title: Role of computed tomography in the evaluation of acute chest pain.
abstract: Chest pain is common and the initial clinical presentation is often nonspecific. The emergency physician faces the challenge of correctly identifying those patients with a life-threatening cause of chest pain while avoiding unnecessary hospital admissions. Three important life-threatening causes of chest pain are aortic dissection, pulmonary embolism, and acute coronary syndrome. Simple clinical tools should be applied to exclude these diagnoses and avoid CT whenever possible. A normal serum d-dimer measurement can safely exclude pulmonary embolism and aortic dissection, although elevated d-dimer levels are common and nonspecific. Promising markers for early myocardial ischemia have been described and should be developed further. CT provides a first-line imaging tool for aortic dissection and pulmonary embolism based on its wide availability, speed, and high level of diagnostic performance. Improvements in CT scanner technology now enable in-depth data on the coronary arteries. Although angiographic information is limited in its relation to physiologic lesion significance, coronary CT is used to safely diagnose or exclude coronary disease as a source of chest pain in emergency department patients. "Triple rule-out" protocols designed to simultaneously assess the aorta, pulmonary arteries, and coronary arteries are a compromise between dedicated protocols for each diagnosis. The diagnostic value and appropriate clinical use of these protocols remain to be shown by randomized, controlled, outcomes-based trials.
authors.affiliation: University of California Medical Center, Department of Radiology and Biomedical Imaging, 505 Parnassus Avenue, Box 0628, San Francisco, CA 94143-0628, USA. Thomas.urbania@radiology.ucsf.edu
authors.forename: Thomas H
authors.initials: TH
authors.lastname: Urbania
authors.forename: Michael D
authors.initials: MD
authors.lastname: Hope
authors.forename: Shannon D
authors.initials: SD
authors.lastname: Huffaker
authors.forename: Gautham P
authors.initials: GP
authors.lastname: Reddy
mesh_terms: D054058:Acute Coronary Syndrome / Q000150:complications / Q000000981:diagnostic imaging*; D000208:Acute Disease; D000784:Aortic Dissection / Q000150:complications / Q000000981:diagnostic imaging*; D001014:Aortic Aneurysm / Q000150:complications / Q000000981:diagnostic imaging*; D002637:Chest Pain / Q000000981:diagnostic imaging* / Q000209:etiology; D003937:Diagnosis, Differential; D004632:Emergency Medical Services / Q000379:methods; D006801:Humans; D011655:Pulmonary Embolism / Q000150:complications / Q000000981:diagnostic imaging*; D013902:Radiography, Thoracic / Q000379:methods*; D014057:Tomography, X-Ray Computed / Q000379:methods*