Chest pain CT in the emergency department: Watch out for the myocardium

Abstract Rationale and Objectives To evaluate the frequency and relevance of hypodense myocardium (HM) encountered in patients undergoing chest-pain CT in the emergency department (ED). Material and Methods In this IRB-approved retrospective study, ECG-gated chest-pain CT examinations of 300 consecutive patients (mean age 60 ± 17 years) presenting with acute chest-pain to our ED were evaluated. Once ST-segment elevation infarction was excluded, chest-pain CT including the coronary arteries (rule-out acute coronary syndrome (ACS), pulmonary embolism (PE) and acute aortic syndrome (AAS): chest-pain CT coronary , n = 121) or not including the coronary arteries was performed (rule-out PE and AAS: chest-pain CT w/o coronary , n = 179). Each myocardial segment was assessed for the presence of HM; attenuation was measured and compared to normal myocardium. Results HM was identified in 27/300 patients (9%): 12/179 in chest-pain CT w/o coronary (7%) and 15/121 in chest-pain CT coronary (12%). Mean attenuation of HM (40 ± 17 HU) was significantly lower than that of healthy myocardium (103 ± 18 HU, p  w/o coronary identified HM in 10/15 patients (66.6%) with a final diagnosis of acute MI. Conclusion HM indicating acute MI are often encountered in chest pain CT in the ED, also in chest-pain CT w/o coronary when MI is not suspected. This indicates that the myocardium should always be analyzed for hypodense regions even when MI not suspected.