急性冠状动脉综合征粥样硬化斑块的多层螺旋CT特征

统计学意义(t=4.82,P<0.01).结论 ACS粥样硬化斑块的MSCT特征包括正性血管重构、低密度斑块、点状钙化和偏心性狭窄.     

Combined stress myocardial CT perfusion and coronary CT angiography as a feasible strategy among patients presenting with acute chest pain to the emergency department

BackgroundA combined approach of myocardial CT perfusion (CTP) with coronary CT angiography (CTA) was shown to have better diagnostic accuracy than coronary CTA alone. However, data on cost benefits and length of stay when compared to other perfusion imaging modalities has not been evaluated. Therefore, we aim to perform a feasibility study to assess direct costs and length of stay of a combined stress CTP/CTA and use SPECT myocardial perfusion imaging (SPECT-MPI) as a benchmark, among chest pain patients at intermediate-risk for acute coronary syndrome (ACS) presenting to the emergency department (ED).MethodsThis is a prospective two-arm clinical trial (NCT02538861) with 43 patients enrolled in stress CTP/CTA arm (General Electric Revolution CT) and 102 in SPECT-MPI arm. Mean age of the study population was 65 ?± ?12 years; 56% were men. We used multivariable linear regression analysis to compare length of stay and direct costs between the two modalities.ResultsOverall, 9 out of the 43 patients (21%) with CTP/CTA testing had an abnormal test. Of these 9 patients, 7 patients underwent invasive coronary angiography and 6 patients were found to have obstructive coronary artery disease. Normal CTP/CTA test was found in 34 patients (79%), who were discharged home and all patients were free of major adverse cardiac events at 30 days. The mean length of stay was significantly shorter by 28% (mean difference: 14.7 ?h; 95% CI: 0.7, 21) among stress CTP/CTA (20 ?h [IQR: 16, 37]) compared to SPECT-MPI (30 ?h [IQR: 19, 44.5]). Mean direct costs were significantly lower by 44% (mean difference: $1535; 95% CI: 987, 2082) among stress CTA/CTP ($1750 [IQR: 1474, 2114] compared to SPECT-MPI ($2837 [IQR: 2491, 3554]).ConclusionCombined stress CTP/CTA is a feasible strategy for evaluation of chest pain patients presenting to ED at intermediate-risk for ACS and has the potential to lead to shorter length of stay and lower direct costs.     

Coronary CT angiography for acute chest pain in the emergency department

Acute chest pain in the emergency department (ED) is a common and costly public health challenge. The traditional strategy of evaluating acute chest pain by hospital or ED observation over a period of several hours, serial electrocardiography and cardiac biomarkers, and subsequent diagnostic testing such as physiologic stress testing is safe and effective. Yet this approach has been criticized for being time intensive and costly. This review evaluates the current medical evidence which has demonstrated the potential for coronary CT angiography (CTA) assessment of acute chest pain to safely reduce ED cost, time to discharge, and rate of hospital admission. These benefits must be weighed against the risk of ionizing radiation exposure and the influence of ED testing on rates of downstream coronary angiography and revascularization. Efforts at radiation minimization have quickly evolved, implementing technology such as prospective electrocardiographic gating and high pitch acquisition to significantly reduce radiation exposure over just a few years. CTA in the ED has demonstrated accuracy, safety, and the ability to reduce ED cost and crowding although its big-picture effect on total hospital and health care system cost extends far beyond the ED. The net effect of CTA is dependent also on the prevalence of coronary artery disease (CAD) in the population where CTA is used, which significantly influences rates of post-CTA invasive procedures such as angiography and coronary revascularization. These potential costs and benefits will warrant careful consideration and prospective monitoring as additional hospitals continue to implement this important technology into their diagnostic regimen.     

Validation of a clinical decision rule: chest X-ray in patients with chest pain and possible acute coronary syndrome

Current literature suggests that a large proportion of chest X-rays (CXRs) performed in emergency department (ED) patients with chest pain and suspected acute coronary syndrome (ACS) are unnecessary. The Canadian ACS Guidelines aim to guide clinicians in the appropriate use of CXR within this patient population. This study determined the prevalence of clinically significant CXR abnormalities and assessed the utility of the guidelines in a population of ED patients with chest pain and suspected ACS. Included in the study were participants over the age of 18 who presented to an Australian metropolitan ED, over a 1-year period, with a primary complaint of chest pain and who had a CXR and troponin level ordered in the ED (N?=?760). We retrospectively compared their radiographic findings with their recommendations for CXR according to the ACS Guidelines. We found that 12 % of the participants had a clinically significant chest X-ray. The guidelines had a sensitivity of 80 % (95 % CI 0.70–0.87) and specificity of 50 % (95 % CI 0.47–0.54). The positive predictive value was 18 % (95 % CI 0.15–0.22) with a 95 % negative predictive value (95 % CI 0.92–0.97). Had the ACS guidelines been applied to our patient population, the number of CXR performed would have been reduced by 47 %. This study suggests that the ACS Guidelines has the potential to reduce the numbers of unnecessary CXR performed in ED patients. However, this would come at the expense of missing a minority of significant CXR abnormalities.     

比较急性胸痛非洲裔美国人和白种人冠状动脉粥样硬化的冠状动脉CTA表现特征

目的利用冠状动脉CT血管成像(CTA)比较研究急性胸痛的非洲裔美国人和白种人之间的动脉粥样硬化斑块病变的发生率、程度与成分。材料与方法本回顾性研究符     

Usefulness of multislice spiral computed tomography coronary angiography in patients with acute chest pain in the emergency department

Background

Despite reports that multislice spiral computed tomography (MSCT) has high sensitivity and specificity in preselected patient populations, the routine clinical feasibility and utility of MSCT coronary angiography in patients with acute chest pain in the emergency department remains uncertain.

Objectives

We sought to determine whether 16-slice MSCT coronary angiography can provide diagnostically useful images in patients with acute chest pain in the emergency department.

Methods

Ninety-eight patients in the emergency department (41 men, 57 women; mean age ± SD, 48.1 ± 11.9 y) with acute chest pain underwent MSCT coronary angiography. Coronary calcium (Agatston) scoring was performed, followed by contrast-enhanced MSCT. Images were evaluated for mean image quality (MIQ) and for degree of stenosis. These data were correlated with body mass index (BMI; in kg/m²), heart rate, beat-to-beat variation, and calcium score to assess their influence on image quality.

Results

The 28 patients (29%) with nondiagnostic MIQs had significantly higher BMIs (mean ± SD, 32.9 ± 9.1 vs 28.9 ± 6.7; P < 0.05) and heart rates (mean ± SD, 71.0 ± 11.9 beats/min vs 65.6 ± 9.9 beats/min; P < 0.05) than patients with diagnostic MIQs. Forty-five patients (46%) had at least 1 nondiagnostic coronary segment. These patients had significantly higher heart rates (mean ± SD, 70.5 ± 10.3 vs 64.1 ± 13.7; P < 0.05) than patients with only diagnostic-quality scans. Image quality correlated inversely and strongly with BMI and heart rate.

Conclusions

Sixteen-slice MSCT coronary angiography cannot routinely provide diagnostically useful images in patients with acute chest pain in the emergency department.     

双源CT前瞻性心电门控扫描在急性胸痛诊断中的临床应用

目的 探讨双源CT(DSCT)前瞻性心电门控扫描在急性胸痛诊断中的临床应用,并比较前瞻性心电门控与回顾性心电门控2种扫描技术的图像质量和辐射剂量.方法 连续搜集30例[A组,平均心率≥85次/min(bpm)]临床症状表现为急性胸痛并行DSCT前瞻性心电门控心胸联合血管成像的患者,连续搜集30例(B组,所有患者平均心率≥85 bpm)表现为急性胸痛行DSCT回顾性心电门控扫描的患者.对2组患者的冠状动脉、肺动脉及主动脉分别进行靶重组,评价2组图像质量,并对疾病进行诊断;应用x2检验和两独立样本t检验比较2组患者的图像质量和有效剂量.结果 A、B组可评价冠状动脉节段比例分别为98.44%(379/385)和98.48%(390/396),差异无统计学意义(x2=0.002,P=0.961);A、B组间图像噪声[分别为(16.23±5.75)、(16.31±3.32)HU]、信噪比(分别为26.85±9.94、24.78±9.91)及对比度噪声比(分别为20.99±9.31、18.65±8.72)差异均无统计学意义(t值分别为0.069、0.908、1.224,P值均＞0.05);A、B 2组有效剂量分别为(8.37±2.69)和(20.05±5.52)mSv,差异有统计学意义(t=9.401,P=0.000).结论 DSCT前瞻性心电门控心胸联合血管成像可以获得与回顾性心电门控扫描相似的图像质量,且辐射剂量降低.

Abstract：

Objective To evaluate the application of prospective ECG-gated dual source CT (DSCT) in patients with acute chest pain, and compare it's image quality and radiation dose with those of retrospective ECG-gated spiral scan. Methods Thirty consecutive patients (Group A, average HR ≥85 bpm) with acute chest pain were scanned with prospective ECG-gated scan and another 30 consecutive patients (Group B, average HR ≥85 bpm)were analyzed by retrospective ECG-gated scan. Tube voltage and tube current were adapted by the BMI of patients. MPR, MIP, CPR and VR were used to display pulmonary arteries (PA), thoracic aorta and coronary arteries (CA). Image quality as well as radiation dose were assessed in 2 groups. Qualitative image quality was compared with chi-square test between the two groups,while quantitative image quality [the image noise ( IN ), signal-to-noise ratio ( SNR ) and contrast-to-noise ratio(CNR)] and radiation dose were evaluated with x2 test and Student's t test. Results The proportion of valid coronary segments for diagnosis were 379/385 ( 98. 44% ) and 390/396 ( 98.48% ) respectively in Group A and Group B with no significant difference(x2 =0. 002,P =0. 961 ). The IN [( 16. 23 ±5.75)vs ( 16. 31 ±3. 32) HU] ,SNR (26. 85 ±9. 94 vs 24. 78 ±9. 91 ) and CNR (20. 99 ±9. 31 vs 18. 65 ±8. 72)showed no significant differences between 2 groups ( t = 0. 069,0. 908 and 1. 224, P ＞ 0. 05, respectively).The ED was on average ( 8. 37 ± 2. 69 ) mSv in Group A, whereas on average ( 20. 05 ± 5.52 ) mSv in Group B. There was a statistical difference between 2 groups ( t = 9. 401, P = 0. 000). Conclusion Low dose prospective ECG-gated DSCT angiography can show similar image quality as retrospective ECG-gated spiral scan with radiation dose.     

急性胸痛患者总冠状动脉钙化和局部钙化的差异与急性冠脉综合征及主要病变之间的关系

目的 探讨急性冠状动脉综合征(ACS)总冠状动脉钙化(CAC)负荷和局部CAC与主要病变之间的关系.方法 对37例ACS患者及223例对照患者进行计算机CAC检查和CT血管造影评估显著狭窄和高风险斑块的表现,测量总评分和节段Agatston评分.对ACS患者的主要病变进行评价.结果 37例ACS患者的CAC总评分较非A...     

Impact of 64-slice coronary CT on the management of patients presenting with acute chest pain: results of a prospective two-centre study

Objective  

Our two-centre prospective study evaluates the usefulness of 64-slice coronary computed tomography (CCT) to rule out significant coronary artery stenosis in patients admitted in emergency departments (ED) for acute coronary syndromes (ACS) with low-to-intermediate risk score.     

Radiological emergency room management with emphasis on multidetector-row CT

Trauma is the fifth leading cause of death after disease of the cardiovascular system, malignomas and disease of the respiratory and digestive system. The management of severely injured patients, including radiological imaging, is a matter of ongoing development. In particular, as for the imaging modalities, multidetector-row CT represents a substantial refinement in the diagnostic work-up of multitrauma patients. Sufficient therapy within the first hour after trauma increases the patient's chances for survival significantly. Thus, therapeutic procedures and diagnostic evaluation have to be concomitant events, performed by a multidisciplinary team, namely trauma surgeon, anesthesiologist and, last but not least, radiologist. The increased performance of multidetector-row CT leads to increased spatial resolution, which is a prerequisite for sophisticated two- and three-dimensional postprocessing. The increased volume coverage speed allows for comprehensive whole-body CT at still high levels of spatial resolution, resulting in significant spare of time which influences patient's survival. Using this technique conventional imaging such as plane film or angiography may be omitted.     

Coronary CT angiography with iterative reconstruction in early triage of patients with acute chest pain

Background

Patients who present to the emergency department (ED) complaining of acute chest pain are of clinical concern because a small percentage will have acute coronary syndrome (ACS). The American College of Cardiology (ACC) and the American Heart Association (AHA) recommend hospitalization for patients with a low-to-intermediate risk of ACS who have initial negative ECG and enzyme test results. A negative coronary CT angiography (CCTA) during the triage has a very high negative predictive value for ruling out ACS decreasing the length of hospital stay. Recent techniques e.g. ASiR in CCTA should be used to decrease the radiation dose as low as possible.

Objective

The aim of this study is to evaluate the role of low radiation dose CCTA with ASiR in triage of low-risk patients with acute chest pain in emergency department. A negative CCTA early in the workup may enable a shorter length of stay.

Subjects and methods

We studied 54 selected patients (55.6% men; mean age 48 ± 6 years) with chest pain who were awaiting hospital admission to rule out ACS despite the absence of diagnostic ECG changes and normal cardiac enzymes on ED presentation. Patients underwent CCTA before hospital admission. Afterward, patients received standard clinical care (SCC). ER physicians involved in the patient’s care were blinded to the results of CCTA. An expert panel established the presence or absence of ACS based on AHA guidelines. The CCTA images were evaluated for the presence of significant coronary artery stenosis (diameter reduction >50%) and were used to make a triage decision.

Results

Four patients (7.4%) with chest pain had at least one significant coronary stenosis on CCTA (sensitivity 100%, specificity 96%, accuracy 96.3%, positive predictive value (PPV) 66.7% and negative predictive value (NPV) 100%). Significant coronary stenosis was excluded in 48 of the 54 patients by CCTA (88.9%), potentially saving about 71.6% of unnecessary hospital admission hours.

Conclusion

CCTA based detection of significant coronary stenosis has potential role to decrease the length of hospital stay , without reducing appropriate patient care, in low risk patients with acute chest pain. CCTA should be done with lowest radiation possible using recent techniques.     

急性胸痛病人CT冠状动脉成像显示的冠状动脉粥样硬化斑块中除钙化外其他成分的预后价值

摘要目的应用CT冠状动脉成像检查进行系统性评估无证据表明为急性冠状动脉综合征(ACS)的急性胸痛病人的预后情况,不仅仅评价冠状动脉钙化(CAC)的情况。材料与方法人类研究委员会批准本项研究,并确定无需书面知情同意。     

Impact of abdominal CT on the management of patients presenting to the emergency department with acute abdominal pain

OBJECTIVE: The purpose of this study is to document the impact of CT performed in the emergency department of patients presenting with nontraumatic acute abdominal pain. SUBJECTS AND METHODS: Fifty-seven patients were enrolled in this prospective study. Using a computer order entry system, emergency department physicians were required to report their most likely diagnosis, level of certainty, and management plan for their patients before ordering abdominal CT. After CT was performed, each physician was required to provide again his or her diagnosis, level of diagnostic certainty, and treatment plan. The outcome of each patient was evaluated by either surgery, other imaging studies, or clinical follow-up. RESULTS: After the abdominal CT, physicians' mean level of certainty in their diagnoses increased by 1.5 points (on a five-point scale; p < 0.0001). Patient management was changed in 33 (60.0%) of 55 patients. Planned treatment before CT was admission in 42 patients. Actual admissions after CT totaled 32 patients (excluding the two patients in whom preimaging information was not recorded). Thus, the net effect of abdominal CT scanning was to avert 10 (23.8%) of 42 hospital admissions. CONCLUSION: CT performed in the emergency department increases the physician's level of certainty, reduces hospital admission rates by 23.8%, and leads to more timely surgical intervention.     

ECG-gated chest CT angiography with 64-MDCT and tri-phasic IV contrast administration regimen in patients with acute non-specific chest pain

The purpose of this study was to evaluate chest CTA protocol using retrospective ECG-gating and triphasic IV contrast regimen for comprehensive evaluation of patients with acute non-specific chest pain. ECG-triggered dose modulation was used with a 64-MDCT scanner in 56 non-critically ill patients with acute nonspecific chest pain using triphasic IV regimen: 50 ml contrast followed by 50 ml 60% contrast/saline and 30 ml normal saline. Lungs, aorta, pulmonary and coronary arteries were graded on a 5-point scale (5, best). Aorta and pulmonary artery attenuation was measured and three coronary artery groups were evaluated. Comparison with invasive coronary angiography was obtained in nine patients on a per segment (16 total) basis. Dosimetry values were obtained. Studies were satisfactory in all patients (score >3). Aorta and pulmonary artery attenuation was >200 HU in 90.5%. Lung or pleura, non-cardiac vascular and coronary arteries disease were detected in 20, 11 and 16 patients, respectively. Median coronary angiography (grade 5) was significantly higher than acceptable for diagnosis grade 4 (p < 0.001). Per segment, weighted kappa statistic was 0.79 indicating substantial agreement with catheter angiography (p<0.001). Average DLP was 1,490 ± 412 mGy-cm. Gated 64-MDCT angiography with triphasic IV contrast is a robust multipurpose technique for patients with acute non-specific chest pain. An erratum to this article can be found at     

严重急性呼吸综合征患者肺内残留病变CT表现的随访观察

目的 探讨严重急件呼吸综合征（SARS）患者临床治疗后，CT复查肺内残留病变的动态变化情况。方法 对124例治疗后的SARS患者进行CT复查随访，失访13例，资料完整111例，对平均病程第3、6、12及18个月行螺旋CT检杏的结果进行对比分析，总结其影像动态变化的特征。结果 病程18个月内，相继有70例（占63．1％）患者肺内CT表现恢复止常。6、12、18个月时CT主要征象：（1）磨玻璃样病变残留率分别为33．3％（37／111）、24．3％（27／111）、20．7％（23／111）。（2）小叶间隔或小叶内间质增厚残留率分别为37．8％（42／111）、28．8％（32／111）、25．2％（28／111）。以上2种主要病变在随访期内的总体变化经对比分析X^2检验，差异有统计学意义（P〈0．01）。（3）胸膜下弧线影15例，随访期内病变有不同程度的吸收，但无一例病变消失。（4）不规则纤维条索影18个月时残留率17．1％（19／111）。少见征象：（1）实变病灶1例，病程第12个月完全吸收。（2）空洞病灶2例，1例于病程第12个月基本吸收，1例随访期内末完全吸收。（3）牵拉性支气管扩张1例，随访期内无明显变化。（4）小结节灶3例，1例病程第12个月基本吸收，2例无明显变化。结论 病程第18个月SARS患者肺内磨玻璃样病变残留率为20．7％。17．1％的患者残留局限性肺间质纤维化改变。对肺内残留磨玻璃样病变的患者继续定期随访间隔6～12个月为宜，其他患者可以延长随访间隔时间至12个月以上。     

应用多层螺旋CT胸部三联合扫描检查急性胸痛

40层螺旋CT的高时间和空间分辨率使一次扫描覆盖冠状动脉、主动脉、肺动脉并清晰重建其血管影像成为可能,即对冠心病、肺动脉栓塞和主动脉夹层等三种常见急性重症的快速联合检查,是急性胸痛患者有效的诊断和筛查手段。本文旨在探讨应用40层螺旋CT胸部三联合扫描检查急性胸痛患者。