Multislice CT Speeds the Diagnosis of Chest Pain in the Emergency Room

Imagine coming to the hospital with crushing chest pain, only to find that emergency room doctors are uncertain whether you’re having a heart attack. The electrocardiogram (ECG) is inconclusive and the blood tests that detect heart damage are normal. The only thing to do is wait, hour after hour, as doctors repeat the tests several times and scrutinize the results for diagnostic clues.

Soon, the wait may be much shorter. According to research reported in the February 27, 2007, issue of the Journal of the American College of Cardiology (JACC), a computed tomography (CT) scan of the heart can quickly detect whether there are fatty blockages or pockets of rock-hard calcium in the arteries of the heart—clues that coronary artery disease may be the cause of the chest pain.

“The new 64-slice CT scanners give us amazing pictures of the heart,” said James A. Goldstein, M.D., F.A.C.C., Director of Research and Education in the Division of Cardiology at William Beaumont Hospital, Royal Oak, MI. “With this very simple outpatient scan, you can rapidly determine whether the arteries are normal or abnormal—and if they’re abnormal, whether the disease is mild, moderate, or severe.”

Those who get a clean bill of health can safely go home from the hospital without further testing. “As a physician, it’s tremendously satisfying to tell an anxious patient, within about 30 minutes, that their heart and arteries are normal,” Dr. Goldstein said.

Each year, some 6 million people in the United States are rushed to the emergency room with chest pain. At least half have inconclusive early test results; of these, approximately 65 percent are eventually found not to have suffered a heart attack—but not before racking up diagnostic costs totaling $10 billion to $12 billion annually.

Even low-risk patients with no history of heart disease can spend 18 to 24 hours in the emergency room as doctors repeat the ECG and blood tests. That’s because doctors want never to mistakenly send home a patient who is actually having a heart attack. “The consequences of missing a heart attack can be disastrous,” Dr. Goldstein said. “So even if you appear to be completely healthy, if you come to the emergency room with chest pain, you’re going to go through a very laborious, expensive, and time-consuming evaluation.”

Dr. Goldstein and his colleagues wanted to see whether a CT scan of the heart could make the evaluation of chest pain more efficient and less costly, allowing emergency physicians to quickly send home patients with normal coronary arteries, while accurately identifying patients with serious heart disease who needed to be admitted to the hospital.

For the study, they recruited 197 patients with heart attack-like chest pain but no history of heart disease. In all patients, the results of the ECG and the blood tests that detect heart damage were normal, both initially and after being repeated four hours later. The researchers then randomly assigned half of the patients to have a CT scan of the heart and the other half to a standard diagnostic plan, which included additional rounds of ECG and blood testing, plus a nuclear scan of the heart.