A 78-year-old woman with a past medical history of systemic hypertension and cigarette smoking was admitted to the emergency department with severe central chest pain radiating to her back. General physical examination was unremarkable other than revealing pronounced hypertension. Her blood pressure in the right arm was 176/116 mm Hg and in the left arm was 185/105 mm Hg. A 12 lead electrocardiogram (ECG) demonstrated atrial fibrillation with a ventricular rate of 94 beats/min and no significant ST segment changes. Her full blood count and electrolytes were normal, but creatinine was elevated at 145 mmol/l (70–120 μmol/l). A computed tomography (CT) scan of the chest was arranged to exclude an aortic dissection.
The CT scan excluded aortic dissection, but a non-ECG gated cardiac CT demonstrated an occluded right coronary artery (fig 1) and acute myocardial infarction affecting the inferior wall of the left ventricle (fig 2). The CT scan also showed bilateral renal artery stenosis and multiple ulcerative plaques throughout the aorta (fig 4). The diagnosis was confirmed by left heart catheterisation (fig 3) and a drug eluting stent was implanted in the right coronary artery following pre-dilatation, with an excellent angiographic result.
Thoracic CT scan is an important tool in emergency medicine and can be helpful not only in establishing the diagnosis but also in excluding important differential diagnosis. CT with the use of emerging technology, especially with the introduction of multislice (640) scanning, has the potential to revolutionarise the management of acute coronary syndrome by providing non-invasive CT coronary angiography.