Background-Managing chest pain in the emergency department remains a challenge with current diagnostic strategies.We hypothesized that cardiac MRI could accurately identify patients with possible or probable acute coronary syndrome. Methods and Results-The diagnostic performance of MRI was evaluated in a prospective study of 161 consecutive patients. Enrollment required 30 minutes of chest pain compatible with myocardial ischemia but an ECG not diagnostic of acute myocardial infarction. MRI was performed at rest within 12 hours of presentation and included perfusion, left ventricular function, and gadolinium-enhanced myocardial infarction detection. MRI was interpreted qualitatively but also analyzed quantitatively. The sensitivity and specificity, respectively, for detecting acute coronary syndrome were 84% and 85% by MRI, 80% and 61% by an abnormal ECG, 16% and 95% for strict ECG criteria for ischemia (ST depression or T-wave inversion), 40% and 97% for peak troponin-I, and 48% and 85% for a TIMI risk score Ն3. The MRI was more sensitive than strict ECG criteria for ischemia (PϽ0.001), peak troponin-I (PϽ0.001), and the TIMI risk score (Pϭ0.004), and MRI was more specific than an abnormal ECG (PϽ0.001). Multivariate logistic regression analysis showed MRI was the strongest predictor of acute coronary syndrome and added diagnostic value over clinical parameters (PϽ0.001). Conclusions-Resting

Plasma lipids play a key role in the development of atherosclerosis. Recent trial data support early identification of asymptomatic adults with high-risk lipid profiles for primary prevention of coronary heart disease. 3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitors have been shown to reduce coronary events in both asymptomatic adults and those with known coronary heart disease. The optimal plasma low-density lipoprotein cholesterol for secondary coronary prevention remains controversial. The Second Report of the Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II), published in 1993 by the National Cholesterol Education Program, recommends guidelines for evaluation and diagnosis of lipids. Subsequently, several clinical trials have identified populations benefiting from pharmacologic intervention and new approaches to the management of lipid disorders. Consequently, these guidelines should be applied with the interval evidence in mind.