title: Triple Rule Out versus CT Angiogram Plus Stress Test for Evaluation of Chest Pain in the Emergency Department.
abstract: BACKGROUND
  Undifferentiated chest pain in the emergency department (ED) is a diagnostic challenge. One approach includes a dedicated chest computed tomography (CT) for pulmonary embolism or dissection followed by a cardiac stress test (TRAD). An alternative strategy is a coronary CT angiogram with concurrent chest CT (Triple Rule Out, TRO). The objective of this study was to describe the ED patient course and short-term safety for these evaluation methods.
  
  
  METHODS
  This was a retrospective observational study of adult patients presenting to a large, community ED for acute chest pain who had non-diagnostic electrocardiograms (ECGs) and normal biomarkers. We collected demographics, ED length of stay, hospital costs, and estimated radiation exposures. We evaluated 30-day return visits for major adverse cardiac events.
  
  
  RESULTS
  A total of 829 patients underwent TRAD, and 642 patients had TRO. Patients undergoing TRO tended to be younger (mean 52.3 vs 56.5 years) and were more likely to be male (42.4% vs. 30.4%). TRO patients tended to have a shorter ED length of stay (mean 14.45 vs. 21.86 hours), to incur less cost (median $449.83 vs. $1147.70), and to be exposed to less radiation (median 7.18 vs. 16.6 mSv). No patient in either group had a related 30-day revisit.
  
  
  CONCLUSIONS
  Use of TRO is feasible for assessment of chest pain in the ED. Both TRAD and TRO safely evaluated patients. Prospective studies investigating this diagnostic strategy are needed to further assess this approach to ED chest pain evaluation.
authors.affiliation: William Beaumont Hospital, Department of Emergency Medicine, Royal Oak, Michigan.
authors.forename: Kelly N
authors.initials: KN
authors.lastname: Sawyer
authors.affiliation: William Beaumont Hospital, Department of Emergency Medicine, Royal Oak, Michigan.
authors.forename: Payal
authors.initials: P
authors.lastname: Shah
authors.affiliation: William Beaumont Hospital, Research Institute Center for Outcomes Research, Royal Oak, Michigan.
authors.forename: Lihua
authors.initials: L
authors.lastname: Qu
authors.affiliation: University of Alabama School of Medicine, Department of Emergency Medicine, Birmingham, Alabama.
authors.forename: Michael C
authors.initials: MC
authors.lastname: Kurz
authors.affiliation: William Beaumont Hospital, Department of Emergency Medicine, Royal Oak, Michigan.
authors.forename: Carol L
authors.initials: CL
authors.lastname: Clark
authors.affiliation: William Beaumont Hospital, Department of Emergency Medicine, Royal Oak, Michigan.
authors.forename: Robert A
authors.initials: RA
authors.lastname: Swor
mesh_terms: D002637:Chest Pain / Q000175:diagnosis / Q000209:etiology*; D017023:Coronary Angiography / Q000009:adverse effects / Q000706:statistics & numerical data; D004636:Emergency Service, Hospital; D005080:Exercise Test / Q000009:adverse effects / Q000706:statistics & numerical data; D005260:Female; D017721:Hospital Costs / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D011655:Pulmonary Embolism / Q000175:diagnosis / Q000000981:diagnostic imaging; D000069079:Radiation Exposure / Q000706:statistics & numerical data; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed / Q000009:adverse effects / Q000706:statistics & numerical data