The edition · Radiology
One CT protocol found a cause in three in four patients with raised troponin and no infarct
Coronary CT angiography with late iodine enhancement changed the working diagnosis in nearly half of 191 emergency patients. Also: raising IPMN high-risk thresholds on MRI, and what acute contrast reactions cost in time and money.
The edition in brief
A prospective single-centre study enrolled 191 emergency patients with acute cardiac symptoms, raised troponin and no criteria for acute myocardial infarction. Coronary CT angiography found obstructive disease in 40%; in the rest, late iodine enhancement and extracellular volume mapping identified myocarditis, infarction with non-obstructive arteries, Takotsubo, amyloidosis or cardiomyopathy in 55%. The protocol changed the working diagnosis in 48%, agreed with the discharge diagnosis in 94%, and no major cardiac events occurred over about two years in patients with a fully negative scan. A single-centre MRI study of 418 resected IPMNs found current high-risk stigmata had 83% sensitivity but only 67% specificity for malignancy; raising mural nodule and duct thresholds improved specificity and AUC at the cost of sensitivity. A five-year review of over 617,000 contrast-enhanced CT and MRI examinations found acute reactions added a median of about 25 minutes in the department; median direct costs were small, but rose steeply for severe reactions and admissions. The pearl covers metformin and iodinated contrast.
IPMN on MRI: current high-risk stigmata often over-called malignancy in one series
Report IPMN nodule and duct measurements precisely and flag borderline values, since current high-risk thresholds have a high false-positive rate for malignancy.
Acute contrast reactions added about 25 minutes per patient, with costs driven by the severe few
Plan for contrast reactions as an operational event: equipment, trained staff and schedule slack matter more than the drug costs.
Metformin and iodinated contrast: stop only when kidney function is poor
Continue metformin around iodinated contrast if eGFR is 30 or above and kidney function is stable; withhold for 48 hours only when it is poor or acutely worse.
Coronary CT with late iodine enhancement found a cause in most patients with troponin rise and no infarct
Consider a combined coronary CT and late iodine enhancement protocol for raised troponin without infarction, especially where cardiac MRI access is limited, but treat it as early single-centre evidence.
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