Coronary artery disease, Computerized tomography angiography, Emergency medicine
Citation Information :
Pattereth N, Chaliyadan S, Mathew R, Kumar S, Das CJ, Aggarwal P, Jamshed N. The Role of Triple Rule-out CT in an Indian Emergency Setting. Indian J Crit Care Med 2023; 27 (3):190-194.
Background: Emergency physicians are acutely aware of the consequences of missing fatal diagnoses for acute non-traumatic chest pain and subjecting patients to over-testing. In the large arsenal of tests that are available to us, a triple rule-out computed tomography (TRO-CT) Angiography is often less pursued, due to concerns about their efficacy and safety or because of nescience. We aim to find the yield of the test in an Indian emergency setting and impart some knowledge about it along the way.
Materials and methods: Twenty-six patients who presented to the emergency department of our institute with acute chest pain, with non-specific electrocardiogram (ECG) findings and negative serial troponin I, underwent TRO-CT. HEART scores of all patients, calculated at their presentation, were correlated with TRO-CT findings.
Results: Triple rule-out computed tomography angiography was positive in 5 patients (20%), of which 4 cases (16%) were diagnosed to have significant coronary artery disease and one had an acute pulmonary embolism. All 4 patients who had significant coronary artery disease (CAD) diagnosed by TRO-CT had a HEART score of intermediate risk. The mean effective radiation dose of the entire TRO study was 19.024 ± 3.319 mSv (range = 13.89–25.95 mSv).
Conclusion: Triple rule-out CT angiography is a useful tool in the evaluation of patients presenting with acute chest pain in the emergency and can be an important adjunct in ruling out significant CAD in intermediate-risk patients. Emergency physicians and young residents need to know about this tool in their armamentarium to tackle doubtful cases.
Razzak J, Usmani MF, Bhutta ZA. Global, the regional and national burden of emergency medical diseases using specific emergency disease indicators: Analysis of the 2015 Global Burden of Disease Study. BMJ Glob Health 2019;4(2):e000733. DOI: http://dx.doi.org/10.1136/bmjgh-2018-000733.
SK Bhoi (2021) AIIMS_STUDY_1.pdf [Internet]. Available from: https://www.niti.gov.in/sites/default/files/2021-12/AIIMS_STUDY_1.pdf.
Sekhri T, Kanwar RS, Wilfred R, Chugh P, Chhillar M, Aggarwal R, et al. Prevalence of risk factors for coronary artery disease in an urban Indian population. BMJ Open 2014;4(12):e005346. DOI: 10.1136/bmjopen-2014-005346.
Clark EG, Watson J, Leemann A, Breaud AH, Feeley FG, Wolff J, et al. Acute care needs in an Indian emergency department: A retrospective analysis. World J Emerg Med 2016;7(3):191–195. DOI: 10.5847/wjem.j.1920-8642.2016.03.005.
Pope JH, Aufderheide TP, Ruthazer R, Woolard RH, Feldman JA, Beshansky JR, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med 2000;342(16):1163–1170. DOI: 10.1056/NEJM200004203421603.
Karcz A, Korn R, Burke MC, Caggiano R, Doyle MJ, Erdos MJ, et al. Malpractice claims against emergency physicians in Massachusetts: 1975–1993. Am J Emerg Med 1996;14(4):341–345. DOI: 10.1016/S0735-6757(96)90044-3.
Naderi S, Acerra JR, Bailey K, Mukherji P, Taraphdar T, Mukherjee T, et al. Patients in a private hospital in India leave the emergency department against medical advice for financial reasons. Int J Emerg Med 2014;7(1):13. DOI: 10.1186/1865-1380-7-13.
Halpern EJ. Triple-Rule-Out CT angiography for evaluation of acute chest pain and possible acute coronary syndrome. Radiology 2009;252(2):332–345. DOI: 10.1148/radiol.2522082335.
Eltabbakh AR, Dawoud MA, Langer M, Moharm MA, Hamdy EA, Hamisa MF. ‘Triple-rule-out’ CT angiography for clinical decision making and early triage of acute chest pain patients: Use of 320-multislice CT angiography. Egypt J Radiol Nucl Med 2019;50(1):3. DOI: 10.1186/s43055-019-0003-1.
Wnorowski AM, Halpern EJ. Diagnostic yield of triple-rule-out CT in an emergency setting. Am J Roentgenol 2016;207(2):295–301. DOI: 10.2214/AJR.15.15717.
Sawyer KN, Shah P, Qu L, Kurz MC, Clark CL, Swor RA. Triple rule out versus CT angiogram plus stress test for evaluation of chest pain in the emergency department. West J Emerg Med 2015;16(5):677–682. DOI: 10.5811/westjem.2015.6.25958.
Russo V, Sportoletti C, Scalas G, Attinà D, Buia F, Niro F, et al. The triple rule-out CT in acute chest pain: A challenge for emergency radiologists? Emerg Radiol 2021;28(4):735–742. DOI: 10.1007/s10140-021-01911-8.
Soliman HH. Value of triple rule-out CT in the emergency department. Egypt J Radiol Nucl Med 2015;46(3):621–627. DOI: 10.1016/j.ejrnm.2015.03.010.
Alimohammadi H, Shojaee M, Sohrabi MR, Salahi S. Heart score in predicting one-month major adverse cardiac events in patients with acute chest pain; a diagnostic accuracy study. Arch Acad Emerg Med 2021;9(1):e31. DOI: 10.22037/aaem.v9i1.1052.
Brady W, de Souza K. The heart score: A guide to its application in the emergency department. Turk J Emerg Med 2018;18(2):47–51. DOI: 10.1016/j.tjem.2018.04.004.
Natarajan B, Mallick P, Thangalvadi TA, Rajavelu P. Validation of the heart score in the Indian population. Int J Emerg Med 2015;8(1):P5. DOI: 10.1186/1865-1380-8-S1-P5.
White CS, Kuo D, Kelemen M, Jain V, Musk A, Zaidi E, et al. Chest pain evaluation in the emergency department: Can MDCT provide a comprehensive evaluation? Am J Roentgenol 2005;185(2):533–540. DOI: 10.2214/ajr.185.2.01850533.
Schuijf JD, Pundziute G, Jukema JW, Lamb HJ, van der Hoeven BL, de Roos A, et al. Diagnostic accuracy of 64-slice multislice computed tomography in the noninvasive evaluation of significant coronary artery disease. Am J Cardiol 2006;98(2):145–148. DOI: 10.1016/j.amjcard.2006.01.092.
Schlosser T, Mohrs OK, Magedanz A, Nowak B, Voigtländer T, Barkhausen J, et al. Noninvasive coronary angiography using 64-detector-row computed tomography in patients with a low to moderate pretest probability of significant coronary artery disease Acta Radiol 2007;48(3):300–307. DOI: 10.1080/02841850701203587.
Lee HY, Yoo SM, White CS. Coronary CT angiography in emergency department patients with acute chest pain: Triple rule-out protocol versus dedicated coronary CT angiography. Int J Cardiovasc Imaging 2009;25(3):319–326. DOI: 10.1007/s10554-008-9375-4.
Ayaram D, Bellolio MF, Murad MH, Laack TA, Sadosty AT, Erwin PJ, et al. Triple rule-out computed tomographic angiography for chest pain: A diagnostic systematic review and meta-analysis. Acad Emerg Med 2013;20(9):861–871. DOI: 10.1111/acem.12210.
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(2):438–446. DOI: 10.1148/radiol.2482072169.
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(4):866–872. DOI: 10.2214/AJR.08.1758.
Durmus T, Rogalla P, Lembcke A, Mühler MR, Hamm B, Hein PA. Low-dose triple-rule-out using 320-row-detector volume MDCT– less contrast medium and lower radiation exposure. Eur Radiol 2011;21(7):1416–1423. DOI: 10.1007/s00330-011-2088-4.
Litmanovich D, Zamboni GA, Hauser TH, Lin PJ, Clouse ME, Raptopoulos V. 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(2):308–317. DOI: 10.1007/s00330-007-0739-2.
Johnson TRC, Nikolaou K, Becker A, Leber AW, Rist C, Wintersperger BJ, et al. Dual-source CT for chest pain assessment. Eur Radiol 2008;18(4):773–780. DOI: 10.1007/s00330-007-0803-y.
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(2):187–195. DOI: 10.1016/j.ajem.2009.09.002.
Litt HI, Gatsonis C, Snyder B, Singh H, Miller CD, Entrikin DW, et al. CT angiography for safe discharge of patients with possible acute coronary syndromes N Engl J Med 2012;366(15):1393–1403. DOI: 10.1056/NEJMoa1201163.
Chang AM, Shofer FS, Weiner MG, Synnestvedt MB, Litt HI, Baxt WG, et al. Actual financial comparison of four strategies to evaluate patients with potential acute coronary syndromes. Acad Emerg Med 2008;15(7):649–655. DOI: 10.1111/j.1553-2712.2008.00159.x.