It Looks Like A Duck, Quacks Like A Duck, but….

A negative coronary angiogram in patients with acute chest pain and elevated cardiac enzymes can be a challenge for ED physicians who are expecting one thing and find another. Now, a German study suggests that cardiac magnetic resonance imaging can be a valuable diagnostic tool to assure appropriate treatment. What are some the conditions that can be reliably diagnosed with an MRI? Read on to find out...

As an emergency physician, you know the challenges involved in diagnosing acute coronary syndromes (ACS). Acute chest pain could be caused by many conditions. Elevated troponin tells you that cardiac injury has occurred, but it doesn’t definitively indicate ACS. How do you identify the 70% of cases of suspected ACS that are really something else?

Researchers at the University of Mainz in Germany presented a study at the recent European Congress of Radiology that found that cardiac magnetic resonance imaging (cMRI) can accurately establish the appropriate diagnosis in the vast majority of cases. The study evaluated 126 patients over a 39-month period using a simple MRI protocol. Researchers found that a cMRI enabled correct diagnosis in 110 patients or nearly 90% of the time. The cMRI allowed physicians to reliably distinguish between ischemic cardiomyopathy, dilative cardiomyopathy, myocarditis, TakoTsubo cardiomyopathy, and hypertensive cardiomyopathy--which accounted for 90% of the cases. It also identified several less common conditions with a high degree of accuracy.

The diagnosis indicated by the cMRI was validated against the consensus-based diagnosis that drew on clinical follow-up and a synopsis of all clinical, laboratory, and imaging data on the patients.

For emergency physicians, cMRI can fairly quickly establish the need for further investigation of suspected ACS and identify the proper course of treatment for a number of cardiac conditions.  The simple cMRI protocol used included cine, edema sensitive and late gadolinium enhancement imaging and has the advantage of not using ionizing radiation.

Researchers found no significant correlation between age, sex, and time to cMRI examination and the accuracy of the diagnosis by cMRI.

View other topics in this week's edition of Pertinent Practice Pearls (free for everyone):

• Normal-Looking Radiographs Can Delay Pneumonia Diagnosis
• What’s To Gain From Aggressive Treatment Of Severe TBI?
• When It Comes To Stair Injuries, Not Just Children Are Falling

View related topics in EB Medicine's publications:

• Complications Of Acute Coronary Syndromes (free for EMCC subscribers)
• Evaluation And Management Of Non–ST–Segment Elevation Acute Coronary Syndromes In The Emergency Department (free for EMP subscribers)
• Low-Risk Chest Pain In The Emergency Department: Current Guidelines (free for EMP subscribers)