Novel approaches to the assessment of patients with chest systoms in the acute medical and outpatient settings: the use of multislice computed tomography

Abstract

This thesis evaluated the clinical utility of cardiopulmonary computed tomography (CT) in patients presenting with chest pain and dyspnoea. Studies within this thesis confirmed the following. Firstly, there is a requirement for improved diagnostic pathways to minimise patients being discharged without a diagnosis, which currently occurs in 30-40% of patients admitted with chest pain and dyspnoea. Historically, CT has been utilised in 32% of admissions with chest pain and 10% of admissions with dyspnoea. Secondly, challenges exist to the wider adoption of cardiopulmonary CT. These include patient-related factors, institutional capabilities and guideline restrictions. In acute admissions, 11% of patients with dyspnoea and 7% of patients with chest pain and a low to moderate likelihood of CAD are suitable for CT. In the RACPC setting, including patients across the entire spectrum of CAD likelihood, 18% of patients are suitable for CT. NICE CG95 would recommend only 1% of acute chest pain admissions and 2% of RACPC attenders for CT. Thirdly, NICE CG95 would recommend 51% of acute chest pain admissions and 66% of RACPC attenders for discharge without cardiac investigation. In the RACPC population, significant CAD is identified in 10% of these patients and a major adverse cardiac event in 2%. Fourthly, in selected patients with suspected cardiac chest pain, cardiac CT has a diagnostic yield of 21% in acute admissions and 13% in RACPC attenders for significant CAD. In acute admissions with dyspnoea, cardiopulmonary CT has a diagnostic yield of 20% for CAD, 20% for pulmonary embolism, nil for aortic dissection and 89% for non-vascular chest pathology. Fifthly, inclusion of CT in diagnostic pathways for chest pain result in fewer patients discharged without a diagnosis, fewer invasive angiography procedures and reduced diagnostic costs. In patients with dyspnoea, CT provides value to clinicians making diagnoses and supports early discharge without detrimental outcomes.