Cardiac CT in emergency department patients with acute chest pain

Current strategies for the triage of patients who have chest pain but normal initial cardiac enzyme levels and nondiagnostic electrocardiograms do not permit efficient risk stratification. The potentially fatal consequences and high malpractice costs of missed acute coronary syndromes lead every year to the unnecessary hospital admission of about 2.8 million patients who present with acute chest pain in emergency departments in the United States. Most of these patients are at very low risk for an acute coronary syndrome. However, the standard clinical work-up does not provide information about the presence and extent of coronary artery disease. In most patients (80%-94%) with an acute coronary syndrome, a significant coronary artery stenosis can be detected with selective coronary angiography. High levels of diagnostic accuracy also have been established for the detection of significant coronary artery stenosis with the use of 16- and 64-section multidetector computed tomography (CT) in patients with stable angina. Preliminary data indicate that multidetector CT also can help quantify and characterize coronary atherosclerotic plaque and that the CT findings are in good agreement with those at intravascular ultrasonography. Although multidetector CT provides accurate information about the presence of coronary artery disease, large blinded observational studies are warranted to identify CT characteristics with high accuracy for diagnosis of acute coronary syndromes. Such information would enable the conduct of randomized controlled trials to determine whether the detection of coronary stenosis and plaque with multidetector CT improves triage and reduces the costs or increases the cost-effectiveness of management of acute chest pain.