Clinical imaging in patients experiencing chest pain

Non-invasive imaging modalities integrate the clinical and laboratory diagnostic work-up of patients admitted in emergency department for chest pain. Transthoracic echocardiography is the first-line imaging tool because it is rapidly and widely available, bedside feasible and cost-effective. Even when a comprensive exam is not feasible, a fast focused ultrasound exam should be performed. Contrast enhanced computed tomography is an easily accessible tool with specific application in patients suspected for pulmonary embolism (PE) and acute coronary syndrome (ACS) according to the pre-test risk assessment and to the clinical status. Cardiac magnetic resonance is not yet very widespread, takes a long time and requires quite stable hemodynamic and clinical condition. It provides accurate information on ventricular systolic function in patients with inadequate echocardiographic windows and gives the unique opportunity to obtain myocardial tissue characterization data that may be diriment in diseases such as ACS, myocarditis and Takotsubo syndrome. Nuclear imaging modalities are generally not available on 24 h service but can be useful in doubtful cases of ACS and PE. Shared diagnostic protocols are the cornerstone of a good practice in emergency rooms and chest pain units. Physician should be familiar with the indication for urgent non-invasive imaging exams in patients admitted for chest pain, in order to achieve rapid diagnosis and start a prompt and proper therapy. Moreover, they should balance identification of critical patients with the safe and early discharge, directly from the emergency room, of low-risk subjects with no evidence of disease.