Diagnosing Chest Pain In Emergency: Latest Guidelines on Imaging

2) Suspected pulmonary embolism (five scenarios)

3) Suspected acute syndrome of the aorta (three scenarios)

4) Patients for whom a leading diagnosis is problematic or not possible (two scenarios)

 

Scenario: ECG diagnostic for ST-segment elevation myocardial infarction (STEMI):

 Modality : Cardiac catheterization is considered appropriate, with all other imaging modalities considered rarely appropriate.

 

Scenario : Initial ECG and/or biomarker unequivocally positive for ischemia:

 Modality : Cardiac catheterization is considered appropriate, with all other imaging modalities rated as rarely appropriate.

 

Scenario: Equivocal initial troponin or single troponin elevation without additional evidence of ACS:

 Modality : CCTA and rest SPECT were considered appropriate, catheterization rarely appropriate, and resting echo and CMR were graded as M* ( maybe).

 

Scenario : Patients in the “observational pathway” after initial assessment (typically 9-24 hours out from presentation) with unequivocal evidence for NSTEMI/ACS:

 Modality : Cardiac catheterization was considered appropriate and all other imaging modalities including rest and stress modalities graded as M* (may be).

 

Scenario : Serial ECG and troponins negative for NSTEMI/ACS in the observational time frame:

 Modality : CCTA and stress rest echo, CMR, and SPECT were considered appropriate. The committee suggested that low-risk patients in this category may be evaluated as outpatients.

 

Scenario : Serial ECG or troponins borderline for NSTEMI/ACS:

 Modality : CCTA and stress/rest modalities were all considered appropriate and catheterization graded as M(may be).

 

Scenarios : Suspected pulmonary embolism with either positive D-dimer or high clinical likelihood:

 Modality : CT pulmonary angiography and ventilation-perfusion (VQ) scan were considered appropriate.

 

Scenario : Suspected acute aortic syndrome:

 Modality : CT aortography was considered appropriate and all other imaging modalities including MR aortography were graded as M* (may be) in the hemodynamically unstable patient.

 

Scenario : Suspected acute aortic syndrome in hemodynamically stable patient:

Modality : CT aortography, MR aortography, and transesophageal echo were considered appropriate.

 

Scenario : Imaging when a definitive diagnosis is problematic or not possible and where the overall likelihood of ACS, pulmonary embolism, or acute aortic syndrome is not low, a “triple-rule-out” CTA to evaluate coronary anatomy, aortic anatomy, and screen for pulmonary embolism was considered appropriate.

Article Source: Appropriate Use of Cardiac Imaging in Emergency Department Patients With Chest Pain  

ABOUT THE AUTHOR

Manav Aggarwal is a DM ( Cardiology) from Amrita Institute of Medical Sciences, Kochi and is presently as researcher in Interventional Cardiology at Lissy Hospital, Kochi