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Triple rule-out computed tomographic angiography for chest pain: a diagnostic systematic review and meta-analysis
David Ayaram1, M Fernanda Bellolio, M Hassan Murad
1Department of Emergency Medicine, Division of Emergency Medicine Research, Mayo Clinic, Rochester, MN.
Insights
Triple rule-out (TRO) computed tomography (CT) is highly accurate for diagnosing coronary artery disease. However, increased radiation and contrast exposure, with low prevalence of other conditions, suggest TRO CT is not recommended for diagnosing pulmonary embolism or aortic dissection.
Area of Science:
- Radiology and Imaging
- Cardiovascular Imaging
- Thoracic Imaging
Background:
- Nontraumatic chest pain evaluation requires differentiating acute coronary syndrome, pulmonary embolism (PE), and aortic dissection.
- Triple rule-out (TRO) computed tomography (CT) aims to diagnose these conditions simultaneously.
- Comparison of TRO CT to dedicated imaging modalities is crucial for optimizing patient care.
Purpose of the Study:
- To compare the image quality, diagnostic accuracy, radiation exposure, and contrast volume of TRO CT versus other diagnostic modalities for nontraumatic chest pain.
- To assess the utility of TRO CT in evaluating suspected acute coronary syndrome (ACS), PE, and aortic dissection.
Main Methods:
- A systematic review of electronic databases and expert consultation was performed.
- Studies included patients with nontraumatic chest pain evaluated with at least 64-slice CT technology.
- Eleven studies (3,539 patients) comparing TRO CT to other diagnostic modalities were included.
Main Results:
- No significant difference in image quality was found between TRO CT and dedicated CT scans.
- TRO CT demonstrated high pooled diagnostic accuracy for coronary artery disease (sensitivity 94.3%, specificity 97.4%).
- Increased radiation exposure (4.84 mSv) and contrast volume (38.0 mL) were associated with TRO CT compared to non-TRO CT.
Conclusions:
- Triple rule-out CT is a highly accurate tool for detecting coronary artery disease.
- Insufficient data exist to recommend TRO CT for diagnosing PE or aortic dissection due to low prevalence and increased exposure risks.
- Further research is needed to clarify the role of TRO CT in specific patient populations.
Objectives:
The objective was to compare the image quality, diagnostic accuracy, radiation exposure, and contrast volume of "triple rule-out" (TRO) computed tomography (CT) to other diagnostic modalities commonly used to evaluate patients with nontraumatic chest pain (dedicated coronary, pulmonary embolism [PE], and aortic dissection CT; invasive coronary angiography; and nuclear stress testing).
Methods:
Four electronic databases were searched, along with reference lists and contacted content experts, for relevant studies from inception until October 2012. Eligible studies enrolled patients with nontraumatic chest pain, shortness of breath, suspected acute coronary syndrome (ACS), PE, or aortic dissection; used at least 64-slice CT technology; and compared TRO CT to another diagnostic modality.
Results:
Eleven studies enrolling 3,539 patients (791 TRO and 2,748 non-TRO) were included (one randomized controlled trial and 10 observational). There was no significant difference in image quality between TRO and dedicated CT scans. TRO CT had the following pooled diagnostic accuracy estimates for coronary artery disease: sensitivity of 94.3% (95% confidence interval [CI] = 89.1% to 97.5%), specificity of 97.4% (95% CI = 96.1% to 98.4%), positive likelihood ratio (LR+) of 17.71 (95% CI = 3.92 to 79.96), and negative likelihood ratio (LR-) of 0.08 (95% CI = 0.02 to 0.27). There were insufficient numbers of patients with PE or aortic dissection to generate diagnostic accuracy estimates for these conditions. Use of TRO CT involved greater radiation exposure (mean difference [MD] = 4.84 mSv, 95% CI = 1.65 to 8.04 mSv) and contrast exposure (MD = 38.0 mL, 95% CI = 28.1 to 48.0 mL) compared to non-TRO CT patients.
Conclusions:
Triple rule-out CT is highly accurate for detecting coronary artery disease. Given the low (<1%) prevalence of PE and aortic dissection in the included studies, and the increased radiation and contrast exposure, there are insufficient data to recommend use of TRO CT in the diagnosis of these conditions.
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