Investigating severe interscapular pain
BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a688 (Published 21 July 2008) Cite this as: BMJ 2008;337:a688
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Haydar et al recommend a wider adoption of multidetector computed
tomography (MDCT) for the investigation of acute interscapular chest pain
(1). The potential to confirm or exclude acute myocardial infarction
(MI), aortic dissection, aortitis or acute pulmonary embolism in a single
radiological study is highly appealing. However, there is no mention of
the potential hazards or limitations of using this new technology in this
setting.
We would like to add a note of caution based on several years
experience of both cardiac MDCT and the clinical assessment of acute
thoracic chest pain.
Firstly and most importantly, thorough clinical history and
examination should, in the majority of cases, allow determination of the
most likely cause of thoracic chest pain without the need for “triple rule
out” by MDCT. To obtain MDCT images of sufficient quality to allow this,
the heart rate must be slowed pharmacologically to less than 65bpm. This
may be difficult in patients with acute pain and inadvisable in the
presence of acute pulmonary oedema. Above 65bpm, the ability of MDCT to
reliably determine the presence and absence of coronary disease is
severely limited (2).
Although transthoracic echocardiography has limitations, it is
nonetheless widely available, can be performed in A&E and carries no
radiation risk. Myocardial perfusion scintigraphy is also well validated
in acute MI and provides valuable prognostic information (3) where
available. As only a resting study is required to exclude MI,
radionuclide injection can be performed in A&E and the patient imaged when
stable.
Finally, the radiation burden quoted in the article is misleading. A
“triple rule out” protocol combining CT aortography, pulmonary and
coronary angiography will be associated with an ionising radiation dose of
10-15mSv. This is of major importance when considering that there were
500,000 acute medical admissions to the NHS in 2003 due to suspected
cardiac chest pain (4). Even using conservative estimates of cancer
induction risk, the potential for increasing malignancy from unnecessary
scanning cannot be overlooked (5).
“Triple rule out” MDCT should be reserved only for the minority of
patients in whom significant diagnostic doubt remains after standard
diagnostic approaches.
Conflict of interest: Nil
(1) Haydar AA, Morgan-Hughes G, Roobottom C. Rational Imaging:
Investigating severe interscapular chest pain. BMJ 2008;337:a688
doi:10.1136/bmj.a688
(2) Brodoefel H, Reimann A, Burgstahler C, et al. Noninvasive
coronary angiography using 64-slice spiral computed tomography in an
unselected patient collective: Effect of heart rate, heart rate
variability and coronary calcifications on image quality and diagnostic
accuracy. Eur J Radiol. 2008 Apr;66(1):134-41
(3) Kontos MC, Jesse RL, Schmidt KL, Ornato JP, Tatum JL. Value of
acute rest sestamibi perfusion imaging for evaluation of patients admitted
to the emergency department with chest pain. J Am Coll Cardiol. 1997
Oct;30(4):976-82.
(4) Medical Middle-grade cover in Acute NHS Hospitals in England.
Royal College of Physicians Statement 2003.
http://www.rcplondon.ac.uk/news/statements/mmahEngland/index.asp
(5) Einstein AJ, Henzlova MJ, Rajagopalan S. Estimating risk of
cancer associated with radiation exposure from 64-slice computed
tomography coronary angiography. JAMA 2007 Jul 18;298(3):317-32
Competing interests:
None declared
Competing interests: No competing interests
Rational use of imaging--comments
I welcome the article on investigating severe interscapular pain by
Haydar et al. and commend the authors on their coverage of this subject. I
would like to make 2 comments.
First, the utility of the ECG, and of a
careful history and examination, is somewhat underplayed in the article
and further imaging is frequently not required if the ECG is diagnostic. A
presentation with interscapular pain is perhaps more likely to require
imaging than with anterior chest pain, and the balance of the 3 diagnoses
put forward (MI, dissection, PE) will vary according to this.
Second, the
authors mention myocardial perfusion imaging. This is an excellent test
for detection of acute coronary syndromes in patients with non diagnostic
ECGs but uptake is low in this country due to constraints on time and
equipment use. The study simply requires administration of the tracer at
rest during pain, and imaging at a later stage depending on urgency. This
only requires 15 to 20 minutes; the 4 hours mentioned in the article is
for a stress-rest study as performed in patients without resting symptoms.
Competing interests:
Dr Harbinson is immediate ex-president of the British Nuclear Cardiology Society
Competing interests: No competing interests