Volume 2 Issue 1 - 2015
Coronary Computed Tomographic Angiography in Assessment of Suspected Coronary Artery Disease and Chest Pain in the ER
Erlon Oliveira de Abreu-Silva1*, Alfredo Augusto Eyer-Rodrigues2
1Division of Interventional Cardiology and Post-graduation Program in Cardiology, Federal University of Sao Paulo, Sao Paulo, Brazil
2Division of Cardiovascular Imaging and Post-graduation Program in Cardiology, Federal University of Sao Paulo, Brazil
*Corresponding Author: Erlon Oliveira de Abreu-Silva, Division of Interventional Cardiology, Vila Clementino, Sao Paulo-SP, Brazil.
Received: August 17, 2015; Published: August 20, 2015
Citation: Erlon Oliveira de Abreu-Silva and Alfredo Augusto Eyer-Rodrigues.“Coronary Computed Tomographic Angiography In Assessment Of Suspected Coronary Artery Disease And Chest Pain In The ER”. EC Cardiology 2.1 (2015): 68-70.
The definitive diagnosis of chest pain in the emergency room (ER) is not always easy. The appropriate workup in these cases begins with a skilled assessment of the patient's symptoms and a careful review of history and physical examination, followed by a series of electrocardiograms and measurement of serum biochemical markers such as troponin, BNP, ProBNP and d-dimer.
The differential diagnosis must be both quickly and precisely drafted, and, in a large number of cases, it is difficult to differentiate between the three major life-threatening causes of chest pain [1,2] coronary artery disease (CAD) , acute aortic syndrome, and pulmonary embolism.
The development of newer generations of multidetector computed tomographic (MDCT) scanners, which are capable not only of performing high-quality noninvasive coronary angiography, but also concurrent aortic and pulmonary angiography, has led to the increased use of MDCT for the so-called "triple rule out." This protocol can be very useful and potentially cost effective when used appropriately, specially for patients who present with acute chest pain but are considered to have low to intermediate risk for acute coronary syndrome, and whose chest pain symptoms might also be attributed to acute pathologic conditions of the aorta or pulmonary arteries [3-5]. MDCT should not be used as a routine screening procedure. Its great value is seen when used for resolution of cases with uncertain diagnosis, mainly when these diagnostic doubts can generate easily avoidable iatrogenic circumstances for the patient.
Coronary computed tomographic angiography (CCTA) is a well established tool for noninvasive evaluation of low to moderate risk chest pain. Several studies have demonstrated the efficacy and safety of this examination to discard CAD in symptomatic patient and, in most cases, it is - at least - as effective as other diagnostic methods such as stress tests and SPECT myocardial perfusion imaging [6-8]. The introduction of CCTA in the ER for evaluating patients with chest pain can reduce the time of in-hospital observation as well as allowing early discharge with greater security [6,8-10]. In addition, within the public service, a complete evaluation and risk stratification in one hospital and the definition of which patient really needs specialized treatment can help to reduce the high demand for outpatient consultations and cardiac tests [11,12].
The findings from the PROMISE [13] (Multicenter Imaging Study for Evaluation of Chest Pain) trial show that CCTA is a viable alternative to functional stress testing to assess symptomatic, intermediate risk patients, i.e., for whom the latter is currently recommended. They also support the expanded use of CCTA as an equally effective and safe procedure for patients presenting with suspected heart disease. As a matter of fact, an initial strategy with CCTA was associated with a significant lower rate of invasive catheterization without obstructive CAD (28%)  compared to a functional strategy with stress test that demonstrated 52% of invasive catheterization without obstructive CAD. This study can significantly impact daily clinical practice, with the potential to reduce the number of unnecessary invasive angiograms, stress tests and other resource-intensive procedures. Interestingly, there was also a significant early benefit of the CCTA strategy over functional imaging for decreasing hard events (death or non-fatal MI) in 12 months.
On the other hand, the SCOT-HEART [14,15] (CT coronary angiography in patients with suspected angina due to coronary heart disease) trial reported encouraging findings about the effectiveness of CCTA compared to conventional stress testing since it demonstrated that CCTA provided a clearer and more precise diagnosis of CAD, reclassifying the diagnosis in one of every 4 patients. The use of CCTA led to changes in treatment strategies, resulting in a 38% reduction on CAD death and non-fatal myocardial infarction (MI) when compared to the standard of care. Although this fell just short of statistical significance, the findings are promising, yet they need to be confirmed by longer term follow-up.  CCTA was also associated with an impressive 38% reduction in MI.  Although this reached borderline statistical significance, it supports the likelihood that CCTA can identify high risk plaque that may be a harbinger of an acute coronary event [16,17].
One of the most important conclusions in the Scottish trial is that median radiation dose for CCTA was only 4.1 mSv, continuing the rapidly accelerating downward trend thanks to technological advances and rigorous professional training. Wherein the latest software and hardware updates have achieved even lower radiation levels downstream 1mSv (or lower) target. 
In summary, for the evaluation of suspected acute coronary syndrome SCOT HEART and PROMISE provide compelling evidence that CCTA should be part of the everyday testing armamentarium for evaluating patients with low to intermediate risk. These results provide persuading evidence to review coverage and medical necessity decision rules: CCTA is of high clinical value in identifying high risk plaque, determining the existence (and severity) of coronary stenosis, and improving clinical outcomes of symptomatic patients. On the other hand with technical improvements in acquisition speed and spatial resolution of computed tomography images, and development of more efficient image reconstruction algorithms which reduce patient exposure to radiation and contrast, may result in increased popularity of MDCT for "triple rule-out."
  1. Hamm CW., et al. “ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation”. European Heart Journal  32.23 (2011): 2999-3054.
  2. Boyle RM. “Value of rapid-access chest pain clinics”. Heart 93.4 (2007): 415-416.
  3. Frauenfelder T., et al. Triple rule-out CT in the emergency department: protocols and spectrum of imaging findings. European Radiology 19.4 (2009): 789-799. 
  4. Khan ZA., et al. “Can computerized tomographic angiography be used to triage patients with chest pain presenting to the emergency department?” Journal of Postgraduate Medical Institute 26.3 (2012): 266-271. 
  5. Schuchlenz H., et al. “High-pitch dual source CT allows triple-rule-out with a high accuracy and a low radiation dose in real live patients: first experience in non selected symptomatic patients”. European Heart Journal 31 (2010): 292-293. 
  6. Pines JM and Szyld D. “Risk tolerance for the exclusion of potentially life-threatening diseases in the ED”. American Journal of Emergency Medicine 25.5 (2007): 540-544.
  7. Miller JM., et al. “Diagnostic performance of coronary angiography by 64-row CT”. The New England Journal of Medicine 359.22 (2008): 2324-2336.
  8. Mowatt G., et al. “Systematic review of the clinical effectiveness and cost-effectiveness of 64-slice or higher computed tomography angiography as an alternative to invasive coronary angiography in the investigation of coronary artery disease”. Health technology assessment 12.17 (2008): iii-iv, ix-143.
  9. Cury RC., et al. “Triage of Patients Presenting With Chest Pain to the Emergency Department: Implementation of Coronary CT Angiography in a Large Urban Health Care System”. American Journal of Roentgenology 200.1 (2013): 57-65. 
  10. Hoffmann U., et al. “Coronary CT Angiography versus Standard Evaluation in Acute Chest Pain”. The New England Journal of Medicine 367.4 (2012): 299-308.
  11. Durmus T., et al. “Low-dose triple-rule-out using 320-row-detector volume MDCT-less contrast medium and lower radiation exposure”. European Radiology  21. 7 (2011):1416-1423.
  12. Ayaram D., et al. “Triple rule-out computed tomographic angiography for chest pain: a diagnostic systematic review and meta-analysis”. Academic Emergency Medicine 20.9 (2013): 861-871. 
  13. Litt HI., et al. “CT Angiography for Safe Discharge of Patients with Possible Acute Coronary Syndromes”. The New England Journal of Medicine 366.15 (2012): 1393-1403.
  14. Douglas., et al.Outcomes of anatomical versus functional testing for coronary artery disease”. The New England Journal of Medicine 372.14 (2015): 1291-1300.
  15. SCOT-HEART investigators. “CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): an open-label, parallel-group, multicentre trial”. Lancet 385.9985 (2015): 2383-2391.
  16. Dewey M., et al. “Noninvasive coronary angiography by 320-row computed tomography with lower radiation exposure and maintained diagnostic accuracy: comparison of results with cardiac catheterization in a head-to-head pilot investigation”. Circulation 120.10 (2009): 867-875.
  17. Layritz C., et al. “Accuracy of prospectively ECG-triggered very low-dose coronary dual-source CT angiography using iterative reconstruction for the detection of coronary artery stenosis: comparison with invasive catheterization”. European Heart Journal - Cardiovascular Imaging 15.11 (2014): 1238-1245. 
Copyright: © 2015 Erlon Oliveira de Abreu-Silva and Alfredo Augusto Eyer-Rodrigues. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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