title: Comparative diagnostic yield and 3-month outcomes of "triple rule-out" and standard protocol coronary CT angiography in the evaluation of acute chest pain.
abstract: BACKGROUND
  "Triple rule-out" CT angiography simultaneously evaluates coronary artery disease, pulmonary embolism, and aortic dissection in a single imaging examination. However, the clinical outcomes of this approach are unknown.
  
  
  OBJECTIVE
  Using standard cardiac CT angiography as a reference, this study was performed to describe the diagnostic yield and clinical outcomes of patients undergoing triple rule-out in clinical practice.
  
  
  METHODS
  We identified consecutive patients at 2 institutions undergoing triple rule-out or cardiac CT angiography for acute chest pain. The primary outcome was a composite diagnostic yield consisting of coronary artery diameter stenosis >50%, pulmonary embolism, and aortic dissection. Other reported outcomes included radiation dose, downstream resource use, and 90-day clinical outcomes.
  
  
  RESULTS
  Among 2068 patients (272 triple rule-out and 1796 cardiac CT angiograms), the composite diagnostic yield was 14.3% with triple rule-out and 16.3% with cardiac CT (P = 0.41) and was driven by the diagnosis of obstructive coronary artery disease (13.2% triple rule-out versus 16.1% cardiac CT, P = 0.22). The diagnostic yield for pulmonary embolism was low (1.1% triple rule-out and 0.2% cardiac CT, P = 0.052) and no aortic dissections were found in either group. Compared with cardiac CT, the triple rule-out approach was associated with higher radiation exposure (12.0 ± 5.6 mSv versus 8.2 ± 4.0 mSv, P < 0.0001), a greater incidence of subsequent emergency center cardiac evaluations (5.9% versus 2.5%, P = 0.0017), and more downstream pulmonary embolism-protocol CT angiography (3.3% versus 0.9%, P = 0.0034).
  
  
  CONCLUSIONS
  Among patients with acute chest pain, a triple rule-out approach resulted in higher radiation exposure compared with cardiac CT, but was not associated with improved diagnostic yield, reduced clinical events, or diminished downstream resource use.
authors.affiliation: Department of Cardiovascular Medicine, William Beaumont Hospital, 3601 W. 13 Mile Road, Royal Oak, MI 48073, USA. ryan.madder@beaumont.edu
authors.forename: Ryan D
authors.initials: RD
authors.lastname: Madder
authors.forename: Gilbert L
authors.initials: GL
authors.lastname: Raff
authors.forename: Leaden
authors.initials: L
authors.lastname: Hickman
authors.forename: Nathan J
authors.initials: NJ
authors.lastname: Foster
authors.forename: Mark D
authors.initials: MD
authors.lastname: McMurray
authors.forename: Lynn M
authors.initials: LM
authors.lastname: Carlyle
authors.forename: Judith A
authors.initials: JA
authors.lastname: Boura
authors.forename: Kavitha M
authors.initials: KM
authors.lastname: Chinnaiyan
mesh_terms: D000328:Adult; D000368:Aged; D000784:Aortic Dissection / Q000150:complications / Q000000981:diagnostic imaging*; D000787:Angina Pectoris / Q000000981:diagnostic imaging / Q000209:etiology; D001014:Aortic Aneurysm / Q000150:complications / Q000000981:diagnostic imaging*; D002637:Chest Pain / Q000000981:diagnostic imaging* / Q000209:etiology; D016009:Chi-Square Distribution; D003287:Contrast Media; D017023:Coronary Angiography / Q000379:methods* / Q000706:statistics & numerical data; D023921:Coronary Stenosis / Q000150:complications / Q000000981:diagnostic imaging*; D005260:Female; D006295:Health Resources / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008824:Michigan; D008875:Middle Aged; D011237:Predictive Value of Tests; D011379:Prognosis; D011655:Pulmonary Embolism / Q000150:complications / Q000000981:diagnostic imaging*; D011829:Radiation Dosage; D012042:Registries; D012189:Retrospective Studies; D012720:Severity of Illness Index; D013997:Time Factors; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data
chemical_list: D003287:Contrast Media