title: Chest pain evaluation in the emergency department: can MDCT provide a comprehensive evaluation?
abstract: OBJECTIVE
  The purpose of our study was to determine whether MDCT can provide a comprehensive assessment of cardiac and noncardiac causes of chest pain in stable emergency department patients.
  
  
  METHODS
  Patients with chest pain who presented to the emergency department without definitive findings of acute myocardial infarction based on history, physical examination, and ECG were recruited immediately after the initial clinical assessment. For each patient, the emergency department physician was asked whether a CT scan would normally have been ordered on clinical grounds (e.g., to exclude pulmonary embolism). Each consenting patient underwent enhanced ECG-gated 16-MDCT. Ten cardiac phases were reconstructed. The images were evaluated for cardiac (coronary calcium and stenosis, ejection fraction, and wall motion and perfusion) and significant noncardiac (pulmonary embolism, dissection, pneumonia, and so forth) causes of chest pain. Correlation was made between the presence of significant cardiac and noncardiac findings on CT and the final clinical diagnosis based on history, examination, and any subsequent cardiac workup at the 1-month follow-up by a consensus of three physicians.
  
  
  RESULTS
  Sixty-nine patients met all criteria for enrollment in the study, of whom 45 (65%) would not otherwise have undergone CT. Fifty-two patients (75%) had no significant CT findings and a final diagnosis of clinically insignificant chest pain. Thirteen patients (19%) had significant CT findings (cardiac, 10; noncardiac, 3) concordant with the final diagnosis. CT failed to suggest a diagnosis in two patients (3%), both of whom proved to have clinically significant coronary artery stenoses. In two patients (3%), CT overdiagnosed a coronary stenosis. Sensitivity and specificity for the establishment of a cardiac cause of chest pain were 83% and 96%, respectively. Overall sensitivity and specificity for all other cardiac and noncardiac causes were 87% and 96%, respectively.
  
  
  CONCLUSIONS
  ECG-gated MDCT appears to be logistically feasible and shows promise as a comprehensive method for evaluating cardiac and noncardiac chest pain in stable emergency department patients. Further hardware and software improvements will be necessary for adoption of this paradigm in clinical practice.
authors.affiliation: Department of Diagnostic Radiology, University of Maryland School of Medicine, 22 S Greene St., Baltimore, MD 21201, USA. cwhite@umm.edu
authors.forename: Charles S
authors.initials: CS
authors.lastname: White
authors.forename: Dick
authors.initials: D
authors.lastname: Kuo
authors.forename: Mark
authors.initials: M
authors.lastname: Kelemen
authors.forename: Vineet
authors.initials: V
authors.lastname: Jain
authors.forename: Amy
authors.initials: A
authors.lastname: Musk
authors.forename: Eram
authors.initials: E
authors.lastname: Zaidi
authors.forename: Katrina
authors.initials: K
authors.lastname: Read
authors.forename: Clint
authors.initials: C
authors.lastname: Sliker
authors.forename: Rajnish
authors.initials: R
authors.lastname: Prasad
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002637:Chest Pain / Q000209:etiology*; D003327:Coronary Disease / Q000150:complications / Q000000981:diagnostic imaging; D004562:Electrocardiography; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D007091:Image Processing, Computer-Assisted; D008297:Male; D008875:Middle Aged; D013902:Radiography, Thoracic; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed