Cane Hoffman, Presenter: Nothing to Disclose

Felix G. Meinel MD, Abstract Co-Author: Nothing to Disclose

Alex Justin Lewis MD, Abstract Co-Author: Nothing to Disclose

Aleksander Krazinski, Abstract Co-Author: Nothing to Disclose

James Spearman, Abstract Co-Author: Nothing to Disclose

U. Joseph Schoepf MD, Abstract Co-Author: Research Grant, Bracco Group Research Grant, Bayer AG Research Grant, General Electric Company Research Grant, Siemens AG

In patients with acute chest pain, it is debated whether CT angiography of the entire chest in a "triple-rule-out" (TRO) fashion versus a dedicated coronary CT angiogram limited to the heart provides the greatest benefit. The aim of this study was to determine the prevalence and nature of pathologies found above the level of the carina in TRO CT studies and their association with the patient’s chest pain episode.

A total of 163 TRO studies in patients referred from the emergency department for evaluation of acute chest pain were analyzed. Studies were reviewed to assign the location of all findings to above or below the level of the carina. Coronary artery stenosis was graded as mild, moderate or severe. Moderate and severe stenosis was considered a potential cause of the patient’s acute chest pain. The freqency and nature of findings above and below the carina was recorded.   

Among the 163 CT studies, coronary artery stenosis likely to be an etiology of the patient’s chest pain was found in 23 cases (14.1%). There were 3 studies which demonstrated pulmonary emboli (1.8%) none of which were isolated to above the carina. No cases of aortic dissection were observed. There were 7 hiatal hernias, 5 aortic aneurysms, 4 pericardial effusions, 3 pleural effusions, 1 aortic stenosis, and 1 malignant origin of the right coronary artery. Likely causes of chest pain were identified in 30% of cases. Of the pathologies found above the carina there were 11 cases with thyroid abnormalities, 7 cases with lung nodules, 5 cases with an aberrant right subclavian artery, 3 cases with pneumonia, 3 cases with apical lung scarring, 3 cases with lymphadenopathy, 1 thymic hyperplasia, and 1 finding of likely healed tuberculosis. A total of 21.5% of studies revealed minor pathology above the carina, none of which was considered to be of immediate critical importance for patient management.

In patients with acute chest pain, CT findings above the carina are mostly incidental and non-explanatory for the patients' symptoms. The significance and effect of such findings on patient management, outcome and down-stream resource utilization are uncertain. .

Compared to a CT angiogram limited to the heart (below the level of the carina), a TRO protocol of the entire chest rarely reveals findings that are immediately contributory in patients with acute chest pain.

Hoffman, C, Meinel, F, Lewis, A, Krazinski, A, Spearman, J, Schoepf, U, Acute Chest Pain CT: Should We Scan the Entire Chest or Only the Heart?.  Radiological Society of North America 2014 Scientific Assembly and Annual Meeting, - ,Chicago IL. http://archive.rsna.org/2014/14011366.html