In this presentation we will discuss different techniques of MDCT Cardiac imaging to role out different causes of chest pain to help cardiologist in management of the patient. We shall discuss it case by case.

1. Role of MDCT Angio in
Management of Acute Chest Pain
Dr. Muhammad Bin Zulfiqar
PGR IV FCPS Services Institute of
Medical Sciences / Hospital
radiombz@gmail.com

2. Objectives
• To look for MDCT Utility in Cardiac Emergency.
• Its role to characterize ACS.
• Effect on hospital stay and expenditure.
• To look for future cardiac risk factors.
• To stop inadvertent interventions.

3. Usual Presentations
• The most clinically relevant conditions
– coronary artery disease presenting as acute coronary
syndrome
– pulmonary embolism
– Acute aortic syndrome
– Other Causes of Chest pain
• Pneumonia
• Pleurisy
• musculoskeletal
Truong et al. Coronary CT Angiography Versus Standard Emergency Department Evaluation for Acute Chest Pain and Diabetic Patients: Is
There Benefit With Early Coronary CT Angiography? J Am Heart Assoc. 2016;5:e003137
Bastarrika et al. Cardiac CT of Acute Chest Pain. AJR 2009; 193:397–409
Helpren E.J. Triple-Rule-Out CT Angiography for Evaluation of Acute Chest Pain and Possible Acute Coronary Syndrome. Radiology: Volume
252: Number 2—August 2009

4. Definition of ACS
• Constellation of clinical symptoms that are
compatible with acute myocardial ischemia
– STEMI
– NSTEMI
– Unstable Angina (UA)
J Am Coll Cardiol. 2007 Aug 14;50(7)

5. Classic Initial Approach
• Detailed patient history
• Physical examination
• ECG
• Measurement of cardiac biomarkers.
Bastarrika et al. Cardiac CT of Acute Chest Pain. AJR 2009; 193:397–409

6. Thrombosis in Myocardial Infarction
(TIMI) risk score
One point to each the following risk factors:
1. Age greater than 65 years
2. known coronary artery disease (documented
previous coronary artery stenosis > 50%)
3. Severe angina (more than two episodes of
chest pain in the preceding 24 hours)
4. St segment changes (persistent depression
or transient elevation) on admission ECG
Bastarrika et al. Cardiac CT of Acute Chest Pain.
AJR 2009; 193:397–409

7. Thrombosis in Myocardial Infarction
(TIMI) risk score
5. Elevated serum markers of myocardial
ischemia (troponins)
6. Use of aspirin in the 7 days before
presentation
7. Three or more conventional risk factors for
coronary artery disease
– (family history, diabetes mellitus, hypertension,
hypercholesterolemia, smoking).
Bastarrika et al. Cardiac CT of Acute Chest Pain.
AJR 2009; 193:397–409

8. Risk Factor Stratification
• High risk (TIMI score, 5–7)
– usually are referred without delay for urgent
coronary angiography and intervention
• Intermediate risk (TIMI score, 3–4)
• Low risk (TIMI score, 0–2)
– Admitted for observation and undergo serial ECG
and cardiac biomarker testing followed by stress
testing.
Thrombosis in Myocardial Infarction (TIMI) risk score
Bastarrika et al. Cardiac CT of Acute Chest Pain. AJR 2009; 193:397–409

9. MDCT Techniques / Protocols
• CT coronary angiogram
• "Triple rule-out” coronary CT angiography
• CT perfusion
Truong et al. Coronary CT Angiography Versus Standard Emergency Department Evaluation for Acute Chest Pain and
Diabetic Patients: Is There Benefit With Early Coronary CT Angiography? J Am Heart Assoc. 2016;5:e003137
Bastarrika et al. Cardiac CT of Acute Chest Pain. AJR 2009; 193:397–409
Helpren E.J. Triple-Rule-Out CT Angiography for Evaluation of Acute Chest Pain and Possible Acute Coronary Syndrome.
Radiology: Volume 252: Number 2—August 2009

10. Patient Selection Criteria
• Low to moderate risk of ACS
• Non ACS diagnosis
• Negative biomarkers
– Troponin-I
– Myoglobin
• Normal ECG or non specific changes
• No history to suggest extensive coronary
calcium
Helpren E.J. Triple-Rule-Out CT Angiography for Evaluation of Acute Chest Pain and Possible Acute
Coronary Syndrome. Radiology: Volume 252: Number 2—August 2009

11. Careful consideration / Exclusion
• Abnormal renal function tests.
• Patients with stents and bypass
• H / O allergy to tolerate CT
• Abnormal cardiac rythems.
Helpren E.J. Triple-Rule-Out CT Angiography for Evaluation of Acute Chest Pain and
Possible Acute Coronary Syndrome. Radiology: Volume 252: Number 2—August 2009

12. Reconstruction Techniques
• Multiplanar Reformation.
• Curved Multiplanar Reformation
• Maximum Intensity Projection
• Volume Rendering
Helpren E.J. Triple-Rule-Out CT Angiography for Evaluation of Acute Chest Pain and
Possible Acute Coronary Syndrome. Radiology: Volume 252: Number 2—August 2009

13. Case 1
• 52-year-old woman with acute atypical chest
pain.
• Study allowed to noninvasively rule-out
pulmonary embolism, acute aortic syndrome,
and coronary artery disease with single scan
• Contrast-enhanced retrospectively ECG-gated
thoracic CT angiogram done which showed
normal findings.

14. Case 1
• Volume-rendered images show (Right)
pulmonary vasculature (Left) aorta

15. Case 1
• Volume rendered images show coronary
arteries

16. Case 1
• Curved multiplanar reformatted
image shows left anterior
descending coronary artery,
right coronary artery, and
circumflex artery.

17. Case 2
• 50-year-old man with acute chest pain, family
history of coronary artery disease,
intermediate cardiovascular risk, and normal
initial cardiac biomarker and ECG results
referred for CT imaging

18. Case 2
• (Right) Curved MPR and (Left) volume rendered images show calcified
plaques causing nonsignificant stenosis in mid segment of artery.
Arrowhead indicates intramyocardial course in distal segment.

19. Case 3
• 40-year-old woman with acute chest pain and
dyspnea.

20. Case 3
• Right. Axial contrast-enhanced image shows bilateral
central pulmonary emboli (arrowheads).
• Left. Axial reformatted volume-rendered color-mapped
image shows pulmonary hypo perfused areas
(arrowheads) mainly at upper lobes.

21. Case 3
• Right and Left, Axial CT image at midheart level (right)
and right ventricular end-diastolic volumetric analysis
(left) show right ventricular (RV) enlargement and
septal flattening indicating right ventricular pressure
overload.

22. Case 4
• 53-year-old woman with acute chest pain
radiating to back and dyspnoea.
• Thoracic CT angiography suggested.

23. Case 4
• Contrast-enhanced axial
CT image shows dissection
flap involving descending
aorta

24. Case 4
• Volume-rendered image
shows origination of
dissection (arrowhead)
distal to left subclavian
artery and extension
into abdominal aorta.

25. Case 5
• 43-year-old man with intermediate
cardiovascular risk and acute chest pain.
• Thoracic CT angiography done

26. Case 5
• Curved MPR (Right) and volume-rendered (Left) images of left
anterior descending coronary artery show intense vascular
remodeling of entire vessel with significant stenosis caused by
predominantly noncalcified plaque (arrow) involving mid and distal
segments.

27. Case 6
• 61-year-old man with chest pain.
• Thoracic CT angiography done

28. Case 6
• Right. Multiplanar reformatted coronal image shows left central
pulmonary artery embolism (arrowhead) extending to segmental
lingula and left inferior lower lobe branches.
• Left Reformatted coronal volume-rendered color-mapped image
shows corresponding perfusion defects. Arrowhead indicates
embolism.

29. Case 7
• 46-year-old man admitted in emergency
department because of acute chest pain.
• Thoracic CT angiography done

30. Case 7
• Right. Unenhanced thoracic CT image shows intramural
hematoma involving descending thoracic aorta (arrow).
• Left. Contrast-enhanced thoracic CT image shows absence
of aortic dissection.

31. Case 8
• 58-year-old man admitted in emergency
department because of acute chest pain
radiating to back.
• Suspicion was aortic dissection.
• Thoracic CT angiography done

32. Case 8
• Right Contrast-enhanced axial CT image shows involvement
of ascending and descending aorta (arrows).
• Left Contrast-enhanced axial CT image shows flap with
whirl-like complex structure at aortic arch.

33. Case 9
• 24-year-old woman with history of Marfan
syndrome who presented with acute onset of
chest pain radiating into the neck. Clinical
suspicion was high for aortic dissection with
possible extension into coronary arteries or
great arteries in the neck.
• Thoracic CT angiography done on TRO
Extended Protocol

34. Case 9
• Right. Coronal maximum intensity projection (MIP) image
demonstrates enhancement of aorta, pulmonary arteries, and great
vessels extending from the aortic arch with no dissection.
• Left Oblique MIP image demonstrates normal aortic arch and
descending thoracic aorta.

35. Case 9
• Right Oblique coronal MIP image demonstrates normal left ventricular
outflow tract extending into proximal part of aortic arch. However, there is
air in tissues of the neck surrounding great vessels (arrows). Left Coronal
MIP image through the trachea demonstrates extensive free air in soft
tissue planes.

36. Case 10
• 37-year-old woman with no relevant cardiac
history presented with sudden onset of chest
pain while at work.
• Thoracic TRO angiography done.

37. Case 10
• MIP images of (right) left anterior descending artery in long axis of
the aortic root and (left) left anterior descending artery in
orthogonal obliquity in the short axis of the aortic root.
• 75% stenosis of the left anterior descending artery (arrow).

38. Raff G.L. et.al. SCCT guidelines on the use of coronary computed tomographic angiography for patients presenting with acute chest pain to the
emergency department: A Report of the Society of Cardiovascular Compute Tomography Guidelines Committee. J o u rnal of Ca r d i o v a s c u l
a r Computed Tomography 8 ( 2 0 1 4 ) 2 5 4e2 7 1

39. Markedly elevated calcium score
• (Right) Axial image at a slightly lower level demonstrates
calcification in the LAD, circumflex, and RCA. Mild calcification is
also identified in the posterior mitral annulus (arrowhead). (Left)
Calcium in the three major coronary arteries is color-coded. The
mitral annular calcification is labeled in pink and is not included in
the calcium score. The total Agatston calcium of 2726.1 is markedly
elevated, suggesting increased risk for a coronary event.

41. Pitfalls In MDCT Cardiac Imaging
• Image quality suffers from fast heart rate
– Requires premedication with β-blockers
• Arrhythmias, ectopy, or ECG artifacts result in
degradation of image quality
– ECG-gating critical to coronary imaging
• Radiation dose to patient
• Provides anatomic information, and debates
about physiologic data
Chinnaiyan KM, et al. Cardiol Clin. 2009 Nov;27(4):587-96.

42. Take Home Message
• Provides excellent spatial resolution provides
superior information of anatomy
• Provides functional information through blood
perfused volume and stress protocols
• Ability for plaque analysis
• Appropriate use of Triple-Rule-Out Protocol can
explore other differential diagnoses for chest
pain
• MDCT imaging protocols incorporated into ACS
workup demonstrates savings in time to
diagnosis, costs while providing good patient
outcomes

43. THANK YOU