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MDCT in Early Triage of Patients with Acute Chest Pain

Udo Hoffmann1, Antonio J. Pena1, Fabian Moselewski1, Maros Ferencik1, Suhny Abbara1, Ricardo C. Cury1, Claudia U. Chae2 and John T. Nagurney3

1 Department of Radiology, Massachusetts General Hospital Cardiac MR CT PET Program and Harvard Medical School, 100 CPZ 400, Boston, MA 02114.
2 Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
3 Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA.


Figure 1
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  		Fig. 1A —63-year-old man presenting to emergency department with 10 minutes of exercise-induced substernal chest pain radiating to his left arm 2.5 hours ago. Initial troponin and creatine kinase, myocardial bound tests were negative, and ECG showed T-wave inversions in V1 to V3; otherwise unremarkable ECG. 64-MDCT was performed 3 hours after emergency department presentation. RCA = right coronary artery, LAD = left anterior descending artery, LCX = left circumflex coronary artery, PDA = posterior descending artery. Volume-rendered 3D image (surface shadowing display) shows anterior tomographic view of heart.

 

Figure 2
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  		Fig. 1B —63-year-old man presenting to emergency department with 10 minutes of exercise-induced substernal chest pain radiating to his left arm 2.5 hours ago. Initial troponin and creatine kinase, myocardial bound tests were negative, and ECG showed T-wave inversions in V1 to V3; otherwise unremarkable ECG. 64-MDCT was performed 3 hours after emergency department presentation. RCA = right coronary artery, LAD = left anterior descending artery, LCX = left circumflex coronary artery, PDA = posterior descending artery. Curved multiplanar reconstruction along centerline of LAD artery shows regular contrast enhancement of all LAD segments with scattered small calcified plaques but no significant luminal narrowing.

 

Figure 3
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  		Fig. 1C —63-year-old man presenting to emergency department with 10 minutes of exercise-induced substernal chest pain radiating to his left arm 2.5 hours ago. Initial troponin and creatine kinase, myocardial bound tests were negative, and ECG showed T-wave inversions in V1 to V3; otherwise unremarkable ECG. 64-MDCT was performed 3 hours after emergency department presentation. RCA = right coronary artery, LAD = left anterior descending artery, LCX = left circumflex coronary artery, PDA = posterior descending artery. Curved multiplanar reconstruction along centerline of RCA shows regular lumen in proximal and mid RCA (arrow) segment with small calcified and noncalcified plaques.

 

Figure 4
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  		Fig. 1D —63-year-old man presenting to emergency department with 10 minutes of exercise-induced substernal chest pain radiating to his left arm 2.5 hours ago. Initial troponin and creatine kinase, myocardial bound tests were negative, and ECG showed T-wave inversions in V1 to V3; otherwise unremarkable ECG. 64-MDCT was performed 3 hours after emergency department presentation. RCA = right coronary artery, LAD = left anterior descending artery, LCX = left circumflex coronary artery, PDA = posterior descending artery. Magnified view of distal RCA segment seen in C shows significant luminal narrowing (> 50%) compared with proximal and distal reference (dashed arrows), approximately 2 cm proximal to bifurcation of PDA and posterior left ventricular branch. In this area, large excentric noncalcified plaque (arrowhead) causing stenosis is seen (arrow).

 

Figure 5
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  		Fig. 2A —43-year-old woman presenting to emergency department with 3 hours of substernal chest pain radiating to back. Initial troponin and creatine kinase, myocardial bound tests were negative and ECG showed sinus bradycardia. 64-MDCT was performed 5 hours after emergency department presentation. RCA = right coronary artery, LAD = left anterior descending artery, IM = ramus intermedius, LCX = left circumflex coronary artery. Volume-rendered 3D image (surface shadowing display) shows anterior tomographic view of heart.

 

Figure 6
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  		Fig. 2B —43-year-old woman presenting to emergency department with 3 hours of substernal chest pain radiating to back. Initial troponin and creatine kinase, myocardial bound tests were negative and ECG showed sinus bradycardia. 64-MDCT was performed 5 hours after emergency department presentation. RCA = right coronary artery, LAD = left anterior descending artery, IM = ramus intermedius, LCX = left circumflex coronary artery. Curved multiplanar reconstruction along centerline of LAD shows regular contrast enhancement of all LAD segments and no evidence of coronary atherosclerotic plaque or luminal narrowing.

 

Figure 7
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  		Fig. 2C —43-year-old woman presenting to emergency department with 3 hours of substernal chest pain radiating to back. Initial troponin and creatine kinase, myocardial bound tests were negative and ECG showed sinus bradycardia. 64-MDCT was performed 5 hours after emergency department presentation. RCA = right coronary artery, LAD = left anterior descending artery, IM = ramus intermedius, LCX = left circumflex coronary artery. Curved multiplanar reconstruction along centerline of RCA shows regular contrast enhancement all RCA segments and no evidence of coronary atherosclerotic plaque or luminal narrowing. Patient was discharged 29 hours after emergency department presentation without any evidence for ACS. IM artery is seen in 37% of population.

 

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