Advances in contrast echocardiography to evaluate ischemic changes in wall thickening [50-53] and strain echocardiography to evaluate abnormal myocardial deformation [54-57] may provide an expanded role for resting echocardiography in the evaluation of ACS, particularly in patients with active chest pain at the time of imaging. US Echocardiography Transesophageal US Echocardiography Transesophageal The primary usefulness of resting transesophageal echocardiography (TEE) in the setting of acute chest pain is in ruling out aortic dissection in unstable patients. TEE is also used to further define valvular dysfunction or intracardiac thrombus, which can be sequelae of ischemic events in the subacute setting. Because of the semi- invasive nature of TEE and because there is limited information that can be added in the setting of acute chest pain, this modality is generally not indicated in the workup of patients with acute chest pain [58]. CTA Coronary Arteries In stable patients with suggested ACS at low or intermediate risk of adverse events, a noninvasive coronary imaging test (ie, coronary CTA [CCTA]) is a proven alternative to stress testing or selective coronary angiography [19,59,60]. CCTA has a very high negative predictive value for the detection of coronary atherosclerosis with or without significant stenosis and is an alternative to stress imaging in the emergency department and inpatient settings in patients at low to intermediate risk for CAD [59,61-64]. Large randomized controlled trials (eg, CT- STAT, ROMICAT I and II, ACRIN-PA, PROSPECT, CT-COMPARE, CATCH, and CATCH-2) have amply established the high negative predictive value (eg, safe discharge) and good prognosis of a negative CCTA in low- to intermediate-risk patients suspected of ACS when compared with standard pathways that predominantly involve stress nuclear MPI [65-72].
Chest Pain Possible Acute Coronary Syndrome PCAs. Advances in contrast echocardiography to evaluate ischemic changes in wall thickening [50-53] and strain echocardiography to evaluate abnormal myocardial deformation [54-57] may provide an expanded role for resting echocardiography in the evaluation of ACS, particularly in patients with active chest pain at the time of imaging. US Echocardiography Transesophageal US Echocardiography Transesophageal The primary usefulness of resting transesophageal echocardiography (TEE) in the setting of acute chest pain is in ruling out aortic dissection in unstable patients. TEE is also used to further define valvular dysfunction or intracardiac thrombus, which can be sequelae of ischemic events in the subacute setting. Because of the semi- invasive nature of TEE and because there is limited information that can be added in the setting of acute chest pain, this modality is generally not indicated in the workup of patients with acute chest pain [58]. CTA Coronary Arteries In stable patients with suggested ACS at low or intermediate risk of adverse events, a noninvasive coronary imaging test (ie, coronary CTA [CCTA]) is a proven alternative to stress testing or selective coronary angiography [19,59,60]. CCTA has a very high negative predictive value for the detection of coronary atherosclerosis with or without significant stenosis and is an alternative to stress imaging in the emergency department and inpatient settings in patients at low to intermediate risk for CAD [59,61-64]. Large randomized controlled trials (eg, CT- STAT, ROMICAT I and II, ACRIN-PA, PROSPECT, CT-COMPARE, CATCH, and CATCH-2) have amply established the high negative predictive value (eg, safe discharge) and good prognosis of a negative CCTA in low- to intermediate-risk patients suspected of ACS when compared with standard pathways that predominantly involve stress nuclear MPI [65-72].