The role of cardiac computed tomography in the emergency department: diagnostic and prognostic insights

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.

To review the clinical uses and impact of CCT in the ED of our centre.

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).

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.

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