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The ‘Triple Rule Out’ CT Angiogram for Acute Chest Pain: Should it be Done, and If So, How?

  • Cardiac Computed Tomography (TC Villines and S Achenbach, Section Editors)
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Abstract

Given the large number of individuals presenting to emergency departments with acute, undifferentiated chest pain and the frequent difficulty in discerning its etiology, there has been great interest in developing techniques that can improve the initial triage of these patients. The ‘Triple Rule Out” CT has recently been touted as a tool to quickly assess for life threatening causes of acute chest pain, namely acute coronary syndrome, pulmonary embolism, and aortic dissection. Initial studies suggest that this protocol is safe and compares favorably with the dedicated CT protocols but at the cost of increased doses of iodinated contrast and radiation. New scanner technology has started to address these limitations but the “Triple Rule Out” CT is still in its infancy. It remains to be seen whether or not this application can ultimately improve diagnostic efficiency, cost, and/or clinical decision making.

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References

Papers of particular interest, published recently, have been highlighted as follows: • Of importance •• Of major importance

  1. Pitts SR, Niska RW, Xu J, Burt CW. National hospital ambulatory medical care survey: 2006 emergency department summary. Natl Health Stat Rep. 2008;7:1–38.

    Google Scholar 

  2. Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005;294:2623.

    Article  PubMed  CAS  Google Scholar 

  3. Boie ET. Initial evaluation of chest pain. Emerg Med Clin North Am. 2005;23:937–58.

    Article  PubMed  Google Scholar 

  4. Rogg JG, De Neve JW, Huang C, et al. The triple work-up for emergency department patients with acute chest pain: how often does it occur? J Emerg Med. 2011;40:128–34.

    Article  PubMed  Google Scholar 

  5. Storrow AB, Gibler WB. Chest pain centers: diagnosis of acute coronary syndromes. Ann Emerg Med. 2000;35:449–61.

    PubMed  CAS  Google Scholar 

  6. Hollander JE, Sease KL, Sparano DM, et al. Effects of neural network feedback to physicians on admit/discharge decision for emergency department patients with chest pain. Ann Emerg Med. 2004;44:199–205.

    Article  PubMed  Google Scholar 

  7. Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000;342:1163–70.

    Article  PubMed  CAS  Google Scholar 

  8. Christenson J, Innes G, McKnight D, et al. Safety and efficiency of emergency department assessment of chest discomfort. Can Med Assoc J. 2004;170:1803.

    Article  Google Scholar 

  9. Goodman LR, Curtin JJ, Mewissen MW, et al. Detection of pulmonary embolism in patients with unresolved clinical and scintigraphic diagnosis: helical CT vs angiography. Am J Roentgenol. 1995;164:1369–74.

    CAS  Google Scholar 

  10. Kuzo RS, Goodman LR. CT evaluation of pulmonary embolism: technique and interpretation. Am J Roentgenol. 1997;169:959–65.

    CAS  Google Scholar 

  11. Schoepf UJ, Costello P. CT angiography for diagnosis of pulmonary embolism: state of the art. Radiology. 2004;230:329.

    Article  PubMed  Google Scholar 

  12. Kruip MJHA, Söhne M, Nijkeuter M, et al. A simple diagnostic strategy in hospitalized patients with clinically suspected pulmonary embolism. J Intern Med. 2006;260:459–66.

    Article  PubMed  CAS  Google Scholar 

  13. Cigarroa JE, Isselbacher EM, DeSanctis RW, Eagle KA. Diagnostic imaging in the evaluation of suspected aortic dissection–old standards and new directions. N Engl J Med. 1993;328:35–43.

    Article  PubMed  CAS  Google Scholar 

  14. Hagan PG, Nienaber CA, Isselbacher EM, et al. The international registry of acute aortic dissection (IRAD). JAMA. 2000;283:897.

    Article  PubMed  CAS  Google Scholar 

  15. Nienaber CA, von Kodolitsch Y, Nicolas V, et al. The diagnosis of thoracic aortic dissection by noninvasive imaging procedures. N Engl J Med. 1993;328:1–9.

    Article  PubMed  CAS  Google Scholar 

  16. Yoshida S, Akiba H, Tamakawa M, et al. Thoracic involvement of Type a aortic dissection and intramural hematoma: diagnostic accuracy—comparison of emergency helical ct and surgical findings. Radiology. 2003;228:430.

    Article  PubMed  Google Scholar 

  17. Hamon M, Biondi-Zoccai GGL, Malagutti P, et al. Diagnostic performance of multislice spiral computed tomography of coronary arteries as compared with conventional invasive coronary angiography: a meta-analysis. J Am Coll Cardiol. 2006;48:1896–910.

    Article  PubMed  Google Scholar 

  18. Achenbach S, Moselewski F, Ropers D, et al. Detection of calcified and noncalcified coronary atherosclerotic plaque by contrast-enhanced, submillimeter multidetector spiral computed tomography. Circulation. 2004;109:14–7.

    Article  PubMed  Google Scholar 

  19. Leber AW, Knez A, von Ziegler F, et al. Quantification of obstructive and nonobstructive coronary lesions by 64-slice computed tomography: a comparative study with quantitative coronary angiography and intravascular ultrasound. J Am Coll Cardiol. 2005;46:147–54.

    Article  PubMed  Google Scholar 

  20. Taylor AJ, Cerqueira M, Hodgson JMB, et al. ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 Appropriate Use Criteria for Cardiac Computed Tomography: A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol. 2010;56:1864.

    Article  PubMed  Google Scholar 

  21. Ropers D, Rixe J, Anders K, et al. Usefulness of multidetector row spiral computed tomography with 64- × 0.6-mm collimation and 330-ms rotation for the noninvasive detection of significant coronary artery stenoses. Am J Cardiol. 2006;97:343–8.

    Article  PubMed  Google Scholar 

  22. Raff GL, Gallagher MJ, O'Neill WW, Goldstein JA. Diagnostic accuracy of noninvasive coronary angiography using 64-slice spiral computed tomography. J Am Coll Cardiol. 2005;46:552.

    Article  PubMed  Google Scholar 

  23. Mollet NR, Cademartiri F, van Mieghem CAG, et al. High-resolution spiral computed tomography coronary angiography in patients referred for diagnostic conventional coronary angiography. Circulation. 2005;112:2318–23.

    Article  PubMed  Google Scholar 

  24. Leschka S, Alkadhi H, Plass A, et al. Accuracy of MSCT coronary angiography with 64-slice technology: first experience. Eur Heart J. 2005;26:1482–7.

    Article  PubMed  Google Scholar 

  25. Stein PD, Yaekoub AY, Matta F, Sostman HD. 64-slice CT for diagnosis of coronary artery disease: a systematic review. Am J Med. 2008;121:715–25.

    Article  PubMed  Google Scholar 

  26. Budoff MJ, Dowe D, Jollis JG, et al. Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial. J Am Coll Cardiol. 2008;52:1724–32.

    Article  PubMed  Google Scholar 

  27. Miller JM, Rochitte CE, Dewey M, et al. Diagnostic performance of coronary angiography by 64-row CT. N Engl J Med. 2008;359:2324–36.

    Article  PubMed  CAS  Google Scholar 

  28. Meijboom WB, Meijs MFL, Schuijf JD, et al. Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study. J Am Coll Cardiol. 2008;52:2135–44.

    Article  PubMed  Google Scholar 

  29. Goldstein JA, Gallagher MJ, O'Neill WW, et al. A randomized controlled trial of multi-slice coronary computed tomography for evaluation of acute chest pain. J Am Coll Cardiol. 2007;49:863–71.

    Article  PubMed  Google Scholar 

  30. Goldstein JA, Chinnaiyan KM, Abidov A, et al. The CT-STAT (Coronary computed tomographic angiography for systematic triage of acute chest pain patients to treatment) trial. J Am Coll Cardiol. 2011;58:1414–22.

    Article  PubMed  Google Scholar 

  31. Rubinshtein R, Halon DA, Gaspar T, et al. Usefulness of 64-slice cardiac computed tomographic angiography for diagnosing acute coronary syndromes and predicting clinical outcome in emergency department patients with chest pain of uncertain origin. Circulation. 2007;115:1762–8.

    Article  PubMed  Google Scholar 

  32. Hoffmann U, Nagurney JT, Moselewski F, et al. Coronary multidetector computed tomography in the assessment of patients with acute chest pain. Circulation. 2006;114:2251–60.

    Article  PubMed  Google Scholar 

  33. Hollander JE, Chang AM, Shofer FS, et al. One–year outcomes following coronary computerized tomographic angiography for evaluation of emergency department patients with potential acute coronary syndrome. Acad Emerg Med. 2009;16:693–8.

    Article  PubMed  Google Scholar 

  34. Litt HI, Gatsonis C, Snyder B, et al. CT angiography for safe discharge of patients with possible acute coronary syndrome. N Engl J Med. 2012;366:1393–403.

    Article  PubMed  CAS  Google Scholar 

  35. Dodd JD, Kalva S, Pena A, et al. Emergency cardiac CT for suspected acute coronary syndrome: qualitative and quantitative assessment of coronary, pulmonary, and aortic image quality. Am J Roentgenol. 2008;191:870–7.

    Article  Google Scholar 

  36. Fleischmann D, Rubin GD, Bankier AA, Hittmair K. Improved uniformity of aortic enhancement with customized contrast medium injection protocols at ct angiography. Radiology. 2000;214:363.

    PubMed  CAS  Google Scholar 

  37. Vrachliotis TG, Bis KG, Haidary A, et al. Atypical chest pain: coronary, aortic, and pulmonary vasculature enhancement at biphasic single-injection 64-section CT angiography. Radiology. 2007;243:368–76.

    Article  PubMed  Google Scholar 

  38. Halpern EJ. Triple-rule-out CT angiography for evaluation of acute chest pain and possible acute coronary syndrome. Radiology. 2009;252:332–45.

    Article  PubMed  Google Scholar 

  39. Shapiro MD, Dodd JD, Kalva S, et al. A comprehensive electrocardiogram-gated 64-slice multidetector computed tomography imaging protocol to visualize the coronary arteries, thoracic aorta, and pulmonary vasculature in a single breath hold. J Comput Assist Tomogr. 2009;33:225.

    Article  PubMed  Google Scholar 

  40. Litmanovitch D, Zamboni GA, Hauser TH, et al. ECG-gated chest CT angiography with 64-MDCT and tri-phasic IV contrast administration regimen in patients with acute non-specific chest pain. Eur Radiol. 2008;18:308–17.

    Article  PubMed  Google Scholar 

  41. Cury RC, Feuchtner G, Mascioli C, et al. Cardiac CT in the emergency department: convincing evidence, but cautious implementation. J Nucl Cardiol. 2011;1–11.

  42. Johnson TRC, Nikolaou K, Wintersperger BJ, et al. ECG-gated 64-MDCT angiography in the differential diagnosis of acute chest pain. Am J Roentgenol. 2007;188:76–82.

    Article  Google Scholar 

  43. Rahmani N, Jeudy J, White CS. Triple rule-out and dedicated coronary artery CTA: comparison of coronary artery image quality. Acad Radiol. 2009;16:604–9.

    Article  PubMed  Google Scholar 

  44. Brenner DJ, Hall EJ. Computed tomography–an increasing source of radiation exposure. N Engl J Med. 2007;357:2277–84.

    Article  PubMed  CAS  Google Scholar 

  45. Hausleiter J, Meyer T, Hadamitzky M, et al. Radiation dose estimates from cardiac multislice computed tomography in daily practice impact of different scanning protocols on effective dose estimates. Circulation. 2006;113:1305–10.

    Article  PubMed  Google Scholar 

  46. Achenbach S, Marwan M, Ropers D, et al. Coronary computed tomography angiography with a consistent dose below 1 mSv using prospectively electrocardiogram-triggered high-pitch spiral acquisition. Eur Heart J. 2010;31:340–6.

    Article  PubMed  Google Scholar 

  47. Achenbach S, Goroll T, Seltmann M, et al. Detection of coronary artery stenoses by low-dose, prospectively ECG-triggered, high-pitch spiral coronary CT angiography. JACC Cardiovasc Imaging. 2011;4:328.

    Article  PubMed  Google Scholar 

  48. Takakuwa KM, Halpern EJ, Gingold EL, Levin DC, Shofer FS. Radiation dose in a “triple rule-out” coronary CT angiography protocol of emergency department patients using 64-MDCT: the impact of ECG-based tube current modulation on age, sex, and body mass index. Am J Roentgenol. 2009;192:866–72.

    Article  Google Scholar 

  49. Thompson RC, Cullom SJ. Issues regarding radiation dosage of cardiac nuclear and radiography procedures. J Nucl Cardiol. 2006;13:19–23.

    Article  PubMed  Google Scholar 

  50. Takakuwa KM, Halpern EJ. Evaluation of a “Triple Rule-Out” Coronary CT Angiography Protocol: use of 64-section ct in low-to-moderate risk emergency department patients suspected of having acute coronary syndrome. Radiology. 2008;248:438–46.

    Article  PubMed  Google Scholar 

  51. Husmann L, Valenta I, Gaemperli O, et al. Feasibility of low-dose coronary CT angiography: first experience with prospective ECG-gating. Eur Heart J. 2008;29:191–7.

    Article  PubMed  Google Scholar 

  52. Ketelsen D, Fenchel M, Thomas C, et al. Estimation of radiation exposure of retrospective gated and prospective triggered 128-slice triple-rule-out CT angiography. Acta Radiol. 2011;52:762–6.

    Article  PubMed  Google Scholar 

  53. • Manheimer ED, Peters MR, Wolff SD, et al. Comparison of radiation dose and image quality of triple-rule-out computed tomography angiography between conventional helical scanning and a strategy incorporating sequential scanning. Am J Cardiol. 2011;107:1093–8. This paper demonstratess that a TRO-CT protocol utilizing sequential scanning as compared to helical scanning results in a 62 % decrease in radiation dose. There is also a trend towards improved image quality with sequential scanning.

    Article  PubMed  Google Scholar 

  54. Lien K, Triolo M, Poon M. Triple rule out Angiography reduces both the initial ct and downstream radiation dose in the evaluation of acute chest pain in the emergency department. J Am Coll Cardiol. 2011;57:e1221.

    Article  Google Scholar 

  55. Lell M, Hinkmann F, Anders K, et al. High-pitch electrocardiogram-triggered computed tomography of the chest: initial results. Invest Radiol. 2009;44:728.

    Article  PubMed  Google Scholar 

  56. •• Durmus T, Rogalla P, Lembcke A, et al. Low-dose triple-rule-out using 320-row-detector volume MDCT-less contrast medium and lower radiation exposure. Eur Radiol. 2011;21:1416–23. The authors describe the use of a TRO-CT protocol with a 320-MDCT scanner to significantly reduce both the amount of iodinated contrast and radiation dose.

    Article  PubMed  Google Scholar 

  57. Ferencik M, Nomura CH, Maurovich-Horvat P, et al. Quantitative parameters of image quality in 64-slice computed tomography angiography of the coronary arteries. Eur J Radiol. 2006;57:373–9.

    Article  PubMed  Google Scholar 

  58. Dewey M, Hoffmann H, Hamm B. Multislice CT coronary angiography: effect of sublingual nitroglycerine on the diameter of coronary arteries. Fortschr Rontgestr. 2006;178:600–4.

    Article  CAS  Google Scholar 

  59. Yoon YE, Wann S. Evaluation of acute chest pain in the emergency department: “Triple Rule-Out” computed tomography angiography. Cardiol Rev. 2011;19:115.

    Article  PubMed  Google Scholar 

  60. Lehman SJ, Abbara S, Cury RC, et al. Significance of cardiac computed tomography incidental findings in acute chest pain. Am J Med. 2009;122:543–9.

    Article  PubMed  Google Scholar 

  61. Savino G, Herzog C, Costello P, Schoepf UJ. 64 slice cardiovascular CT in the emergency department: concepts and first experiences. La Radiologia Medica. 2006;111:481–96.

    Article  PubMed  CAS  Google Scholar 

  62. Schertler T, Frauenfelder T, Stolzmann P, et al. Triple Rule-Out CT in patients with suspicion of acute pulmonary embolism: findings and accuracy1. Acad Radiol. 2009;16:708–17.

    Article  PubMed  Google Scholar 

  63. •• Takakuwa KM, Halpern EJ, Shofer FS. A time and imaging cost analysis of low-risk ED observation patients: a conservative 64-section computed tomography coronary angiography “triple rule-out” compared to nuclear stress test strategy. Am J Emerg Med. 2011;29:187–95. In this single center, prospective cohort trial the use of TRO-CT reduced length-of-stay and time to diagnosis when compared to patients who underwent nuclear stress testing.

    Article  PubMed  Google Scholar 

  64. •• Rogers IS, Banerji D, Siegel EL, et al. Usefulness of comprehensive cardiothoracic computed tomography in the evaluation of acute undifferentiated chest discomfort in the emergency department (CAPTURE). Am J Cardiol. 2011;107:643–50. This study in the only prospective randomized controlled trial of TRO-CT to date. The investigators found no benefit with the use of TRO-CT compared with the dedicated CT protocols in terms of length-of-stay, rate of discharge without additional imaging, costs of care, or the number of revisits.

    Article  PubMed  Google Scholar 

  65. Stein PD, Hull RD, Ghali WA, et al. Tracking the uptake of evidence: two decades of hospital practice trends for diagnosing deep vein thrombosis and pulmonary embolism. Arch Intern Med. 2003;163:1213.

    Article  PubMed  Google Scholar 

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  1. Division of Cardiovascular Medicine – UHN62, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA

    Ted A. Foster & Michael D. Shapiro

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Foster, T.A., Shapiro, M.D. The ‘Triple Rule Out’ CT Angiogram for Acute Chest Pain: Should it be Done, and If So, How?. Curr Cardiovasc Imaging Rep 5, 310–317 (2012). https://doi.org/10.1007/s12410-012-9152-6

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