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Published on: August 28, 2018
Triple rule-out computed tomography for risk stratification of patients with acute chest pain
Minjung Kathy Chae1, Eun Kyoung Kim2, Ka-Young Jung3
1Department of Emergency Medicine, Ajou University Hospital, Suwon, South Korea.
Insights
Triple rule-out CT (TRO-CT) effectively screens for cardiovascular disease in acute chest pain patients. This imaging technique demonstrates high accuracy in predicting major adverse cardiovascular events (MACE) and aids in rapid patient triage.
Area of Science:
- Cardiovascular Imaging
- Emergency Medicine
- Radiology
Background:
- Clinical evidence for triple rule-out computed tomography (TRO-CT) in cardiovascular disease screening is limited.
- Acute chest pain is a common emergency department presentation requiring rapid and accurate diagnosis.
Purpose of the Study:
- To investigate the clinical value of TRO-CT in patients presenting with acute chest pain.
- To assess TRO-CT's ability to detect significant cardiovascular disease and predict major adverse cardiovascular events (MACE).
Main Methods:
- Retrospective enrollment of 1024 patients with acute chest pain undergoing 128-slice TRO-CT.
- TRO-CT classified as positive for obstructive coronary artery disease, pulmonary thromboembolism, or acute aortic syndrome.
- Comparison of TRO-CT findings with 30-day MACE and established clinical risk scores (TIMI, GRACE, Diamond-Forrester, HEART).
Main Results:
- TRO-CT identified significant cardiovascular disease in 23.3% of patients.
- High sensitivity (95%) and specificity (88%) for detecting MACE.
- TRO-CT significantly outperformed clinical risk scores in predicting MACE (c-statistics 0.91 vs. 0.64-0.71).
- Negative TRO-CT associated with shorter ED stays and lower admission rates, regardless of clinical risk scores.
Conclusions:
- Triple rule-out CT demonstrates high predictive performance for 30-day MACE in acute chest pain patients.
- TRO-CT facilitates rapid triage and reduces hospital admission rates.
- The utility of TRO-CT is independent of traditional clinical risk scores.
Aims:
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).
Conclusion:
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.
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