64-MDCT Scan Research Articles

Application Value of 64-slice Multidetector Spiral CT Contrast-enhanced Scan in Maxillofacial Soft Tissue Hypervascular Tumours.

To evaluate the diagnostic ability and clinical imaging features in maxillofacial soft tissue hypervascular tumours by 64-slice multidetector spiral computed tomography (64-MDCT) contrast-enhanced scanning. In a retrospective study of 21 cases of hypervascular tumours, the degree of blood supply and indexes were assessed, and the pathological results were used as the diagnostic gold standard to evaluate the sensitivity and specificity of 64-MDCT plain scan and enhanced CT in the diagnosis of oral and maxillofacial soft tissue hypervascular tumours, using the receiver operating characteristic curve to analyse and evaluate the efficacy. Among 21 patients, the diagnostic accuracy of 64-MDCT contrast-enhanced scan was 90.48%, the area under the curve of venous phase CT value was 0.80, the sensitivity was 83.30% and the specificity was 72.73%. 64-MDCT contrast-enhanced scan can be used to evaluate the blood supply of maxillofacial soft tissue hypervascular tumours before an operation. The CT value in the venous phase of tumours has the highest diagnostic effectiveness, which can reduce the risk of blood loss during surgery for maxillofacial hypervascular tumours. In addition, it has certain guiding significance for the formulation of clinical treatment plans.

Accuracy of Preoperative MDCT in Patients With Penetrating Abdominal and Pelvic Trauma.

This study aims to evaluate the overall diagnostic accuracy of preoperative multidetector computed tomography (MDCT) in penetrating abdominal and pelvic injuries (PAPI). We used our hospitals' trauma registry to retrospectively identify patients with PAPI from January 1, 2006, to December 31, 2016. Only patients who had a 64-MDCT scan at presentation and subsequently underwent laparotomy or laparoscopy were included in our study cohort. Each finding noted on MDCT was rated using a 5-point scale to indicate certainty of injury, with a score of 0 being definitive. Using surgical findings as the gold standard, the accuracy of radiology reports was analyzed in 2 ways. A κ statistic was calculated to evaluate each pair of values for absolute agreement, and ratings for all organ systems were analyzed using a repeated measures analysis of variance (ANOVA) to determine whether radiology and surgical findings were similar enough to be clinically meaningful. Qualitative review of the radiology and surgical reports focused on the gastrointestinal (GI) tract was conducted. Our cohort consisted of 38 males and 4 females with a median age of 29 years and a median injury severity score of 15.6. For this study, 12 different organ groups were categorized and analyzed. Of those organ groups, absolute agreement between MDCT and surgical findings was found only for liver and spleen (κ values ranging from 0.2 to 0.5). Additionally, the ANOVA revealed an interaction between finding type and organ system (F 1, 33 = 7.4, P < .001). The most clinically significant discrepancies between MDCT and surgical findings were for gallbladder, bowel, mesenteric, and diaphragmatic injuries. Qualitative review of the GI tract revealed that radiologists can detect significant findings such as presence of injury, however, localization and extent of injury pose a challenge. The detection of clinically significant injuries to solid organs in trauma patients with PAPI on 64-MDCT is adequate. However, detection of injury to the remaining organ groups on MDCT, especially bowel, mesentery, and diaphragm, remains a challenge.

Utility of biphasic multi-detector computed tomography in suspected acute mesenteric ischemia in the emergency department.

To retrospectively evaluate the utility of biphasic multi-detector computed tomography (MDCT) with arterial and portal venous phases for the detection of suspected acute mesenteric ischemia (AMI) in emergency department (ED) patients compared to limited surgical confirmation. A research ethics board (REB)-approved retrospective review of all consecutive adult patients who underwent an emergency biphasic 64-MDCT examination of the abdomen and pelvis due to clinical suspicion for AMI over a 5-year period at a single tertiary-care institution was performed. Patients who underwent biphasic 64-MDCT scans performed for any clinical concern other than suspected acute mesenteric ischemia were excluded. Specifically, reported vascular and bowel findings were used to establish occlusive arterial, venous, and non-occlusive MDCT findings of AMI. Correlation was made with surgical findings in operatively managed patients and with serum lactate values preceding imaging assessment. Diagnostic yield and positive predictive value calculations were performed. Two hundred and twenty-five patients underwent MDCT for suspected occlusive AMI between 10 Jan 2011 and 31Jul 2016. Of these, 200 patients were negative for AMI and 25 patients (mean age 73.5years; age range 48 to 94years; 13 men and 12 women) had MDCT findings positive for bowel ischemia (yield of 11.1%). On MDCT, 18/25 (72%) had an occlusive arterial etiology for AMI, 2/25 (8%) had an occlusive venous etiology, and 5/25 (20%) had non-occlusive AMI. Twenty of 25 (80%) patients with positive MDCT findings of AMI also had an elevated serum lactate level, including 14/18 (77.8%) patients with arterial occlusive AMI on MDCT, 2/2 (100%) with venous-occlusive AMI on MDCT, and 4/5 (80%) with non-occlusive AMI on MDCT. Correlation with surgical findings led to a positive predictive value (PPV) of biphasic MDCT for surgically proven all-cause occlusive ischemia of 92.9%. Further substratification revealed PPVs of arterial and venous-occlusive ischemia of 85.7% and 7.1%, respectively. Of the 225 patients MDCT-positive for AMI, 213 had pre-imaging serum lactate assessments. Of 188 patients MDCT-negative for AMI, 85 patients had elevated serum lactate (45.2%). Twenty of the 25 patients with positive MDCT findings of AMI (80%) also had an elevated serum lactate level, including 14/18 (77.8%) patients with arterial occlusive AMI on MDCT, 2/2 (100%) with venous-occlusive AMI on MDCT, and 4/5 (80%) with non-occlusive AMI on MDCT. Emergent biphasic MDCT demonstrated low but non-trivial yield (11.1%) for the depiction of suspected acute mesenteric ischemia but was particularly low for occlusive venous AMI (0.9%). The relationship between serum lactate elevation and positive MDCT findings of AMI in our study conforms to prior work and cautiously suggests value in routine serum lactate assessment preceding imaging for patient prioritization.

Qualitative and Quantitative Assessment of Abdominal and Pelvic CT Image Quality Using Iopromide With Different Concentrations of Iodine (300 and 370 mg I/mL).

The purpose of this study was to analyze the quality of MDCT images obtained using iopromide with two different concentrations of iodine (300 and 370 mg I/mL) in daily clinical settings. Patients from 38 hospitals in China undergoing abdominal or pelvic CT with iopromide were prospectively recruited. MDCT was performed using iopromide with an iodine concentration of 300 or 370 mg I/mL. CT quality image was graded as excellent, good, adequate, and poor. Objective indicators were the contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR). Outcomes were compared according to organ studied, tumor type (benign vs malignant), saline usage, and type of MDCT (16-MDCT vs 64-MDCT). A total of 4506 patients (63.7% men) with a mean (± SD) age of 56.3 ± 14.1 years and mean body mass index (weight in kilograms divided by the square of height in meters) of 23.2 ± 3.3 were included. Iopromide with 300 mg I/mL was used for 3042 patients (67.5%), and 370 mg I/mL was used for 1464 patients (32.2%). A total of 1847 scans (41.0%) had excellent image quality, 2454 (54.5%) had good quality, 176 (3.9%) had adequate quality, and 29 (0.6%) had poor quality. No differences were noted between CT scans that did or did not use saline, 16-MDCT versus 64-MDCT scans, and 300 versus 370 mg I/mL iopromide. Variations in the CNR and SNR were noted between the two iodine concentrations with respect to other parameters examined. Iopromide with both concentrations of iodine provided acceptable image quality, though according to CNR and SNR, one or the other may provide better quality in different situations.

Imaging of Traumatic Diaphragmatic Rupture: Evaluation of Diagnostic Accuracy at a Level 1 Trauma Centre

PurposeTraumatic diaphragmatic rupture (TDR) is an uncommon injury that can be associated with significant morbidity if not detected and treated in a timely manner. The purpose of our study was to evaluate the diagnostic accuracy of 64-slice multidetector computed tomography (64-MDCT) for the detection of TDR in patients at our level 1 trauma centre. MethodsWe used our hospital's trauma registry to identify patients with a diagnosis of TDR from January 1, 2008, to December 31, 2012. Only patients with a 64-MDCT scan at presentation who subsequently underwent laparotomy/laparoscopy were included in the study cohort. Using surgical findings as the gold standard, the accuracy of the prospective radiology reports was analyzed. ResultsOf the 3225 trauma patients who presented to our institution, 38 (1.2%) had a TDR. Fourteen of the 38 were excluded as they did not have MDCT before surgery. The study cohort consisted of 20 males and 4 females with a median age of 34.5 years and a median Injury Severity Score (ISS90) of 26. Fifteen had blunt trauma while 9 had a penetrating injury. The overall sensitivity of the radiology reports was 66.7% (95% confidence interval [CI]: 46.7%-82.0%), specificity was 100% (95% CI: 94.1%-100%), positive predictive value was 100% (95% CI: 80.6%-100%), negative predictive value was 88.4% (95% CI: 78.8%-94.0%), and accuracy was 90.6% (95% CI: 82.5%-95.2%). However, only 3 of 9 patients with penetrating injury had a correct preoperative diagnosis. Two of the 6 missed penetrating trauma cases had only indirect signs of injury. ConclusionsThe detection of TDR in trauma patients on 64-MDCT can be improved, especially in patients presenting with penetrating injury. A careful search for subtle diaphragmatic defects and indirect evidence of injury is important to avoid missing the diagnosis.

A long and narrow pulmonary vein thrombus attached to the wall of a pulmonary vein

Pulmonary vein thrombosis (PVT) is often not diagnosed because PVT has subtle symptoms and PVT is believed to be rare. The mechanism for the formation of PVT is unclear. In this case, I describe a small thrombus in a small branch of a pulmonary vein draining into a larger vein, the right lower pulmonary vein (RLPV).The patient was a 70-year-old male with angina pectoris, and he presented with chest pain. He had no symptoms of cerebral infarction. He previously had been treated with percutaneous coronary intervention and had four stents in the coronary arteries. A 64-slice multidetector computed tomography (64-MDCT) scan was performed to evaluation for in-stent restenosis. A thrombus in the RLPV was shown in axial and sagittal images as a defect in contrast enhancement, representing a small thrombus in a small branch of a pulmonary vein draining into the RLPV.The 64-MDCT scan depicted them well. The effects of PVT are unknown, and more studies are needed.

A jumping left atrial thrombus connected to a pulmonary vein thrombus using transthoracic echocardiography and 64-slice multi-detector computed tomography

Few studies have reported the differences between transthoracic echocardiography (TTE) and 64-slice multidetector CT (64-MDCT) in identifying left atrium (LA) thrombi. I report the case of a 70 year old man with coronary artery disease and angina who was diagnosed with a thrombus in the left lower pulmonary vein extending to the LA using a non-invasive 64-MDCT scan and TTE. TTE was unable to clearly identify a thrombus in the pulmonary veins, whereas a 64-MDCT scan identified a thrombus in the pulmonary vein but was unable to detect a moving thrombus attached to the mitral valves. The 64-MDCT images of LA thrombi are smaller than those of TTE and the video created using TTE demonstrated a moving thrombus connected to the mitral valve, which was underdiagnosed by a 64-MDCT scan. This case illustrates the complementary role for both TTE and 64-MDCT in the noninvasive diagnosis of left atrial-pulmonary vein thrombi.

A network of pulmonary vein thrombi is a risk factor for ischemic stroke, especially after cardiac surgery: A case report and mini review

Stroke remains a devastating complication following cardiac surgery. Pulmonary vein thrombi (PVT) are believed to be rare, but I have reported 37 cases of PVT in elderly patients with chest pain since 2012, indicating that PVT are not unusual. The present case showed that PVT can make a network among four pulmonary veins and left atrium. Currently, PVT are not recognized as a risk factor for ischemic stroke, especially following cardiac surgery.A 76-year-old male was examined by 64-slice multidetector CT (64-MDCT) to assess chest pain. The 64-MDCT scan revealed thrombi in the left upper and lower pulmonary veins, the right upper and lower pulmonary veins and the left atrium (LA) as the defects of contrast enhancements. The LA thrombi seemed to be connected to PVT forming a network of thrombi.To avoid stroke following cardiac surgery, it is important to cope with PVT. How to treat PVT during cardiac surgery should be developed.

High prevalence of pulmonary vein thrombi in elderly patients with chest pain, which has relationships with aging associated diseases

AimPulmonary vein thrombi (PVT) are believed to be rare. Some cases of PVT were reported in patients with lung cancer, thoracic surgery or catheter ablation. PVT are a possible cause of systemic embolism, but little is known about its complications. Since 2012, we have reported seven cases of PVT in patients without these predisposing factors.The aim of the present study was to clarify whether PVT were rare or not in patients without these predisposing factors and how can we treat patients with PVT. MethodsWe performed 64-slice multidetector CT (64-MDCT) scans on 57 consecutive Japanese patients (28 men and 29 women; age = 73.8 ± 8.6 years old) with chest pain, but they didn't have lung cancer, thoracic surgery or catheter ablation, from September 2012 to March 2013. ResultsCoronary artery plaque was detected in 32 patients (56%). PVT were clearly demonstrated in 35 patients (61%), which indicated that PVT are not rare. Furthermore, 32 patients (91%) among 35 patients with PVT had no cerebral infarctions. In older people, PVT are not uncommon and have many clinico-pathologic correlations. Small or fine thrombi in the pulmonary vein should occlude a small artery of every organ and make effects on many diseases, which are not recognized by almost all medical doctors. ConclusionsPVT are common observation in patients with chest pain and no clear predisposing factor. Further studies are required to assess if PVT can be considered as an etiology of chest pain and to determine its optimal management.

Prevalence of Temporal Bone Fractures in Patients with Mandibular Fractures Using Multidetector-Row CT

Temporal bone fracture after mandibular trauma is thought to be rare, and its prevalence has not been reported in the literature. The purpose of this study was to investigate the prevalence of temporal bone fractures in patients with mandibular fractures and the relationship between temporal bone fractures and the mandibular fracture location using multidetector-row computed tomography (MDCT). A prospective study was performed in 201 patients with mandibular fractures who underwent 64-MDCT scans. The mandibular fracture locations were classified as median, paramedian, angle, and condylar types. Statistical analysis for the relationship between prevalence of temporal bone fractures and mandibular fracture locations was performed using χ(2) test with Fisher's exact test. A P-value < 0.05 was considered statistically significant. The percentage of cases with temporal bone fracture was 3.0 % of all patients with mandibular fractures and 19.0 % of those with multiple mandibular fractures of paramedian and condylar type. There was a significant relationship between the incidence of temporal bone fracture and the paramedian- and condylar-type mandibular fracture (P = 0.001). Multiple mandibular fractures of paramedian and condylar type may be a stronger indicator for temporal bone fractures. This study suggests that patients with mandibular fracture, especially the paramedian and condylar type, should be examined for coexisting temporal bone fracture using MDCT.

Left atrial volumetry from routine diagnostic work up prior to pulmonary vein ablation is a good predictor of freedom from atrial fibrillation

This study aimed to identify whether left atrial (LA) volume assessed by multidetector computed tomography (MDCT) is related to the long-term success of pulmonary vein ablation (PVA). MDCT is used to guide PVA for the treatment of atrial fibrillation (AF). MDCT permits accurate sizing of LA dimensions. We analysed data from 368 ablation procedures of 279 consecutive patients referred for PVA due to drug-refractory symptomatic AF (age 62 ± 10; 58% men; 71% paroxysmal AF). Prior to the procedure, all patients underwent ECG-gated 64-MDCT scan for assessment of LA and PV anatomy, LA thrombus evaluation, LA volume estimation, and electroanatomical mapping integration. Within a mean follow-up of 356 ± 128 days, 64% of the patients maintained sinus rhythm after the initial ablation, and 84% when including repeat PVA. LA diameter (P = 0.004), LA volume (P = 0.002), and type of AF (P = 0.001) were independent predictors of AF recurrence in univariate analysis. There was a relatively low correlation between the echocardiographic LA diameter and LA volume from MDCT (P = 0.01, r = 0.5). In multivariate analysis, paroxysmal AF (P < 0.006) and LA volume below the median value of 106 mL (P = 0.042) were significantly associated with the success of PVA, whereas LA diameter was not (P = 0.245). Analysing receiver-operator characteristics, the area under the curve for LA volume was 0.73 (P = 0.001) compared with 0.60 (P = 0.09) for LA diameter from echocardiography. LA volume assessed by MDCT is a better predictor of AF recurrence after PVA than echocardiograpic LA diameter and can be derived from the pre-procedural imaging data set.

Right ventricular dysfunction and dilatation in patients with mitral regurgitation: Analysis using ECG-gated multidetector row computed tomography

BackgroundThis study prospectively compared the accuracy of a sixty-four slice multidetector row CT (64-MDCT) in cardiac magnetic resonance imaging (MRI) for the assessment of right ventricular (RV) dysfunction and dilatation in patients with mitral regurgitation. MethodsEighty-four patients underwent ECG-gated 64-MDCT for the assessment of RV dysfunction and dilatation; 54 of these patients had known mitral regurgitation. End-diastolic and end-systolic volumes, stroke volume, and ejection fraction were measured using the 64-MDCT, and these results were retrospectively compared to the results of MRI (reference standard). Agreement between the 64-MDCT and MRI results was investigated using linear regression and Bland–Altman analyses. Receiver operating characteristic analyses calculated the sensitivity and specificity of RV dilatation on 64-MDCT scans for the prediction of mitral regurgitation severity and dysfunction, respectively. ResultsNo significant differences in RV function parameters were calculated between 64-MDCT and MRI (r=0.87 to 0.94; all p<0.001). Good intertechnique agreement was obtained using linear regression and Bland–Altman analyses. ROC analyses revealed that RV enlargement (>33mm) on 64-MDCT scans predicted the RV dysfunction of mitral regurgitation with a sensitivity of 92.9% and a specificity of 82.9%. ConclusionsECG-gated 64-MDCT accurately and reliably assessed RV function in patients with and without mitral regurgitation. Moreover, the presence of RV dilatation on the 64-MDCT scan assisted in the prediction of RV dysfunction and mitral regurgitation severity.

Interobserver agreement in fusion status assessment after instrumental desis of the lower lumbar spine using 64-slice multidetector computed tomography: impact of observer experience

Persistent lower back pain after instrumental posterolateral desis may arise from incomplete fusion. We investigate the impact of experience on interobserver agreement in fusion estimation. Four independent observers, two residents and two musculoskeletal radiologists, reviewed dedicated lumbar 64-MDCT scans and scored vertebral levels 1-5 after Glassman's grades, 1: solid bilateral fusion, 2: solid unilateral fusion, 3: partial bilateral fusion, 4: partial unilateral fusion, 5: non-fusion. We investigated two simplifying dichotomizations, solid bilateral fusion (Glassman 1) versus all others and uni- or bilateral fusion (Glassman 1-2) versus partial or non-fusion. Thirty-six patients with 61 operated lumbar levels were included. Interobserver agreement rates for four observers using Glassman's system were fair (kappa 0.32), either dichotomization showed moderate agreement (kappa 0.53 and 0.59). Observer pairs had comparable prevalence adjusted interobserver agreement rates (residents: PABAK 0.67 and 0.54; consultants: PABAK 0.57 and 0.71). Difference in observer experience seems of minor impact.

64-MDCT Scan Demonstrated Pulmonary Vein Thrombus

Although the relationship between deep venous thrombosis and pulmonary embolism is well known and studied extensively, the relationship between pulmonary vein thrombus (PVT) and systemic embolism such as cerebral infarction is unknown. 64-slice multidetector computed tomography (64-MDCT) scan can demonstrate PVT. We had reported two cases of small thrombus within the right upper pulmonary vein and the left upper pulmonary vein. A 74-year-old male with chronic atrial fibrillation was referred to be examined cardiac thrombus. 64-MDCT scan demonstrated large thrombi, which expanded from the right upper pulmonary vein to the left upper pulmonary vein and the left atrium. Three months warfarin therapy decreased the size of thrombi and changed the shape of thrombi. PVT is potentially life threatening condition and is thought to be a rare, but PVT seems to have been significantly underestimated. The 64-MDCT scan can assess PVT effectively and completely.

Depiction of Hypervascular Hepatocellular Carcinoma With 64-MDCT: Comparison of Moderate- and High-Concentration Contrast Material With and Without Saline Flush

The purpose of this study was to evaluate prospectively the depiction of hypervascular hepatocellular carcinoma on 64-MDCT scans obtained with contrast agents of varying iodine concentrations administered with and without saline flush. The study included 149 patients, among whom 36 patients with hypervascular hepatocellular carcinoma were identified. Patients were randomly assigned to one of three protocols: A, contrast material of 300 mg I/mL; B, 370 mg I/mL; C, 370 mg I/mL plus saline flush. In all protocols, the same iodine load per kilogram of body weight (516 mg/kg) was administered for the same injection duration (30 seconds). Enhancement values in the aorta, liver, and portal vein and tumor-liver contrast were measured at multiphase CT. Aortic enhancement was significantly different between protocols A and B (p = 0.04, p < 0.0001) and protocols B and C (p = 0.02, p < 0.001) in the first and second phases. Portal venous enhancement was significantly different between protocols B and C (p = 0.02) in the first phase and between protocols B and C and protocols A and C (p < 0.01, p = 0.02) in the second phase. Tumor-liver contrast was significantly different between protocols A and B (p = 0.03, p = 0.02) and protocols B and C (p = 0.03, p = 0.04) in the first and second phases but not between protocols A and C. There was no significant difference in hepatic enhancement among the three protocols. Use of moderate concentration was more effective than use of a high concentration of contrast material for depiction of hepatocellular carcinoma. Adding a saline flush to the high-concentration protocol eliminated the difference in depiction of hepatocellular carcinoma between the moderate- and high-concentration protocols.

Acute Traumatic Thoracic Aortic Injuries: Experience with 64-MDCT

At some institutions, catheter angiography is used for confirmation of aortic injuries and equivocal MDCT findings. Because of the speed and efficiency of 64-MDCT, we believe that diagnostic catheter angiography may be obsolete. The purpose of this study was to review our experience with 64-MDCT in the evaluation of acute traumatic aortic injury (ATAI). The trauma registry at a level 1 trauma center was reviewed to find cases of ATAI occurring between March 1, 2005, and July 31, 2007. MDCT images were correlated with transcatheter angiograms when obtained. Surgical and clinical reports were reviewed to confirm abnormal and normal findings and the stability of the conditions of patients undergoing conservative treatment. After level 1 or level 2 trauma, 1,344 patients underwent contrast-enhanced 64-MDCT. Twenty-four patients (1.79%) were found to have 25 aortic injuries. All patients had direct MDCT signs of ATAI. Ten catheter angiograms were obtained after MDCT. The presence of direct signs was confirmed in three cases. In five cases, indirect signs were found to be normal findings. In two cases, the findings remained equivocal after MDCT and conventional angiography. Fourteen patients underwent surgical repair of the aorta, six underwent conservative management, and four patients died of other injuries. No patient with equivocal or indirect findings needed surgical repair. The sensitivity of 64-MDCT was 96.0%; specificity, 99.8%; positive predictive value, 92.3%; negative predictive value, 99.9%; and accuracy, 99.8%. Direct signs of ATAI on contrast-enhanced 64-MDCT scans do not have to be confirmed with catheter angiography. In our population, diagnostic transcatheter angiography was of limited value for clarifying equivocal or indirect MDCT findings.

100: Multidetector CT in the Detection of Coronary Anomalies

Pulmonary vein thrombi (PVT) are believed to be rare. Some cases of PVT were reported in patients with lung cancer, thoracic surgery or catheter ablation. PVT are a possible cause of systemic embolism, but little is known about its complications. Since 2012, we have reported seven cases of PVT in patients without these predisposing factors.The aim of the present study was to clarify whether PVT were rare or not in patients without these predisposing factors and how can we treat patients with PVT.We performed 64-slice multidetector CT (64-MDCT) scans on 57 consecutive Japanese patients (28 men and 29 women; age = 73.8 ± 8.6 years old) with chest pain, but they didn't have lung cancer, thoracic surgery or catheter ablation, from September 2012 to March 2013.Coronary artery plaque was detected in 32 patients (56%). PVT were clearly demonstrated in 35 patients (61%), which indicated that PVT are not rare. Furthermore, 32 patients (91%) among 35 patients with PVT had no cerebral infarctions. In older people, PVT are not uncommon and have many clinico-pathologic correlations. Small or fine thrombi in the pulmonary vein should occlude a small artery of every organ and make effects on many diseases, which are not recognized by almost all medical doctors.PVT are common observation in patients with chest pain and no clear predisposing factor. Further studies are required to assess if PVT can be considered as an etiology of chest pain and to determine its optimal management.