The Use of Coronary Computed Tomography Angiography for Patients Presenting with Acute Coronary Syndrome
- Introduction
Acute coronary syndrome is characterized by myocardial ischemia, typically secondary to Coronary Artery Disease (CAD). This condition often manifests during exertion and is directly related to impaired myocardial function.
The primary cause of CAD is the atherosclerosis of coronary arteries. It occurs when atherosclerotic plaque builds up within the walls of coronary arteries leading to the luminal narrowing and presentation with clinical manifestations of Acute Coronary Syndrome (ACS) that include unstable angina and myocardial infarction.
Risk factors of CAD exist among many individuals in the general population, which include hypertension, dyslipidemia, diabetes mellitus, chronic kidney disease, age, gender, lifestyle, cigarette smoking, diet, obesity, and family history.
Coronary Artery Disease is the most important cause of heart disease. Coronary artery disease (CAD) is one of the primary causes of death. The incidence of CAD is related to age, gender, and economic status. Cardiovascular Disease (CVD) has become the largest single cause of death worldwide. It is responsible for an estimated 17 million deaths and led to 151 million disability-adjusted life years (DALYs) lost (~30.0% of all deaths and 14.0% of all DALYs lost). It is a leading cause of morbidity, disability, and mortality worldwide. Further, by 2020, 32.0% of the world population deaths will be caused by CVD, and by 2030; it will be responsible for 33.0% of all deaths (24.2 million) (1).
In Egypt, the National Hypertension Project (NHP) found an adjusted overall prevalence of CAD is 8.3% (2). In Egypt, WHO reports showed in 2014 that CAD deaths reached 107,232 (23.14%) of all deaths. Age-adjusted death rate is186.36/100,000 population; this ranks Egypt #23 in the world]. CAD deaths were 78,897 (21.73%) of all deaths, which made CAD the first killer in Egypt in 2013 (3).
Complications of acute myocardial infarction include left ventricular dysfunction, cardiogenic shock, and structural complications. Other risks include arrhythmia, recurrent chest discomfort, recurrent ischemia or re-infarction, pericardial effusion, pericarditis, and post-myocardial infarction syndrome. Additionally, patients may experience venous thrombosis, pulmonary embolism, left ventricular aneurysm, left ventricular thrombus, and arterial embolism
The combination of rising usage of sensitive myocardial infarction biomarkers and precise imaging techniques, including electrocardiograph (ECG), computed tomography, and cardiac magnetic resonance imaging, made diagnosis of CHD easy and early. During the last 40 years, a decrease in global coronary heart disease mortality has been seen to decline by up to 50% (4).
Diagnosis and triage of patients with suspected acute chest pain secondary to ACS consume a large and increasing amount of healthcare resources. Further, the consequences of missing ACS are both a source of morbidity and mortality in such patients and remain a source of significant malpractice litigation. Therefore, expeditious, safe evaluation of ACP is a pressing need to increase healthcare providers’ efficiency, contain costs, and improve outcomes.
Coronary computed tomography angiography (CTA) has been shown to be very good for prognosticating risk, excluding significant coronary artery disease in stable patients with chest pain, and has a high sensitivity for the identification of significant coronary stenosis. CTA improves the quality of care for patients presenting with acute chest pain, particularly in patients with low to intermediate likelihood of acute coronary syndrome. Coronary CTA offers a rapid evaluation of the degree of coronary stenosis and atherosclerosis, allows a significant reduction in time-to-discharge, and ensures high-risk patients are appropriately triaged to cardiac catheterization.
Because of the increasing use of coronary CTA testing for the evaluation of ACP patients. These recommendations were produced as an educational tool for practitioners evaluating acute chest pain patients, in the interest of developing systematic standards of practice for coronary CTA based on the best available data or broad expert consensus. Due to the highly variable nature of medical care, approaches to patient selection, preparation, protocol selection, interpretation, or reporting that differ from these guidelines may represent an appropriate variation based on a legitimate assessment of an individual patient's needs.