Cardiac CT identified obstructive CAD in 15.3% of ED patients with chest pain, guiding invasive treatment in 11.8%, and safely ruled out CAD in 77%, with low adverse events.
Does urgent cardiac computed tomography improve diagnostic assessment and prognostic evaluation in patients admitted to the emergency department?
Urgent cardiac CT in the emergency department is a versatile and safe imaging modality that effectively rules out obstructive CAD and guides management, associated with excellent long-term clinical outcomes.
Abstract Background Cardiac computed tomography scan (CCT) is widely used for accessing obstructive coronary artery disease (CAD) in patients with a low to moderate pre-test likelihood. However, its clinical role in the emergency department (ED) extends beyond CAD assessment. Purpose To review the clinical uses and impact of CCT in the ED of our centre. Methods All patients admitted to the ED since Jan 2020 who underwent urgent CCT were included and a descriptive analysis was conducted to determine the respective indications. Patients with suspected obstructive CAD were further evaluated regarding their final diagnosis in the ED and clinical outcomes during follow-up (FU). Results Over a median FU of 1070 days (IQR 556-1401), 210 patients underwent urgent CCT. Coronary CT angiography (CCTA) was frequently performed in patients presenting with chest pain to exclude obstructive CAD (80%), acute aortic syndrome (13%) and pulmonary embolism (9.5%). A "triple-rule-out" strategy was used in 8% of cases. A dual-energy protocol was performed in 2% of patients to further assist the differential diagnosis when obstructive CAD was excluded. Additionally, CCT was used to safely guide urgent pericardiocentesis (12.4%), exclude intracardiac thrombus (3.8%), evaluate for myocardial perforation (1.8%), and rule out mechanical complications related to endocarditis (0.5%). Among patients who underwent CCTA for obstructive CAD assessment (n=170), 58% were male and most of them had no previous evidence of stablished atherosclerotic disease. Hypertension, dyslipidaemia and diabetes were present in 45%, 49% and 13% of patients, respectively. CCTA was most commonly performed in patients presenting with chest pain suggestive of non-cardiac origin (58%), and low median levels of high-sensitivity cardiac troponin (12ng/dL, IQR 5-64). CCTA findings revealed no or non-obstructive CAD in 77% of patients. Obstructive CAD was identified in 15.3% of cases and the exam was inconclusive in 6.5% of patients. Following CCTA, 23.5% of patients required invasive coronary angiography and 11.8% underwent invasive treatment. The most frequent final diagnosis was "non-specific" chest pain (48.8%). 11.2% of patients were admitted for acute coronary syndrome and 12.4% were diagnosed with peri/myocarditis (Fig 1). During FU, 28.2% of patients reported recurrent chest pain. Only 2.4% of patients underwent invasive revascularization, and 0.6% experienced an acute coronary syndrome. At 1 year, a single patient died due to prosthetic aortic valve endocarditis. Conclusion CCT is a valuable imaging modality for the differential diagnosis of chest pain, providing accurate and safe assessments without compromising patient prognosis. Additionally, CCT plays a crucial role guiding pericardiocentesis, excluding intracardiac thrombus and assessing for ventricular perforation. Given its non-invasive nature and broad clinical utility, CCT should be widely available in ED to optimize patient management.Chest pain final diagnosis in the ED
Rodrigues et al. (2025) studied this question. Cardiac CT identified obstructive CAD in 15.3% of ED patients with chest pain, guiding invasive treatment in 11.8%, and safely ruled out CAD in 77%, with low adverse events.