Dual-source CT for chest pain assessment
Thorsten R. C. Johnson Konstantin Nikolaou Alexander Becker Alexander W. Leber Carsten Rist Bernd J. Wintersperger Maximilian F. Reiser Christoph R. Becker
thorsten.johnson@med
Comprehensive CT angi- viewed for further diagnoses. Techniography protocols offering a simulta- cal limitations were insufficient conneous evaluation of pulmonary trast opacification in six and artifacts embolism, coronary stenoses and aor- from respiration in three patients. The tic disease are gaining attractiveness most frequent diagnoses were corowith recent CT technology. The aim of nary stenoses, valvular and myocarthis study was to assess the diagnostic dial disease, pulmonary embolism, accuracy of a specific dual-source CT aortic aneurysm and dissection. protocol for chest pain assessment. Overall sensitivity for the identificaOne hundred nine patients suffering tion of the cause of chest pain was from acute chest pain were examined 98%. Correlation to invasive coronary on a dual-source CT scanner with angiography showed 100% sensitivity ECG gating at a temporal resolution of and negative predictive value for cor83 ms using a body-weight-adapted onary stenoses. Dual-source CT offers contrast material injection regimen. a comprehensive, robust and fast chest The images were evaluated for the pain assessment. cause of chest pain, and the coronary findings were correlated to invasive Keywords Chest pain . coronary angiography in 29 patients CT angiography . Coronary artery (27%). The files of patients with disease . Pulmonary . Embolism . negative CT examinations were re- Aortic dissection
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Comprehensive CT angiography protocols for a complete
assessment of the thoracic vessels, often referred to as
triple rule out protocols, are used in the differential
diagnosis of chest pain increasingly often [14]. These
protocols aim to opacify pulmonary and coronary arteries
as well as the aorta simultaneously to rule out pulmonary
embolism, coronary artery disease and aortic aneurysm or
dissection in a single exam. With ECG gating, the acquired
images of the coronary arteries should have a similar
diagnostic accuracy as a specific coronary CT angiography.
Quite a few studies have meanwhile shown the feasibility
of a simultaneous evaluation of these vascular territories in
one single breathhold scan with a good sensitivity in the
identification of the cause of chest pain [5]. Also, recent
studies indicate that coronary CT angiography can be
helpful for a fast and cost-effective triage of chest pain
patients [6, 7]. So far, a major limitation of these studies
especially in acutely ill patients is the restricted image
quality of the coronary arteries in high heart rates [8]. The
administration of beta-blockers to lower heart rates is
general practice in 16- and 64-slice CT [9]. However, this
approach is time consuming and limited by
contraindications, and a sufficient reduction of the heart rate cannot be
achieved in many acutely ill patients. Initial studies of
dualsource CT (DSCT) cardiac imaging have shown a robust
image quality and a very good diagnostic accuracy of
coronary CT angiography even in high heart rates [10, 11].
Additionally, a more comprehensive cardiac assessment
including wall motion and valve function is possible with
DSCT [10]. The aim of this study was to assess the
diagnostic accuracy of a specific dual-source CT protocol
for chest pain assessment, regarding a 6-month follow-up
for other findings and coronary angiography in patients in
whom coronary artery disease could not be reliably
excluded as standard of reference.
Materials and methods
One hundred nine consecutive patients [31 women, 78
men; median age 64 (5967) years] were prospectively
enrolled in the trial. The study was approved by the
institutional review board, and informed written consent
was obtained from every patient prior to the examination.
All patients with acute chest pain were eligible for the
study if referred by a colleague after initial diagnostic
workup including physical examination, ECG and serum
levels of creatinine and TSH. Exclusion criteria were
positive ECG changes or troponine test, severe ventricular
arrhythmia, a history of severe allergoid reaction to
iodinated contrast material, renal insufficiency and young
age below 30 years. Also, severe dyspnea with inability to
hold the breath for at least 15 s was regarded as exclusion
criterion. The patients were asked to hold their breath for
approximately 15 s prior to the examination. If the
breathhold could not be maintained, the patient was
excluded from the study, and seven otherwise eligible
patients had to be excluded for this reason. Heart rates
were 68 14, ranging from 58 to 118 bpm. Beta-blockers
were not administered in preparation of the scan. Eighteen
patients had known coronary artery disease and 14 were
on continuous oral beta blocker medication. One patient
had a known chronic aortic dissection.
Examinations were acquired on a DSCT Somatom
Definition (Siemens, Forchhei (...truncated)