Ruling out coronary stenosis in acute chest pain
Case history
43-year-old patient with acute chest pain, not entirely typical for myocardial infarction. ST segment elevation [fig. 1] and enzyme elevation. Echo was normal.
Question
Myocarditis versus myocardial infarction: Can coronary stenoses/occlusions be ruled out?
Diagnosis / Differential diagnosis
Chest pain and ST segment elevation are the lead symptoms of acute myocardial infarction. Here, however, the clinical presentation suggested that myocarditis might be more likely. Coronary CTA was performed in order to rapidly determine the status of the coronary arteries and thus differentiate between infarction and myocarditis.
Findings
In DSCT (heart rate 77/min), optimal image quality was achieved at 70% of the R-R interval. In the original images, multiplanar reconstructions [fig. 2] and 3-dimensional display [figs. 3 and 4], it was demonstrated that the coronary arteries were free of stenosis and atherosclerotic plaque, thus allowing the diagnosis of perimyocarditis. No invasive angiography was performed. The patient recovered uneventfully.
Comment
In selected situations of patients with acute chest pain, coronary DSCT angiography can be useful to rule out the presence of coronary lesions (stenoses or occlusions). In chest pain with ST segment elevation, DSCT will not usually be the test of choice. Here, however, clinical suspicion of perimyocarditis was strong and hence DSCT imaging was performed to avoid invasive angiography.
Authors: Stephan Achenbach, Axel Kuettner, Dieter Ropers
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See corresponding procotol: Protocol coronary CT angiography
See corresponding case: Diagnosis of a coronary occlusion in a patient with atypical chest pain
