Calcium Imaging in the Emergency Department

The triage of patients with acute chest pain is a clinical challenge encountered by physicians on a daily basis. It is also a logistic challenge, associated with long periods of observation and monitoring, contributes to overcrowding of emergency rooms, and is associated with substantial cost. Coronary computed tomographic (CT) angiography has long been considered a means to improve diagnostic uncertainty and alleviate the logistic burden in the triage of acute chest pain. During the past decade, a series of randomized clinical trials have tested the value of cardiac CT for patients with low–intermediate risk chest complaints and demonstrated that in comparison with standard care or specific other diagnostic tests, CT angiography is equally safe but can permit substantially earlier hospital discharge.1–7 Although CT angiography has an excellent negative predictive value, there is a reciprocal tendency to overestimate the angiographic and hemodynamic severity of coronary artery disease, particularly in patients with high calcium scores. Consequently, CT is associated with more diagnostic and therapeutic invasive procedures,8 blunting the potential for cost saving. Based on these observations, the question emerges whether CT angiography is equally effective in patients with a high atherosclerotic burden and whether the test should perhaps be avoided in patients with extensive coronary calcification.See Article by Bittner et al In this issue of Circulation: Cardiovascular Imaging , Bittner et al9 combined data from the ACRIN-PA-4005 (American College of Radiology Imaging Network, Pennsylvania Department of Health-4005) and the ROMICAT-II (Rule Out Myocardial Ischemia/Infarction Using Computer Assisted Tomography-II) trials,2,3 to investigate the association between the …