left ventricular pseudoaneurysm (LVPA) is associated with a significant mortality rate of up to 45% in the first year after diagnosis. It is a very rare entity and hence the true incidence and natural history are not clearly known. Clinical presentation varies widely and requires a high index of suspicion for diagnosis. We report the case of a 72-year-old woman with a remote history of left ventricular aneurysm repair during coronary bypass surgery who presented to the emergency department with acute onset of left-sided chest pain and a pulsatile chest wall swelling. She was haemodynamically stable but required an intravenous morphine drip for pain control. Contrast-enhanced computed tomography of the chest showed a large LVPA dissecting through the anterior chest wall. Surgical treatment was discussed with the patient but she opted in favour of comfort care. She died 5 days later from complete rupture of the LVPA. With this report, we aim to raise the level of awareness of LVPA that could anatomically expand and rupture. Early diagnosis and timely surgical intervention is the treatment of choice.

Doxycycline induced oesophageal ulcers in a navy ship crewmember

A healthy 25-year-old crewmember of a navy ship was diagnosed with suspected pneumonia and prescribed 100 mg twice a day of doxycycline for 10 days. During the 7th day of treatment the patient joined his navy ship to sail aboard and 2 days later, immediately after taking the doxycycline capsule, he felt a forceful pain in the median chest which was followed with odynophagia of both solid foods and liquids. The patient adhered to the administration guidelines of the doxycycline, except drinking 330 mL of beer, 3 h before taking the capsule. A working diagnosis of atypical chest pain, possibly due to oesophagitis, was made. The patient was advised to fast and rest and treatment with intravenously (IV) H2-receptor antagonist, clear fluids and analgesics was started. Later on, due to lack of improvement in the patient's status and the potential risk of future deterioration, a decision was made to evacuate the patient to a hospital. Gastroscopy, revealed 3 ulcers in the mid-oesophagus and the patient was hospitalised for treated of IV antacids and fluids with gradual improvement. This case emphasizes the limitation of diagnosing and treating a common side effect in the middle of the sea and the potential risk in taking medications with alcohol.

Diagnostic Yield of Triple-Rule-Out CT in an Emergency Setting

OBJECTIVE

The objective of the present study is to quantify the diagnostic yield of triple-rule-out (TRO) CT for the evaluation of acute chest pain in emergency department patients.

MATERIALS AND METHODS

All TRO CT studies performed at our institution from 2006 to 2015 were reviewed. Scans were performed on a 256-MDCT scanner, with the use of ECG gating and a biphasic contrast injection. Radiology reports were reviewed to identify diagnoses that could explain chest pain, including coronary and noncoronary diagnoses, and significant incidental findings that did not account for the patient's presentation. The total numbers of coronary and noncoronary diagnoses and incidental findings were calculated.

RESULTS

Four of 1196 total cases that were identified were excluded from the study because of inadequate image quality. A total of 970 patients (81.4%) had a negative study result without a significant coronary or noncoronary diagnosis. A total of 139 patients (11.7%) had significant coronary artery disease (50% stenosis or greater). One hundred six patients (8.9%) had a noncoronary diagnosis that could explain chest pain (p < 0.02), most commonly pulmonary embolism (28 patients [2.3%]), aortic aneurysm (24 patients [2.0%]), or pneumonia (20 patients [1.7%]). Thirty cases (27.3%) of pulmonary embolism and aortic pathologic findings would not have been detected with coronary CT angiography because of unopacified right-side circulation or limited z-axis coverage. A total of 528 incidental findings not considered to explain chest pain were noted in 418 patients (35.1%).

CONCLUSION

In 8.9% of patients, TRO CT detected a significant noncoronary diagnosis that could explain acute chest pain, including pathologic findings that would not be identified on dedicated coronary CT angiography.

[Acute Chest Pain]

Acute chest pain is a frequent consultation reason in general practice as well as in emergency departments. With the help of history, physical examination, ECG, laboratory and newly developed risk scores, potentially life-threatening diseases and high-risk patients may be detected and treated early, quickly and cost-effectively. New biomarkers and their combination with risk scores can increase the negative predictive value to exclude certain diseases.

The prognostic value of CT coronary angiography in patients attending hospital with troponin-negative acute chest pain and inconclusive exercise treadmill tests

AIMS

Once acute coronary syndrome (ACS) is excluded in patients presenting to hospital with acute chest pain, usual practice is to stratify future risk of adverse cardiovascular events. Commonly this is performed by pre-discharge exercise treadmill testing (ETT). Often however, patients are unable to perform the test for various reasons, or the final result is inconclusive. This potentially could lead to uncertainty and to unnecessary invasive coronary angiography. We wished to evaluate the potential prognostic significance of CT coronary angiography (CTCA) in patients with prior inconclusive ETTs.

METHODS AND RESULTS

Two hundred and thirty-two consecutive patients underwent CTCA and calcium scoring following hospital attendance with acute chest pain and following exclusion of ACS. All patients were followed up for a combined primary outcome of death, non-fatal myocardial infarction, and late revascularization. The mean follow-up period was 2.5 ± 0.9 years. The combined primary outcome occurred in 26 patients (11.2%). Calcium score (HR 1.16; 95% CI 1.02-1.31, P = 0.023 per 100 Agatston unit increase), the presence of coronary artery disease (CAD) on CTCA (non-obstructive CAD, HR 4.52; 95% CI 1.30-15.73, P = 0.018; obstructive CAD, HR 17.00; 95% CI 4.60-62.85, P < 0.001), and ≥3 segments with non-calcified plaque (HR 3.30; 95% CI 1.24-8.76, P = 0.017) were significant univariable predictors of the primary outcome. CTCA was the only significant multivariable predictor of adverse outcome.

CONCLUSIONS

The presence of CAD assessed by CTCA is a strong predictor of adverse events in patients with troponin-negative acute chest pain and could potentially be used as an alternative, non-invasive risk stratifier in patients with inconclusive exercise tests.

Diagnostic performance of reproducible chest wall tenderness to rule out acute coronary syndrome in acute chest pain: a prospective diagnostic study

OBJECTIVES

Acute chest pain (ACP) is a leading cause of hospital emergency unit consultation. As there are various underlying conditions, ranging from musculoskeletal disorders to acute coronary syndrome (ACS), thorough clinical diagnostics are warranted. The aim of this prospective study was to assess whether reproducible chest wall tenderness (CWT) on palpation in patients with ACP can help to rule out ACS.

METHODS

In this prospective, double-blinded diagnostic study, all consecutive patients assessed in the emergency unit at the University Hospital Zurich because of ACP between July 2012 and December 2013 were included when a member of the study team was present. Reproducible CWT on palpation was the initial step and was recorded before further examinations were initiated. The final diagnosis was adjudicated by a study-independent physician.

RESULTS

121 patients (60.3% male, median age 47 years, IQR 34-66.5 years) were included. The prevalence of ACS was 11.6%. Non-reproducible CWT had a high sensitivity of 92.9% (95% CI 66.1% to 98.8%) for ACS and the presence of reproducible CWT ruled out ACS (p=0.003) with a high negative predictive value (98.1%, 95% CI 89.9% to 99.7%). Conversely non-reproducible CWT ruled in ACS with low specificity (48.6%, 95% CI 38.8% to 58.5%) and low positive predictive value (19.1%, 95% CI 10.6% to 30.5%).

CONCLUSIONS

This prospective diagnostic study supports the concept that reproducible CWT helps to rule out ACS in patients with ACP in an early stage of the evaluation process. However, ACS and other diagnoses should be considered in patients with a negative CWT test.

TRIAL REGISTRATION NUMBER

ClinicalTrial.gov: NCT01724996.

High-risk plaque detected on coronary CT angiography predicts acute coronary syndromes independent of significant stenosis in acute chest pain: results from the ROMICAT-II trial

BACKGROUND

It is not known whether high-risk plaque, as detected by coronary computed tomography angiography (CTA), permits improved early diagnosis of acute coronary syndromes (ACS) independently to the presence of significant coronary artery disease (CAD) in patients with acute chest pain.

OBJECTIVES

The primary aim of this study was to determine whether high-risk plaque features, as detected by CTA in the emergency department (ED), may improve diagnostic certainty of ACS independently and incrementally to the presence of significant CAD and clinical risk assessment in patients with acute chest pain but without objective evidence of myocardial ischemia or myocardial infarction (MI).

METHODS

We included patients randomized to the coronary CTA arm of the ROMICAT-II (Rule Out Myocardial Infarction/Ischemia Using Computer-Assisted Tomography II) trial. Readers assessed coronary CTA qualitatively for the presence of nonobstructive CAD (1% to 49% stenosis), significant CAD (≥50% or ≥70% stenosis), and the presence of at least 1 of the high-risk plaque features (positive remodeling, low <30 Hounsfield units plaque, napkin-ring sign, spotty calcium). In logistic regression analysis, we determined the association of high-risk plaque with ACS (MI or unstable angina pectoris) during the index hospitalization and whether this was independent of significant CAD and clinical risk assessment.

RESULTS

Overall, 37 of 472 patients who underwent coronary CTA with diagnostic image quality (mean age 53.9 ± 8.0 years; 52.8% men) had ACS (7.8%; MI n = 5; unstable angina pectoris n = 32). CAD was present in 262 patients (55.5%; nonobstructive CAD in 217 patients [46.0%] and significant CAD with ≥50% stenosis in 45 patients [9.5%]). High-risk plaques were more frequent in patients with ACS and remained a significant predictor of ACS (odds ratio [OR]: 8.9; 95% CI: 1.8 to 43.3; p = 0.006) after adjustment for ≥50% stenosis (OR: 38.6; 95% CI: 14.2 to 104.7; p < 0.001) and clinical risk assessment (age, sex, number of cardiovascular risk factors). Similar results were observed after adjustment for ≥70% stenosis.

CONCLUSIONS

In patients presenting to the ED with acute chest pain but negative initial electrocardiogram and troponin, presence of high-risk plaques on coronary CTA increased the likelihood of ACS independent of significant CAD and clinical risk assessment (age, sex, and number of cardiovascular risk factors). (Multicenter Study to Rule Out Myocardial Infarction by Cardiac Computed Tomography [ROMICAT-II]; NCT01084239).

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.

Chest pain in an out-of-hospital emergency setting: no relationship between pain severity and diagnosis of acute myocardial infarction

BACKGROUND

Chest pain frequently prompts emergency medical services (EMS) call-outs. Early management of acute coronary syndrome (ACS) cases is crucial, but there is still controversy over the relevance of pain severity as a diagnostic criterion.

STUDY OBJECTIVE

The aim of this study was to determine whether there is a relationship between the severity of chest pain at the time of out-of-hospital emergency care and diagnosis of acute myocardial infarction (AMI).

METHODS

This was a subsidiary analysis of prehospital data collated prospectively by EMS in a large suburb. It concerned patients with chest pain taken to hospital by a mobile intensive care unit. Pain was rated on EMS arrival using a visual analog, numeric or verbal rating scale and classified on severe or not severe according to the pain score. A diagnosis of AMI was confirmed or ruled out on the basis of 2 plasma troponin measurements and/or coronary angiography results.

RESULTS

Among the cohort of 2,279 patients included, 234 were suitable for analysis, of which 109 (47%) were diagnosed with AMI. The rate of severe pain on EMS arrival was not significantly different between AMI patients and no myocardial infarction patients (49% [95% CI 40 to 58] and 43% [34 to 52], respectively; P = 0.3; odds ratio 1.3 [0.8 - 2.3] after adjustment for age and gender).

CONCLUSION

In our out-of-hospital emergency setting, the severity of chest pain was not a useful diagnostic criterion for AMI.

Coronary CT and the coronary calcium score, the future of ED risk stratification?

Accurate and efficient evaluation of acute chest pain remains clinically challenging because traditional diagnostic modalities have many limitations. Recent improvement in non-invasive imaging technologies could potentially improve both diagnostic efficiency and clinical outcomes of patients with acute chest pain while reducing unnecessary hospitalizations. However, there is still controversy regarding much of the evidence for these technologies. This article reviews the role of coronary artery calcium score and the coronary computed tomography in the assessment of individual coronary risk and their usefulness in the emergency department in facilitating appropriate disposition decisions. The evidence base and clinical applications for both techniques are also described, together with cost- effectiveness and radiation exposure considerations.

Growth-differentiation factor-15 for early risk stratification in patients with acute chest pain

AIMS

Growth-differentiation factor-15 (GDF-15) has emerged as a biomarker of increased mortality and recurrent myocardial infarction (MI) in patients diagnosed with non-ST-elevation acute coronary syndrome. We explored the usefulness of GDF-15 for early risk stratification in 479 unselected patients with acute chest pain.

METHODS AND RESULTS

Sixty-nine per cent of the patients presented with GDF-15 levels above the previously defined upper reference limit (1200 ng/L). The risks of the composite endpoint of death or (recurrent) MI after 6 months were 1.3, 5.1, and 12.6% in patients with normal (<1200 ng/L), moderately elevated (1200-1800 ng/L), or markedly elevated (>1800 ng/L) levels of GDF-15 on admission, respectively (P < 0.001). By multivariable analysis that included clinical characteristics, ECG findings, peak cardiac troponin I levels within 2 h (cTnI(0-2 h)), N-terminal pro-B-type natriuretic peptide, C-reactive protein, and cystatin C, GDF-15 remained an independent predictor of the composite endpoint. The ability of the ECG combined with peak cTnI(0-2 h) to predict the composite endpoint was markedly improved by addition of GDF-15 (c-statistic, 0.74 vs. 0.83; P < 0.001).

CONCLUSION

GDF-15 improves risk stratification in unselected patients with acute chest pain and provides prognostic information beyond clinical characteristics, the ECG, and cTnI.