From the Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy (A.P., D.V., D.D.S., F.D.C., A.E.); School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (A.P., D.V., E.B., F.D.C., A.E.); Department of Cardiology, University Hospital Dr Dragiša Mišović Dedinje, Belgrade, Serbia (M.T.); Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (F.M., M.M.); UOC Diagnostica per Immagini e Radiologia Interventistica, Policlinico Universitario Campus Bio-Medico, Rome, Italy (D.D.S.); Department of Surgical Sciences, Radiology Unit, University of Turin, Turin, Italy (M.G., R.F., F.G., M.R.); Clinical Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele University Hospital, Milan, Italy (M.O., M.S., A.M.); Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy (G.P., S.S.); Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (E.A.); and Department of Diagnostic Radiology, Ospedale Maria Vittoria, Turin, Italy (G.C.).
Radiology. 2022 Mar;302(3):545-553. doi: 10.1148/radiol.211288. Epub 2021 Dec 7.
Background Acute chest pain with mild troponin rise and inconclusive diagnosis after clinical evaluation represents a diagnostic challenge. Triple-rule-out (TRO) CT may exclude coronary artery disease (CAD), as well as acute aortic syndrome and pulmonary embolism, but cannot help identify other causes of myocardial injury. Purpose To investigate the diagnostic value of a comprehensive CT protocol including both an angiographic and a late contrast enhancement (LCE) scan in participants with troponin-positive acute chest pain. Materials and Methods In this prospective study, consecutive patients with troponin-positive acute chest pain or anginal equivalent and inconclusive diagnosis after clinical evaluation (symptoms, markers, electrocardiography, and echocardiography) who underwent TRO CT between June 2018 and September 2020 were enrolled. TRO CT was performed to evaluate the presence of obstructive CAD (stenosis ≥50%), acute aortic syndrome, and pulmonary embolism. If the findings on the TRO CT scan were negative, an LCE CT scan was acquired after 10 minutes to assess the presence and pattern of scar and quantify the myocardial extracellular volume fraction. CT-based diagnoses were compared with diagnoses obtained with reference standard methods, including invasive coronary angiography, cardiac MRI, and endomyocardial biopsy. Results Eighty-four patients (median age, 69 years [interquartile range, 50-77 years]; 45 men) were enrolled. TRO CT helped identify obstructive CAD in 35 participants (42%), acute aortic syndrome in one (1.2%), and pulmonary embolism in six (7.1%). LCE CT scans were acquired in the remaining 42 participants. The following diagnoses were reached with use of LCE CT: myocarditis (22 of 42 participants [52%]), takotsubo cardiomyopathy (four of 42 [10%]), amyloidosis (three of 42 [7.1%]), myocardial infarction with nonobstructed coronary arteries (three of 42 [7.1%]), dilated cardiomyopathy (two of 42 [4.8%]), and negative or inconclusive findings (eight of 42 [19%]). The addition of LCE CT improved the diagnostic rate of TRO CT from 42 of 84 participants (50% [95% CI: 38.9, 61.1]) to 76 of 84 (90% [95% CI: 82.1, 95.8]) ( < .001). Conclusion A CT protocol including triple-rule-out and late contrast enhancement CT scans improved diagnostic rate in participants presenting with acute chest pain syndrome. © RSNA, 2021 See also the editorial by Nagpal and Bluemke in this issue.
背景 临床评估后出现肌钙蛋白轻度升高伴急性胸痛且诊断不明确的情况具有一定的诊断挑战性。三导联检查（TRO）CT 可排除冠状动脉疾病（CAD）、急性主动脉综合征和肺栓塞，但无法帮助确定心肌损伤的其他原因。目的 探讨包括血管造影和晚期对比增强（LCE）扫描的综合 CT 方案在肌钙蛋白阳性的急性胸痛患者中的诊断价值。材料与方法 本前瞻性研究纳入了 2018 年 6 月至 2020 年 9 月期间行 TRO CT 检查的肌钙蛋白阳性的急性胸痛或等效胸痛且临床评估后诊断不明确（症状、标志物、心电图和超声心动图）的连续患者。TRO CT 用于评估是否存在阻塞性 CAD（狭窄≥50%）、急性主动脉综合征和肺栓塞。如果 TRO CT 扫描结果为阴性，则在 10 分钟后进行 LCE CT 扫描以评估瘢痕的存在和模式并量化心肌细胞外容积分数。基于 CT 的诊断与参考标准方法（包括有创冠状动脉造影、心脏 MRI 和心内膜活检）获得的诊断进行比较。结果 共纳入 84 例患者（中位年龄，69 岁[四分位距，50-77 岁]；45 例男性）。TRO CT 有助于确定 35 例患者（42%）存在阻塞性 CAD、1 例（1.2%）存在急性主动脉综合征和 6 例（7.1%）存在肺栓塞。剩余 42 例患者进行了 LCE CT 扫描。使用 LCE CT 得出以下诊断：心肌炎（42 例患者中的 22 例[52%]）、心尖球形综合征（42 例患者中的 4 例[10%]）、淀粉样变性（42 例患者中的 3 例[7.1%]）、非阻塞性冠状动脉心肌梗死（42 例患者中的 3 例[7.1%]）、扩张型心肌病（42 例患者中的 2 例[4.8%]）和阴性或不确定发现（42 例患者中的 8 例[19%]）。LCE CT 的加入使 TRO CT 的诊断率从 42 例患者（50%[95%CI：38.9，61.1]）提高至 84 例患者中的 76 例（90%[95%CI：82.1，95.8]）（ <.001）。结论 包括三导联检查和晚期对比增强 CT 扫描的 CT 方案可提高急性胸痛综合征患者的诊断率。
