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Radiology. 2008 Aug;248(2):438-46. doi: 10.1148/radiol.2482072169.

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.

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  • 1Department of Emergency Medicine and Radiology, Thomas Jefferson University Hospital, 132 S 10th St, Philadelphia, PA 19107-5244, USA.



To determine whether coronary computed tomographic (CT) angiography "triple rule-out" evaluation of emergency department (ED) patients presenting with symptoms suggestive of acute coronary syndrome (ACS) can help identify a subset of patients who can be discharged without adverse clinical outcomes within 30 days.


This protocol was approved by the university institutional review board. Each patient provided written informed consent prior to inclusion. Coronary CT angiography was performed in 201 consecutive low-to-moderate risk ACS patients. A triple rule-out protocol was used to evaluate for coronary disease, pulmonary embolism, aortic dissection, and other thoracic disease. Four patients were excluded because of technical problems. The remaining subjects underwent a 30-day follow-up.


A disease process other than coronary atherosclerosis that explained the presenting symptoms was diagnosed in 22 (11%) of 197 patients. Clinically important noncoronary diagnoses that did not explain patient symptoms were identified in 27 (14%) of 197 additional patients. With respect to coronary artery disease, 10 patients had severe disease (>70% stenosis), 12 had moderate disease (50%-70% stenosis), 46 had mild disease (up to 50% stenosis), and 129 had no disease. No further diagnostic testing was performed in 133 (76%) of 175 of patients with no to mild coronary disease. At 30-day follow-up, the negative predictive value of coronary CT angiography with no more than mild disease was 99.4%. There were no adverse outcomes at 30 days.


Triple rule-out coronary CT angiography evaluation of low-to-moderate risk ACS patients presenting to the ED provided a noncoronary diagnosis that explained the presenting complaint in 11% of patients, suggested the presence of significant moderate-to-severe coronary disease in 11% (22 of 197) of patients, and precluded additional diagnostic cardiac testing in the majority of patients with no adverse outcomes at 30-day follow-up.

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