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The use of 320 slice coronary CT in low risk ACS clinical decision pathway in the ED
  1. Aidan McNamara

Abstract

Chest pain is an extremely common presentation to all Emergency Departments in the UK. Many Departments now run evidence-based pathways to exclude acute coronary syndrome (ACS) in low risk patients. Most current pathways rely on the use of biochemical markers for cardiac injury (Troponin I, Troponin T) and electrophysiological testing (stress ECG) with some Units using ST monitoring. Recent National Institute for Clinical Excellence (NICE) guidance has suggested that stress ECG is not a useful tool and has advocated the use of cardiac CT and calcium scoring in the assessment and management of these patients. Previous published studies and the recent NICE guidance has been based on the premise of 64 slice cardiac CT being the utility employed. We report our experience using 320 slice cardiac CT in a low risk ACS pathway in an Emergency Department Clinical Decision Unit in a busy, urban Emergency Department.

Analysis of findings
Total No26
AgeMean = 50 years, range 29–71
Gender female: male9 (35%): 17 (65%)
TIMI-RS scores
31
22
11
022
Initial Troponin TAll negative (<0.01 ng/ml), including one = 0.02 ng/ml (TIMI score 3)
12 h Troponin TAll negative (<0.01 ng/ml)
Coronary CTA ResultsNormal
TIMI score 3 (1)Both normal
TIMI score 2 (2)Extensive three vessel disease
TIMI score 1 (1)Three with significant stenosis (requiring CA intervention / further investigation)TIMI score 0 (22)One mild disease requiring further CA investigation
One normal CA, but incidental pulmonary cavitations referred to Resp
One aberrant RCA, referred for Cardiology follow-up.
16 normal
  • 20 (77%) patients were discharged with no further investigation, 6 (23%) required further investigation. In four of these cardiac CT identified significant coronary artery disease despite a low TIMI-RS score and negative biochemical markers.

  • CA, coronary artery; CTA, CT angiography; RCA, right coronary artery; TIMI, thrombolysis in myocardial infarction risk score.

  • Data collection is on-going and data will be up-dated. Four of the patients had significant coronary artery disease (1 TIMI 1 and 3 TIMI 0) and one had mild disease requiring Cardiology referral for further evaluation (TIMI 0).

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