Author + information
- Received May 1, 2018
- Revision received August 1, 2018
- Accepted August 9, 2018
- Published online April 1, 2019.
- Antonio Esposito, MDa,∗∗ (, )
- Anna Palmisano, MDa,∗,
- Maurizio Barbera, MDa,
- Davide Vignale, MDa,
- Giulia Benedetti, MDa,
- Roberto Spoladore, MDb,
- Marco Bruno Ancona, MDc,
- Francesco Giannini, MDc,
- Michele Oppizzi, MDb,
- Alessandro Del Maschio, MDa and
- Francesco De Cobelli, MDa
- aClinical and Experimental Radiology Unit, Experimental Imaging Center, San Raffaele Scientific Institute, Milan, Italy
- bClinical Cardiology, Heart Failure Unit, San Raffaele Scientific Institute, Milan, Italy
- cInterventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
- ↵∗Address for correspondence:
Dr. Antonio Esposito, San Raffaele Scientific Institute, Via Olgettina 60, 20144, Milan, Italy.
Acute chest pain with elevated cardiac troponin in patients not fulfilling the diagnostic criteria for acute myocardial infarction represents a clinical dilemma. Clear-cut guidelines for the management of these patients are lacking, but the prompt identification of the correct diagnosis is essential for tailored treatment and prognostic evaluation. Different large clinical trials have demonstrated that coronary computed tomography angiography (CTA) is a safe and effective means to rule out an acute coronary syndrome in low-risk chest pain patients presenting to the emergency department (1). In some patients, according with risk factors and clinical presentation, the coronary CTA can be extended to the entire thorax to achieve a triple rule-out scan, which allows us to exclude pulmonary embolism and acute aortic syndrome as well. However, a negative coronary CTA does not exclude the commonest causes of troponin-positive acute chest pain with unobstructed coronaries, such as acute myocarditis, myocardial infarction with normal coronary arteries, and cardiomyopathies. In this clinical scenario, cardiac magnetic resonance (CMR) with late gadolinium enhancement emerged as a powerful diagnostic tool and novel CMR mapping techniques, including native T1, T2, and extracellular volume fraction (ECV), may even increase CMR diagnostic accuracy.
Nowadays cardiac CT may include the evaluation of myocardial damage through scar detection and myocardial ECV assessment, through the analysis of low-dose pre-contrast and late iodine enhancement (LIE) scans. CT-based scar detection and ECV are not yet widely applied in the clinical routine and their diagnostic role needs to be investigated on large-scale studies. However, their good capability to characterize myocardial structure alterations was already demonstrated using a different standard of reference (1,2). Hence, CT-based LIE and ECV might increase the diagnostic potential of cardiac CT in patients with troponin-positive chest pain, allowing us to direct the differential diagnosis. For this reason, we usually adopt a multiphasic protocol, including pre-contrast, coronary CTA and a 10-min post-contrast LIE scan, to perform cardiac CT in troponin-positive chest pain patients.
In this report, we present 4 clinical cases (Figures 1, 2, 3, and 4) where LIE and ECV, assessed by multiphasic cardiac CT, allow us to diagnose, in emergency, structural myocardial alteration explaining the troponin-positive chest pain.⇓⇓⇓⇓
↵∗ Drs. Esposito and Palmisano contributed equally to this work and are joint first authors.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received May 1, 2018.
- Revision received August 1, 2018.
- Accepted August 9, 2018.
- 2019 American College of Cardiology Foundation