ARRS 2022 Abstracts

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E1814. Appropriate Use of Coronary CTA in Assessment of Patients Presenting to the Emergency Department with Acute Chest Pain
Authors
  1. Omid Ebrahimzadeh; University of British Columbia
  2. Ali Silver; University of British Columbia
  3. Tejas Phaterpekar; University of British Columbia
  4. Tony Sedlic; University of British Columbia
Background
Coronary CTA (CCTA) has become an integral part of assessment of patients presenting to the emergency department (ED) with acute chest pain. Historically, the main utility of this excellent “rule out” test was in patients with low to intermediate risk of coronary artery disease (CAD) in the absence of acute coronary syndrome (ACS). The recent guidelines and recommendations have introduced additional roles for the use of CCTA even in patients with suspicion of ACS in ED; however, no benefit has been demonstrated at improving outcomes in the intermediate- and high-risk patients presenting with acute chest pain and suspected or provisional diagnosis of ACS. Therefore, appropriate patient selection remains essential to target patients who would benefit the most from this non-invasive diagnostic tool.

Educational Goals / Teaching Points
In this educational exhibit, we will cover the benefits versus potential drawbacks of CCTA, evolution of guidelines and recommendation on the use of CCTA in the emergency setting, and role of CCTA in ACS. We will provide an update on the most recent guidelines and recommendations for performing CCTA in the emergency settings, including in patients with suspicion of ACS. We will discuss scenarios in which using CCTA may not be appropriate and expand on the role of CCTA in the emergency setting in special populations or indications such as in patients with prior Coronary Artery Bypass Graft (CABG) and stent, suspected Spontaneous Coronary Artery Dissection (SCAD), Vasospasm, Anomalous Coronary anatomy, and suspected cardiomyopathy. Finally, a practical algorithm for multi-modality imaging evaluation of chest pain in ED will be provided based on the current guidelines that can facilitate appropriate patient selection upon triaging request

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Use of CCTA in the ED has excellent negative predictive value in excluding ACS in patients with low to intermediate risk of CAD. The newest guidelines recommend the use of CCTA in patients with suspicion of ACS when there is no significant troponin elevation or change. On the other hand, a recent negative CCTA within the past 5 years is reassuring for exclusion of obstructive lesions and repeating the scan should only be considered in selected patients, as it would likely not alter the management. Use of CCTA in patients with history of CABG and stents is not validated in patients with acute chest pain; however, they may provide some prognostic and anatomical information that make it potentially appropriate in selected patients. Use of CCTA in very young patients should only be considered in select cases to limit radiation, especially if an alternative diagnosis is more likely. For example, when there is clinical suspicion for myocarditis, the CCTA should be only considered after completion of other investigations such as echocardiogram and cardiac MRI to assess the presence of myocarditis.

Conclusion
Appropriate patients selection based on clinical evaluation, CAD risk factors, cardiac enzyme levels, and ECG findings remain essential to target patients who would benefit the most from this non-invasive diagnostic tool, CCTA.