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Ms Patricia Pellikka
Echocardiography, cardiac CT scan and cardiac MRI all offer promise for the assessment of patients with chest pain, but improved strategies for clinical risk assessment are needed to optimize selection of appropriate tests.
Chest pain accounts for about 8 million visits to the emergency room/year in the US alone; the evaluation of these patients is costly and costs are increasing. Although the majority of patients are at low risk, it is estimated that 3-5% of patients are dismissed in error and subsequently suffer acute coronary syndromes. Therefore, improved strategies for evaluating patients presenting with acute chest pain are needed.The European Society of Cardiology guidelines recommend echocardiography as the most important additional test after the electrocardiogram and troponin, not only because of its utility in assessment of left ventricular global and regional function to recognize acute coronary events, but also because non-ischemic causes of chest pain such as aortic dissection, valvular heart disease, hypertrophic cardiomyopathy, pulmonary embolism, and pericardial effusion can be detected. Cardiac computed tomography angiography (CTA) has been shown to be useful in evaluation of patients presenting with chest pain. Newer methods including assessment of perfusion, plaque characterization, and computational assessments of flow and pressure may further enhance the utility of CTA. CTA has been shown to be sufficiently sensitive to reliably allow dismissal of patients with negative studies. Cardiac magnetic resonance (CMR) offers considerable promise for assessment of patients with acute chest pain, as it allows for assessment of cardiac structure, function, and perfusion. High spatial resolution permits detection of very small amounts of scar. However, processing and analysis of images make this test at present less optimal for assessment of acute chest pain.Cost effectiveness analysis suggests that CTA may be the best test for assessment of acute chest pain because of its high sensitivity, and because, in contrast to stress testing, it can be performed immediately without waiting for serial troponins. However, the results of large clinical trials are awaited. Improved strategies for clinical risk assessment are needed to optimize selection of patients who require CTA or other testing.
Acute chest pain: game changer or waste of resources?
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