CT for chest pain

[Just Plain Ruff]

Here is an interesting article I just found.

Seems like you can get a 15 second ct scan done to rule out cardiac causes of chest pain.

Good or bad? Discuss

http://www.americanheart.org/presenter.jht...ntifier=3043217

[spenac]

I think it can be a great tool. I do worry that if not careful some docs would treat the machine rather than the patient. I do know it would've saved me a $10000 hospital stay. Even though EKG and blood work normal they erred on side of caution and kept me 2 nights and sent me home, unknown cause of chest pain. Quickly found out cause once home but different story. I do think it would have been comforting even if kept in hospital to have a higher degree of certainty that it was not heart related.

[Arizonaffcep]

If it's what I think it is, in Arizona it's called a "Heart saver CT." This type of CT tracks the amount of calcium (not plaque) in the coronary arteries. There is a well established correlation between the amount of calcium vs. the amount of plaque build up in the vessels. The only thing I would be concerned with, is it's another CT that they would get while in the hospital. The first being a CT angio to R/O PE.

[VentMedic]

This has been around for awhile with EMS/FFs being the initial guinea pigs for the first scanners.

[mshow00]

If this is confirmed to work, it will be an excellent additional tool. It is, however, a tool, with that I agree with spenac. I also fear that in a pinch the doctor will rely too heavily on this, missing/skipping another test to result in a sad ending. I do hope that this can help confirm/nullify the thoughts/suspicions.

[ERDoc]

If this truly does turn out to be as good as the study claims, it will significantly change medicine. Obviously we need to see larger scale studies to determine the utility of the test. I was unable to locate the original paper after a very brief search. I would argue that the scanners are not as cheap as the article makes them out to be, especially at the smaller community hospitals where this would be ideal. It will be interesting to see the future studies.

[Doczilla]

The study is small, as are other studies on MDCT for ACS. There was a review of this topic in the January episode of EM:RAP, and the panel agreed that it may have some utility in a small subset of patient population, but not widely.

The issue that we're looking at is not acute STEMI, but more NSTEMI and unstable angina. the question that we have to answer is whether or not the patient will die in the next 30 days or so before they get to some form of perfusion testing, such as a nuclear stress test.

The MDCT is a substantial contrast dye load and radiation dose. The big issue is that we haven't yet done population studies that tell us how effective it really is at ruling out cardiac ischemia, and how well those patients do when sent home after a negative scan. There are segments of the coronary arteries which are not adequately seen on coronary CT angio. Another problem is that significant calcification obscures the picture of the arteries. What we're left with is telling the patient, "I think you're okay, but we can't see a couple of these segments", or "there are these mildly narrowed areas, and we're not sure how relevant they are to your symptoms today." There is also the issue of these 10-20% plaques, which are the ones that rupture and cause acute MI, which aren't seen so well on these coronary angios. For that matter, they aren't seen well on traditional angiography. The bottom line is, we haven't figured out who will truly benefit from this test, and who will fall through the cracks.

There may be some use for it in older patients (less risk for radiation-associated cancers) for the "triple threat CT", which would hit ACS, PE, and aortic dissection all in one scan. This would help get to an answer faster, but probably not obviate the need for serial cardiac enzyme testing.

Contrast dye load is less of an issue with healthy kidneys, but the radiation is something that is not insignificant, particularly in a young person with long expected life span. Current estimates are that we cause 1 fatal cancer for every 1000 CT scans ordered. Doing serial cardiac enzymes is harmless to the patient with the exception of the long boarding time in the ED/chest pain unit/inpatient floor and subsequent ED crowding. At some point we'll have to decide if the risks to the patient from radiation outweigh the risks to the patients in the waiting room that have to wait to be seen.

The "calcium" scans are of far less utility. They will tell you if you have a small quantity of calcifications or a large one, but there is no good answer for those who have an intermediate scan. Do we perform direct angiography with the 1:1000 risk of a serious complication (does not count the radiation risk from the fluoroscopy). What if a stress test shows nothing? It's those smaller plaques that rupture and cause MI, and less likely to show up on the scan. Do we put a stent in? Muddying these waters is the fact that there are plenty of unscrupulous folks who will be happy to perform this test at the local mall for you (cash only, of course), whether or not it's actually indicated.

'zilla

[zzyzx]

CT scans cause cancer in one in a thousand patients? That's a great risk considering how common CT scans are. I've had one, and so have all the other millions of people who've gone to the ER for kidney stones. I hadn't realized that there is such great risk involved with CT scans. Are those numbers controversial? Have we seen a big increase in certain cancers since the introduction of CT scans?