Rajan Agarwal MD, Presenter: Nothing to Disclose

Harold Ira Litt MD, PhD, Abstract Co-Author: Research grant, Siemens AG Research grant, Volume Interactions Pte Ltd Corporate Advisory Board, Siemens AG Corporate Advisory Board, Volume Interactions Pte Ltd Speakers Bureau, Siemens AG

Judd Hollander MD, Abstract Co-Author: Nothing to Disclose

Woojin Kim MD, Abstract Co-Author: Partner, iVirtuoso, Inc, Baltimore, MD

To determine the frequency and nature of alternative diagnoses found on coronary CTA performed on low risk emergency department patients presenting with symptoms of acute coronary syndrome (ACS).

All low risk patients presenting to the ED of a large academic health center between 10/18/2005 and 4/11/2007 with symptoms of ACS who received coronary CTA were included. Low risk patients were those with TIMI score of 0-2 and a normal or near-normal ECG. Coronary CTA was performed with a triple-phase contrast injection protocol which maintains RV opacification throughout the study in most patients. Results of coronary CTA were reviewed to determine the incidence of non-coronary artery related potential causes for the chest pain.

Of the 339 patients included, 72 (21%) had abnormal studies. 48 patients had a potential coronary cause for the chest pain, of which, 18 of 339 (5%) had coronary stenosis >50% and 20 had coronary anomalies which may cause ischemia (16 myocardial bridging, 6 anomalous RCA. The remaining 24 patients (7%) had a non coronary artery related potential cause for the chest pain (alternative diagnosis) including 7 probable pneumonias, 4 findings of sarcoidosis, 2 bicuspid valves, 1 lung mass eventually diagnosed as lung cancer, 1 bronchiolitis, 1 dilated aortic root, 1 possible Boerhaave’s syndrome, 1 myocardial noncompaction, 1 nonischemic cardiomyopathy, 1 suspected pericarditis, 1 ventricular arrhythmia likely of RV origin, 1 breast mass, 1 atrial septal defect, and 1 pulmonary hypertension. Of note, no patients had pulmonary embolism or aortic dissection.

7% of low-risk patients presenting to the ED with symptoms of ACS and who received a coronary CTA had non-coronary related diagnoses on CTA, which is higher than the incidence of coronary stenosis. Most were related to pulmonary pathology, and none had pulmonary embolus or aortic dissection. In this patient population, a triple rule-out study may not have a high yield.

In a low risk population, pulmonary disease is as common as coronary stenosis, readers should be familiar with non-cardiac causes of chest pain, and a triple rule-out study may not have high yield.

Agarwal, R, Litt, H, Hollander, J, Kim, W, Alternative Diagnoses Found at Coronary Computed Tomography Angiography (CTA) of Low Risk Emergency Department (ED) Patients with Chest Pain Syndromes.  Radiological Society of North America 2007 Scientific Assembly and Annual Meeting, November 25 - November 30, 2007 ,Chicago IL. http://archive.rsna.org/2007/5009389.html