N o v e m b e r 2 0 0 5 • w w w. e c a r d i o l o g y n e w s .

c o m Imaging 21

New Scan Gives Speedy

Diagnosis of Chest Pain
A single 15-second scan may replace a battery of
tests for serious conditions in emergency situations.
BY ROBERT FINN In addition to aortic dissection, pul-
San Francisco Bureau monary embolism, and coronary artery
disease, the technique will allow clear
S A N F R A N C I S C O — Chest pain repre- views of the pericardium, permitting the
sents one of the most common presenting diagnosis of calcified or thickened peri-
symptoms in emergency departments, cardium and sometimes pericarditis.
and it also represents a diagnostic chal- In addition, “you might pick up pneu-
lenge: Is it a pulmonary embolism? Is it an monia, and you might pick up pulmonary
aortic dissection? Is it coronary artery dis- adhesions or even pericardial adhesions,”
ease? Or is it nothing? Dr. Budoff said. “There are a lot of things
Now, new CT technology promises to you could possibly see. And it could be
revolutionize this diagnosis, giving the done during the chest pain episode, which
ability to rule out all three conditions with is a great advantage over some of the oth-
a single 15-second scan. er modalities where you’d want to wait
In theory, this scan can replace stress until their chest pain is quiescent.”
testing for coronary artery disease, Dr. Budoff described the case of an el-
echocardiography or CT for aortic dis- derly woman who complained of chest
section, and CT pulmonary angiography pain and shortness of breath. Because of
or a ventilation-perfusion scan for pul- her age, he was reluctant to order a stress
monary embolism, Matthew J. Budoff, test. The CT angiography showed that her
M.D., said at a cardiovascular imaging coronary arteries were normal and that
conference sponsored by the American her ejection fraction was acceptably high.
College of Cardiology. When he examined the lung images close-
Although no diagnostic or prognostic ly, however, he discovered several pul-
studies on the triple rule out have yet monary emboli.
been published, there’s some indication “We admitted her to the hospital, put
that the single scan will have 90% accura- her on heparin, and it all cleared up,” he
cy or better for each of the three condi- said.
tions, said Dr. Budoff of Harbor-UCLA Despite its promise, the triple rule out
Medical Center in Torrance, Calif. does have some limitations. For one thing,
The technology involves a 64-slice CT it subjects patients to a relatively high
scan from the apex to the base of the dose of radiation—in the neighborhood of
lungs. Patients will have to hold their 24-30 millisieverts, equivalent to 240-300
breath for 20-30 seconds as contrast is in- chest x-rays.
jected and the images are acquired. Ac- Because it’s a gated study, more contrast
quisition of the slices will be gated to the must be used and the injection time is
heart’s rhythm, allowing for stable, high- longer than for a standard CT. Some pa-
resolution images of the heart and lungs. tients may have trouble holding their
The slice thickness will be 0.625 mm. breath for 20-30 seconds.
Software and a sophisticated workstation Then there’s the issue of who is going
will allow the clinician to construct three- to read these images when a patient pre-
dimensional images sents at 3 a.m. The radiologist staffing the
of the heart, lungs, emergency department may not be facile
or aorta, and to ma- with cardiac CT angiography. Although
nipulate three-di- the images could be transferred over data
mensional and two- lines, the cardiologist is not likely to have
dimensional images a workstation with the proper software at
in a variety of ways. home. In all likelihood, someone will have
to come to the hospi-
tal to read the study.
Still, Dr. Budoff ex-
pects the triple rule
out to become a rou-
tine test in the emer-
gency department, a
prospect he greets
D R . M ATTHEW J. B UDOFF

with mixed emotions.

“We really need to
see how this is going
to pan out, and work
out the reading issues
before we start apply-
COURTESY

ing this to everybody

who comes in with a
twinge in their chest
P HOTOS

or shortness of
breath,” he said. “I’m a
Views of aortic dissection: Left, it is shown as a long, thin little leery ...to say just
dissection flap in the descending aorta; right, the true lumen because we can do it
(larger area) and false lumen are shown endoscopically. we should.” ■