title: Triple rule-out computed tomography for risk stratification of patients with acute chest pain.
abstract: OBJECTIVE
  Clinical evidence supporting triple rule-out computed tomography (TRO-CT) for rapid screening of cardiovascular disease is limited. We investigated the clinical value of TRO-CT in patients with acute chest pain.
  
  
  METHODS
  We retrospectively enrolled 1024 patients who visited the emergency department (ED) with acute chest pain and underwent TRO-CT using a 128-slice CT system. TRO-CT was classified as "positive" if it revealed clinically significant cardiovascular disease including obstructive coronary artery disease, pulmonary thromboembolism, or acute aortic syndrome. The clinical endpoint was occurrence of a major adverse cardiovascular event (MACE) within 30 days, defined by a composite of all cause death, myocardial infarction, revascularization, major cardiovascular surgery, or thrombolytic therapy. Clinical risk scores for acute chest pain including TIMI, GRACE, Diamond-Forrester, and HEART were determined and compared to the TRO-CT findings.
  
  
  RESULTS
  TRO-CT revealed clinically significant cardiovascular disease in 239 patients (23.3%). MACE occurred in 119 patients (49.8%) with positive TRO-CT and in 7 patients (0.9%) with negative TRO-CT (p < 0.001). Sensitivity, specificity, positive predictive value, and negative predictive value of TRO-CT was 95%, 88%, 54%, and 99%, respectively. TRO-CT was a better discriminator between patients with vs. without events as compared to clinical risk scores (c-statistics = 0.91 versus 0.64 to 0.71; integrated discrimination improvement = 0.31 to 0.37; p < 0.001 for all comparisons). Patients with a negative TRO-CT showed shorter ED stay times and admission rates compared to patients with positive TRO-CT, irrespective of clinical risk scores (p < 0.001 for all comparisons).
  
  
  CONCLUSIONS
  Triple rule-out CT has high predictive performance for 30-day MACE and permits rapid triage and low admission rates irrespective of clinical risk scores.
authors.affiliation: Department of Emergency Medicine, Ajou University Hospital, Suwon, South Korea.
authors.forename: Minjung Kathy
authors.initials: MK
authors.lastname: Chae
authors.affiliation: Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
authors.forename: Eun Kyoung
authors.initials: EK
authors.lastname: Kim
authors.affiliation: Department of Emergency Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
authors.forename: Ka-Young
authors.initials: KY
authors.lastname: Jung
authors.affiliation: Department of Emergency Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
authors.forename: Tae Gun
authors.initials: TG
authors.lastname: Shin
authors.affiliation: Department of Emergency Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
authors.forename: Min Seob
authors.initials: MS
authors.lastname: Sim
authors.affiliation: Department of Emergency Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
authors.forename: Ik-Joon
authors.initials: IJ
authors.lastname: Jo
authors.affiliation: Department of Emergency Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
authors.forename: Keun Jeong
authors.initials: KJ
authors.lastname: Song
authors.affiliation: Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
authors.forename: Sung-A
authors.initials: SA
authors.lastname: Chang
authors.affiliation: Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
authors.forename: Young Bin
authors.initials: YB
authors.lastname: Song
authors.affiliation: Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
authors.forename: Joo-Yong
authors.initials: JY
authors.lastname: Hahn
authors.affiliation: Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
authors.forename: Seung Hyuk
authors.initials: SH
authors.lastname: Choi
authors.affiliation: Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
authors.forename: Hyeon-Cheol
authors.initials: HC
authors.lastname: Gwon
authors.affiliation: Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
authors.forename: Sang-Hoon
authors.initials: SH
authors.lastname: Lee
authors.affiliation: Department of Radiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
authors.forename: Sung Mok
authors.initials: SM
authors.lastname: Kim
authors.affiliation: Department of Radiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
authors.forename: Hong
authors.initials: H
authors.lastname: Eo
authors.affiliation: Department of Radiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
authors.forename: Yeon Hyeon
authors.initials: YH
authors.lastname: Choe
authors.affiliation: Department of Emergency Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea. Electronic address: jhchoimd@gmail.com.
authors.forename: Jin-Ho
authors.initials: JH
authors.lastname: Choi
mesh_terms: D000368:Aged; D000787:Angina Pectoris / Q000000981:diagnostic imaging* / Q000209:etiology / Q000401:mortality / Q000628:therapy; D016507:Cardiology Service, Hospital; D002318:Cardiovascular Diseases / Q000150:complications / Q000000981:diagnostic imaging* / Q000401:mortality / Q000628:therapy; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D061330:Multidetector Computed Tomography; D010343:Patient Admission; D011237:Predictive Value of Tests; D011379:Prognosis; D012042:Registries; D015203:Reproducibility of Results; D056910:Republic of Korea; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D014218:Triage / Q000379:methods*
keywords: Acute cardiac care; Chest pain; Triple rule-out computed tomography