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Cetin T, Kantarci M, Irgul B, Aydin S, Aydin F, Koseturk T, Levent A. Quadruple-Rule-Out Computed Tomography Angiography (QRO-CT): A Novel Dual-Energy Computed Tomography Technique for the Diagnostic Work-Up of Acute Chest Pain. Diagnostics (Basel) 2023; 13:2799. [PMID: 37685337 PMCID: PMC10486597 DOI: 10.3390/diagnostics13172799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/19/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Computerized tomography (CT) has been increasingly utilized in the differential diagnosis of acute chest pain. Combining the triple rule out CT angiography (TRO-CT) approach with dual-energy CT (DECT) can enhance the diagnostic capability by identifying myocardial perfusion deficiencies. This combination can yield a quadruple-rule-out computed tomography angiography (QRO-CT) technique. The aim of this study is to determine the efficacy of the QRO-CT. METHODS Intraluminal diseases and abnormalities in the main coronary arteries and branches were investigated. The myocardial dark spots on the color-coded iodine map were identified as perfusion deficiencies. Pulmonary arteries and aorta were also evaluated. RESULTS The study population consisted of 211 patients. The sensitivity, specificity, and positive and negative predictive values of QRO-CT for pulmonary embolism were 93.5%, 100%, 100%, and 95.3%, respectively. For obstructive coronary artery disease, the values were 96.1%, 93.4%, 89.2%, and 97.7%, respectively. For myocarditis, the values were 69.2%, 100%, 100%, and 93.6%, respectively. CONCLUSIONS the QRO-CT method may successfully evaluate myocardial perfusion deficits, hence expanding the differential diagnosis capabilities of the standard TRO-CT method for myocarditis. It can provide useful information on myocardial perfusion, which may influence the choice to perform invasive catheterization in cases of coronary artery obstruction.
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Affiliation(s)
- Turkhun Cetin
- Department of Radiology, Erzincan Binali Yidirim University, Erzincan 24100, Turkey; (T.C.); (S.A.); (A.L.)
| | - Mecit Kantarci
- Department of Radiology, Ataturk University, Erzurum 25100, Turkey; (M.K.); (F.A.)
| | - Baris Irgul
- Department of Radiology, Erzincan Binali Yidirim University, Erzincan 24100, Turkey; (T.C.); (S.A.); (A.L.)
| | - Sonay Aydin
- Department of Radiology, Erzincan Binali Yidirim University, Erzincan 24100, Turkey; (T.C.); (S.A.); (A.L.)
| | - Fahri Aydin
- Department of Radiology, Ataturk University, Erzurum 25100, Turkey; (M.K.); (F.A.)
| | - Taner Koseturk
- Department of Anatomy, Erzincan Binali Yidirim University, Erzincan 24100, Turkey;
| | - Akin Levent
- Department of Radiology, Erzincan Binali Yidirim University, Erzincan 24100, Turkey; (T.C.); (S.A.); (A.L.)
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Kirsch J, Wu CC, Bolen MA, Henry TS, Rajiah PS, Brown RKJ, Galizia MS, Lee E, Rajesh F, Raptis CA, Rybicki FJ, Sams CM, Verde F, Villines TC, Wolf SJ, Yu J, Donnelly EF, Abbara S. ACR Appropriateness Criteria® Suspected Pulmonary Embolism: 2022 Update. J Am Coll Radiol 2022; 19:S488-S501. [PMID: 36436972 DOI: 10.1016/j.jacr.2022.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/27/2022]
Abstract
Pulmonary embolism (PE) remains a common and important clinical condition that cannot be accurately diagnosed on the basis of signs, symptoms, and history alone. The diagnosis of PE has been facilitated by technical advancements and multidetector CT pulmonary angiography, which is the major diagnostic modality currently used. Ventilation and perfusion scans remain largely accurate and useful in certain settings. MR angiography can be useful in some clinical scenarios and lower-extremity ultrasound can substitute by demonstrating deep vein thrombosis; however, if negative, further studies to exclude PE are indicated. In all cases, correlation with the clinical status, particularly with risk factors, improves not only the accuracy of diagnostic imaging but also overall utilization. Other diagnostic tests have limited roles. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Carol C Wu
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Travis S Henry
- Panel Chair, Division Chief of Cardiothoracic Imaging, Duke University, Durham, North Carolina; Co-Director, ACR Education Center HRCT Course; Chair
| | | | - Richard K J Brown
- Vice Chair of Clinical Operations, Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah; Commission on Nuclear Medicine and Molecular Imaging
| | | | - Elizabeth Lee
- University of Michigan Health System, Ann Arbor, Michigan; Director M1Radiology Education University of Michigan Medical School; Associated Program Director Diagnostic Radiology Michigan Medicine; Director of Residency Education Cardiothoracic Division Michigan
| | - Fnu Rajesh
- MetroHealth Medical Center, Cleveland, Ohio; Primary care physician
| | | | | | | | - Franco Verde
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Todd C Villines
- University of Virginia Health System, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography
| | - Stephen J Wolf
- Denver Health, Denver, Colorado; American College of Emergency Physicians; Director of Service for Emergency Medicine, Denver Health Medical Center, Denver Colorado; Co-Chair, American College of Emergency Physicians Clinical Policies Committee
| | - Jeannie Yu
- Deputy Chief of Medicine, VA Medical Center, University of California-Irvine, Irvine, California; Society for Cardiovascular Magnetic Resonance
| | - Edwin F Donnelly
- Specialty Chair, Ohio State University Wexner Medical Center, Columbus, Ohio; Ohio State University Medical Center: Chief of Thoracic Radiology, Interim Vice Chair of Academic Affairs, Department of Radiology
| | - Suhny Abbara
- Specialty Chair, UT Southwestern Medical Center, Dallas, Texas
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Nicolau JC, Feitosa Filho GS, Petriz JL, Furtado RHDM, Précoma DB, Lemke W, Lopes RD, Timerman A, Marin Neto JA, Bezerra Neto L, Gomes BFDO, Santos ECL, Piegas LS, Soeiro ADM, Negri AJDA, Franci A, Markman Filho B, Baccaro BM, Montenegro CEL, Rochitte CE, Barbosa CJDG, Virgens CMBD, Stefanini E, Manenti ERF, Lima FG, Monteiro Júnior FDC, Correa Filho H, Pena HPM, Pinto IMF, Falcão JLDAA, Sena JP, Peixoto JM, Souza JAD, Silva LSD, Maia LN, Ohe LN, Baracioli LM, Dallan LADO, Dallan LAP, Mattos LAPE, Bodanese LC, Ritt LEF, Canesin MF, Rivas MBDS, Franken M, Magalhães MJG, Oliveira Júnior MTD, Filgueiras Filho NM, Dutra OP, Coelho OR, Leães PE, Rossi PRF, Soares PR, Lemos Neto PA, Farsky PS, Cavalcanti RRC, Alves RJ, Kalil RAK, Esporcatte R, Marino RL, Giraldez RRCV, Meneghelo RS, Lima RDSL, Ramos RF, Falcão SNDRS, Dalçóquio TF, Lemke VDMG, Chalela WA, Mathias Júnior W. Brazilian Society of Cardiology Guidelines on Unstable Angina and Acute Myocardial Infarction without ST-Segment Elevation - 2021. Arq Bras Cardiol 2021; 117:181-264. [PMID: 34320090 PMCID: PMC8294740 DOI: 10.36660/abc.20210180] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- José Carlos Nicolau
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Gilson Soares Feitosa Filho
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA - Brasil
- Centro Universitário de Tecnologia e Ciência (UniFTC), Salvador, BA - Brasil
| | - João Luiz Petriz
- Hospital Barra D'Or, Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
| | | | | | - Walmor Lemke
- Clínica Cardiocare, Curitiba, PR - Brasil
- Hospital das Nações, Curitiba, PR - Brasil
| | | | - Ari Timerman
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
| | - José A Marin Neto
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Ribeirão Preto, SP - Brasil
| | | | - Bruno Ferraz de Oliveira Gomes
- Hospital Barra D'Or, Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | | | | | - Carlos Eduardo Rochitte
- Hospital do Coração (HCor), São Paulo, SP - Brasil
- Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | - Edson Stefanini
- Escola Paulista de Medicina da Universidade Federal de São Paulo (UNIFESP), São Paulo, SP - Brasil
| | | | - Felipe Gallego Lima
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | | | - José Maria Peixoto
- Universidade José do Rosário Vellano (UNIFENAS), Belo Horizonte, MG - Brasil
| | - Juliana Ascenção de Souza
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Lilia Nigro Maia
- Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP - Brasil
| | | | - Luciano Moreira Baracioli
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Luís Alberto de Oliveira Dallan
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Luis Augusto Palma Dallan
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Luiz Carlos Bodanese
- Pontifícia Universidade Católica do Rio Grande do Sul (PUC-RS), Porto Alegre, RS - Brasil
| | | | | | - Marcelo Bueno da Silva Rivas
- Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
- Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brasil
| | | | | | - Múcio Tavares de Oliveira Júnior
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Nivaldo Menezes Filgueiras Filho
- Universidade do Estado da Bahia (UNEB), Salvador, BA - Brasil
- Universidade Salvador (UNIFACS), Salvador, BA - Brasil
- Hospital EMEC, Salvador, BA - Brasil
| | - Oscar Pereira Dutra
- Instituto de Cardiologia - Fundação Universitária de Cardiologia do Rio Grande do Sul, Porto Alegre, RS - Brasil
| | - Otávio Rizzi Coelho
- Faculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP), Campinas, SP - Brasil
| | | | | | - Paulo Rogério Soares
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | - Roberto Esporcatte
- Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | - Talia Falcão Dalçóquio
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - William Azem Chalela
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Wilson Mathias Júnior
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
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Gunn AJ, Kalva SP, Majdalany BS, Craft J, Eldrup-Jorgensen J, Ferencik M, Ganguli S, Kendi AT, Khaja MS, Obara P, Russell RR, Sutphin PD, Vijay K, Wang DS, Dill KE. ACR Appropriateness Criteria® Nontraumatic Aortic Disease. J Am Coll Radiol 2021; 18:S106-S118. [PMID: 33958105 DOI: 10.1016/j.jacr.2021.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 02/08/2021] [Indexed: 01/16/2023]
Abstract
Nontraumatic aortic disease can be caused by a wide variety of disorders including congenital, inflammatory, infectious, metabolic, neoplastic, and degenerative processes. Imaging examinations such as radiography, ultrasound, echocardiography, catheter-based angiography, CT, MRI, and nuclear medicine examinations are essential for diagnosis, treatment planning, and assessment of therapeutic response. Depending upon the clinical scenario, each of these modalities has strengths and weaknesses. Whenever possible, the selection of a diagnostic imaging examination should be based upon the best available evidence. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment. The purpose of this document is to assist physicians select the most appropriate diagnostic imaging examination for nontraumatic aortic diseases.
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Affiliation(s)
- Andrew J Gunn
- University of Alabama at Birmingham, Birmingham, Alabama, Director, Interventional Oncology, Director, Ambulatory Clinic, Assistant Program Director, Diagnostic Radiology Residency, Assistant Program Director, Interventional Radiology Residency, University of Alabama at Birmingham, Member, American College of Radiology-Radiologic Society of North America Patient Information Committee.
| | - Sanjeeva P Kalva
- Panel Chair, Massachusetts General Hospital, Boston, Massachusetts, Chief, Division of Interventional Radiology, Massachusetts General Hospital
| | | | - Jason Craft
- St. Francis Hospital, Catholic Health Services of Long Island, Roslyn, New York, Society for Cardiovascular Magnetic Resonance
| | - Jens Eldrup-Jorgensen
- Tufts University School of Medicine, Boston, Massachusetts, Society for Vascular Surgery
| | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, Society of Cardiovascular Computed Tomography
| | | | - A Tuba Kendi
- Mayo Clinic, Rochester, Minnesota, Director of Nuclear Medicine Therapies at Mayo Clinic Rochester
| | - Minhajuddin S Khaja
- University of Virginia, Charlottesville, Virginia, Vice-Chair ACR Vascular Imaging Panel 2, Program Director, Independent IR Residency, UVA Health
| | - Piotr Obara
- Loyola University Medical Center, Maywood, Illinois
| | - Raymond R Russell
- The Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, Nuclear cardiology expert, Program Director, Cardiology Fellowship, Director, Nuclear Cardiology, Director, Cardio-Oncology Program, Rhode Island Hospital
| | | | | | - David S Wang
- Stanford University Medical Center, Stanford, California
| | - Karin E Dill
- Specialty Chair, Emory University Hospital, Atlanta, Georgia
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5
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Monica MP, Merkely B, Szilveszter B, Drobni ZD, Maurovich-Horvat P. Computed Tomographic Angiography for Risk Stratification in Patients with Acute Chest Pain - The Triple Rule-out Concept in the Emergency Department. Curr Med Imaging 2020; 16:98-110. [PMID: 32003310 DOI: 10.2174/1573405614666180604095120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 06/20/2017] [Accepted: 03/19/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Acute chest pain is one of the most common reasons for Emergency Department (ED) visits and hospital admissions. As this could represent the first symptom of a lifethreatening condition, urgent identification of the etiology of chest pain is of utmost importance in emergency settings. Such high-risk conditions that can present with acute chest pain in the ED include Acute Coronary Syndromes (ACS), Pulmonary Embolisms (PE) and Acute Aortic Syndromes (AAS). DISCUSSION The concept of Triple Rule-out Computed Tomographic Angiography (TRO-CTA) for patients presenting with acute chest pain in the ED is based on the use of coronary computed tomographic angiography as a single imaging technique, able to diagnose or exclude three lifethreatening conditions in one single step: ACS, AAS and PE. TRO-CTA protocols have been proved to be efficient in the ED for diagnosis or exclusion of life-threatening conditions and for differentiation between various etiologies of chest pain, and application of the TRO-CTA protocol in the ED for acute chest pain of uncertain etiology has been shown to improve the further clinical evaluation and outcomes of these patients. CONCLUSION This review aims to summarize the main indications and techniques used in TRO protocols in EDs, and the role of TRO-CTA protocols in risk stratification of patients with acute chest pain.
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Affiliation(s)
- Marton-Popovici Monica
- Department of Internal Medicine and Critical Care, Swedish Medical Center, Edmonds, Washington, United States
| | - Béla Merkely
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Bálint Szilveszter
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Zsófia Dora Drobni
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Pál Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
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6
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Kirsch J, Brown RKJ, Henry TS, Javidan-Nejad C, Jokerst C, Julsrud PR, Kanne JP, Kramer CM, Leipsic JA, Panchal KK, Ravenel JG, Shah AB, Mohammed TL, Woodard PK, Abbara S. ACR Appropriateness Criteria ® Acute Chest Pain-Suspected Pulmonary Embolism. J Am Coll Radiol 2018; 14:S2-S12. [PMID: 28473076 DOI: 10.1016/j.jacr.2017.02.027] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 02/06/2017] [Accepted: 02/07/2017] [Indexed: 01/08/2023]
Abstract
Pulmonary embolism (PE) remains a common and important clinical condition that cannot be accurately diagnosed on the basis of signs, symptoms, and history alone. The diagnosis of PE has been facilitated by technical advancements and multidetector CT pulmonary angiography, which is the major diagnostic modality currently used. Ventilation and perfusion scans remain largely accurate and useful in certain settings. Lower-extremity ultrasound can substitute by demonstrating deep vein thrombosis; however, if negative, further studies to exclude PE are indicated. In all cases, correlation with the clinical status, particularly with risk factors, improves not only the accuracy of diagnostic imaging but also overall utilization. Other diagnostic tests have limited roles. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Jacobo Kirsch
- Principal Author, Cleveland Clinic, Weston, Florida.
| | | | - Travis S Henry
- University of California San Francisco, San Francisco, California
| | - Cylen Javidan-Nejad
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri
| | | | | | - Jeffrey P Kanne
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Christopher M Kramer
- University of Virginia Health System, Charlottesville, Virginia; American College of Cardiology
| | | | | | - James G Ravenel
- Medical University of South Carolina, Charleston, South Carolina
| | - Amar B Shah
- Westchester Medical Center, Valhalla, New York
| | - Tan-Lucien Mohammed
- Specialty Chair, University of Florida College of Medicine, Gainesville, Florida
| | - Pamela K Woodard
- Specialty Chair, Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri
| | - Suhny Abbara
- Panel Chair, UT Southwestern Medical Center, Dallas, Texas
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Ropp A, White C. Current and Future Applications of Coronary CT Angiography with and Without FFR in the Emergency Room. CURRENT CARDIOVASCULAR IMAGING REPORTS 2016. [DOI: 10.1007/s12410-016-9391-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Park J, Kim J, Kim K. Limiting scan range of cardiac CT and the chance of missed acute aortic syndrome. Am J Emerg Med 2016; 34:2007-2010. [PMID: 27567418 DOI: 10.1016/j.ajem.2016.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 06/28/2016] [Accepted: 08/03/2016] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Recently, dedicated cardiac computed tomography (CT) has been performed to rule out acute coronary syndrome in patients with chest pain equivalents. However, acute aortic syndrome (AAS) could mimic acute coronary syndrome. We investigated the reliability of CT with a limited scan range for the detection of AAS. METHODS Patients older than 18 years with a diagnosis of AAS were included for a 10-year period. We reviewed all patients' electronic medical record and cardiac CT scan images. The AAS lesions outside of the upper or lower margin of the cardiac CT scan range were measured. Other abnormalities defined as indirect evidence of AAS such as pericardial effusion were also collected. RESULTS Of a total of 309 cases, 6 (1.9%; 95% confidence interval, 0.71-4.17) patients had aortic lesions outside of the cardiac CT scan range. One patient had an aortic lesion above the cardiac CT scan range, and 5 patients had aortic lesions below the cardiac CT scan range. CONCLUSIONS Aortic lesions outside of the cardiac CT scan range were not rare. Therefore, using a cardiac CT might not guarantee ruling out AAS completely.
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Affiliation(s)
- Jongdae Park
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Joonghee Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Kyuseok Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea.
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Triple rule-out computed tomography for risk stratification of patients with acute chest pain. J Cardiovasc Comput Tomogr 2016; 10:291-300. [PMID: 27375202 DOI: 10.1016/j.jcct.2016.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 05/27/2016] [Accepted: 06/07/2016] [Indexed: 12/22/2022]
Abstract
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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Abstract
OBJECTIVE The objective of the present study is to quantify the diagnostic yield of triple-rule-out (TRO) CT for the evaluation of acute chest pain in emergency department patients. MATERIALS AND METHODS All TRO CT studies performed at our institution from 2006 to 2015 were reviewed. Scans were performed on a 256-MDCT scanner, with the use of ECG gating and a biphasic contrast injection. Radiology reports were reviewed to identify diagnoses that could explain chest pain, including coronary and noncoronary diagnoses, and significant incidental findings that did not account for the patient's presentation. The total numbers of coronary and noncoronary diagnoses and incidental findings were calculated. RESULTS Four of 1196 total cases that were identified were excluded from the study because of inadequate image quality. A total of 970 patients (81.4%) had a negative study result without a significant coronary or noncoronary diagnosis. A total of 139 patients (11.7%) had significant coronary artery disease (50% stenosis or greater). One hundred six patients (8.9%) had a noncoronary diagnosis that could explain chest pain (p < 0.02), most commonly pulmonary embolism (28 patients [2.3%]), aortic aneurysm (24 patients [2.0%]), or pneumonia (20 patients [1.7%]). Thirty cases (27.3%) of pulmonary embolism and aortic pathologic findings would not have been detected with coronary CT angiography because of unopacified right-side circulation or limited z-axis coverage. A total of 528 incidental findings not considered to explain chest pain were noted in 418 patients (35.1%). CONCLUSION In 8.9% of patients, TRO CT detected a significant noncoronary diagnosis that could explain acute chest pain, including pathologic findings that would not be identified on dedicated coronary CT angiography.
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11
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2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients With Chest Pain: A Joint Document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Radiol 2016; 13:e1-e29. [PMID: 26810814 DOI: 10.1016/j.jacr.2015.07.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 07/08/2015] [Indexed: 01/02/2023]
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Rybicki FJ, Udelson JE, Peacock WF, Goldhaber SZ, Isselbacher EM, Kazerooni E, Kontos MC, Litt H, Woodard PK. 2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients With Chest Pain: A Joint Document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Cardiol 2016; 67:853-79. [PMID: 26809772 DOI: 10.1016/j.jacc.2015.09.011] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Al-Mallah MH, Aljizeeri A, Villines TC, Srichai MB, Alsaileek A. Cardiac computed tomography in current cardiology guidelines. J Cardiovasc Comput Tomogr 2015; 9:514-23. [DOI: 10.1016/j.jcct.2015.09.003] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 09/22/2015] [Indexed: 01/06/2023]
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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; 16:677-82. [PMID: 26587090 PMCID: PMC4644034 DOI: 10.5811/westjem.2015.6.25958] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 06/01/2015] [Accepted: 06/30/2015] [Indexed: 11/18/2022] Open
Abstract
Introduction Undifferentiated chest pain in the emergency department (ED) is a diagnostic challenge. One approach includes a dedicated chest computed tomography (CT) for pulmonary embolism or dissection followed by a cardiac stress test (TRAD). An alternative strategy is a coronary CT angiogram with concurrent chest CT (Triple Rule Out, TRO). The objective of this study was to describe the ED patient course and short-term safety for these evaluation methods. Methods This was a retrospective observational study of adult patients presenting to a large, community ED for acute chest pain who had non-diagnostic electrocardiograms (ECGs) and normal biomarkers. We collected demographics, ED length of stay, hospital costs, and estimated radiation exposures. We evaluated 30-day return visits for major adverse cardiac events. Results A total of 829 patients underwent TRAD, and 642 patients had TRO. Patients undergoing TRO tended to be younger (mean 52.3 vs 56.5 years) and were more likely to be male (42.4% vs. 30.4%). TRO patients tended to have a shorter ED length of stay (mean 14.45 vs. 21.86 hours), to incur less cost (median $449.83 vs. $1147.70), and to be exposed to less radiation (median 7.18 vs. 16.6mSv). No patient in either group had a related 30-day revisit. Conclusion Use of TRO is feasible for assessment of chest pain in the ED. Both TRAD and TRO safely evaluated patients. Prospective studies investigating this diagnostic strategy are needed to further assess this approach to ED chest pain evaluation.
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Affiliation(s)
- Kelly N Sawyer
- William Beaumont Hospital, Department of Emergency Medicine, Royal Oak, Michigan
| | - Payal Shah
- William Beaumont Hospital, Department of Emergency Medicine, Royal Oak, Michigan
| | - Lihua Qu
- William Beaumont Hospital, Research Institute Center for Outcomes Research, Royal Oak, Michigan
| | - Michael C Kurz
- University of Alabama School of Medicine, Department of Emergency Medicine, Birmingham, Alabama
| | - Carol L Clark
- William Beaumont Hospital, Department of Emergency Medicine, Royal Oak, Michigan
| | - Robert A Swor
- William Beaumont Hospital, Department of Emergency Medicine, Royal Oak, Michigan
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Qahtani SA, Kandeel AY, Breault S, Jouannic AM, Qanadli SD. Prevalence of Acute Coronary Syndrome in Patients Suspected for Pulmonary Embolism or Acute Aortic Syndrome: Rationale for the Triple Rule-Out Concept. J Clin Med Res 2015; 7:627-31. [PMID: 26124909 PMCID: PMC4471750 DOI: 10.14740/jocmr2197w] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2015] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The aims of the study were to evaluate the prevalence of acute coronary syndrome (ACS) among patients presenting with atypical chest pain who are evaluated for acute aortic syndrome (AAS) or pulmonary embolism (PE) with computed tomoangiography (CTA) and discuss the rationale for the use of triple rule-out (TRO) protocol for triaging these patients. METHODS This study is a retrospective analysis of patients presenting with atypical chest pain and evaluated with thoracic (CTA), for suspicion of AAS/PE. Two physicians reviewed patient files for demographic characteristics, initial CT and final clinical diagnosis. Patients were classified according to CTA finding into AAS, PE and other diagnoses and according to final clinical diagnosis into AAS, PE, ACS and other diagnoses. RESULTS Four hundred and sixty-seven patients were evaluated: 396 (84.8%) patients for clinical suspicion of PE and 71 (15.2%) patients for suspicion of AAS. The prevalence of ACS and AAS was low among the PE patients: 5.5% and 0.5% respectively (P = 0.0001), while the prevalence of ACS and PE was 18.3% and 5.6% among AAS patients (P = 0.14 and P = 0.34 respectively). CONCLUSION The prevalence of ACS and AAS among patients suspected clinically of having PE is limited while the prevalence of ACS and PE among patients suspected clinically of having AAS is significant. Accordingly patients suspected for PE could be evaluated with dedicated PE CTA while those suspected for AAS should still be triaged using TRO protocol.
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Affiliation(s)
- Saad Al Qahtani
- Department of Radiology & Medical Imaging, Armed Forces Hospital, Southern Region, Saudi Arabia
| | - Ahmed Y Kandeel
- Department of Radiology & Medical Imaging, Armed Forces Hospital, Southern Region, Saudi Arabia
| | - Stephane Breault
- Cardio-Thoracic and Vascular Unit, Department of Radiology, University Hospital of Lausanne, Switzerland
| | - Anne-Marie Jouannic
- Cardio-Thoracic and Vascular Unit, Department of Radiology, University Hospital of Lausanne, Switzerland ; Quantitative Medical Imaging Laboratory, Department of Radiology, University Hospital of Lausanne, Switzerland
| | - Salah D Qanadli
- Cardio-Thoracic and Vascular Unit, Department of Radiology, University Hospital of Lausanne, Switzerland ; Quantitative Medical Imaging Laboratory, Department of Radiology, University Hospital of Lausanne, Switzerland
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Relevante Nebenbefunde im CT. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0005-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Kendziorra C, Meyer H, Dewey M. Implementation of a phase detection algorithm for dynamic cardiac computed tomography analysis based on time dependent contrast agent distribution. PLoS One 2014; 9:e116103. [PMID: 25545863 PMCID: PMC4278835 DOI: 10.1371/journal.pone.0116103] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 12/01/2014] [Indexed: 11/30/2022] Open
Abstract
This paper presents a phase detection algorithm for four-dimensional (4D) cardiac computed tomography (CT) analysis. The algorithm detects a phase, i.e. a specific three-dimensional (3D) image out of several time-distributed 3D images, with high contrast in the left ventricle and low contrast in the right ventricle. The purpose is to use the automatically detected phase in an existing algorithm that automatically aligns the images along the heart axis. Decision making is based on the contrast agent distribution over time. It was implemented in KardioPerfusion--a software framework currently being developed for 4D CT myocardial perfusion analysis. Agreement of the phase detection algorithm with two reference readers was 97% (95% CI: 82-100%). Mean duration for detection was 0.020 s (95% CI: 0.018-0.022 s), which was 800 times less than the readers needed (16±7 s, p<03001). Thus, this algorithm is an accurate and fast tool that can improve work flow of clinical examinations.
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Affiliation(s)
- Carsten Kendziorra
- Department of Radiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Henning Meyer
- Department of Radiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Marc Dewey
- Department of Radiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Chen YA, Gray BG, Bandiera G, MacKinnon D, Deva DP. Variation in the utilization and positivity rates of CT pulmonary angiography among emergency physicians at a tertiary academic emergency department. Emerg Radiol 2014; 22:221-9. [DOI: 10.1007/s10140-014-1265-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 08/27/2014] [Indexed: 01/17/2023]
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Abstract
The term acute aortic syndrome (AAS) incorporates aortic dissection, intramural haematoma, and penetrating atherosclerotic ulcer. The common feature of these entities is disruption of the medial layer of the aortic wall. Owing to the life-threatening nature of these conditions, prompt and accurate diagnosis is of paramount importance--misdiagnosis can be fatal. The noninvasive imaging techniques that have a fundamental role in the diagnosis and management of patients with AAS include CT, MRI, transoesophageal echocardiography (TEE), and transthoracic echocardiography (TTE). CT is the most-commonly used imaging modality owing to its wide availability, accuracy, and large field of view. CT plus TTE is the best combination for diagnosing AAS and its complications, and allows important morphological and dynamic aspects of AAS to be assessed and appropriately managed. Ideally, TEE should be performed immediately before surgery or endovascular treatment, in the operating theatre and under general anaesthesia. In stable patients with an uncertain diagnosis of intramural haematoma despite high clinical suspicion, MRI is the technique of choice to make a definitive diagnosis. Imaging techniques have an important role in the primary diagnosis, treatment strategy, and risk stratification of patients with AAS.
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Evangelista A, Carro A, Moral S, Teixido-Tura G, Rodríguez-Palomares JF, Cuéllar H, García-Dorado D. Imaging modalities for the early diagnosis of acute aortic syndrome. Nat Rev Cardiol 2013; 10:477-86. [DOI: 10.1038/nrcardio.2013.92] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Branch KR, Strote J, Shuman WP, Mitsumori LM, Busey JM, Rue T, Caldwell JH. Diagnostic accuracy and clinical outcomes of ECG-gated, whole chest CT in the emergency department. PLoS One 2013; 8:e61121. [PMID: 23613797 PMCID: PMC3629052 DOI: 10.1371/journal.pone.0061121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 03/06/2013] [Indexed: 11/18/2022] Open
Abstract
PURPOSE The purpose of this study was to assess the diagnostic accuracy and one year prognosis of whole chest, "multiple rule out" CT for coronary artery disease (CAD) in Emergency Department patients. METHODS AND FINDINGS One hundred and two Emergency Department patients at low to intermediate risk of acute coronary syndrome (ACS), pulmonary embolism and/or acute aortic syndrome underwent a research 64 channel ECG-gated, whole chest CT and a standard of care evaluation. Patients were classified with obstructive CAD with either a coronary CT stenosis greater than 50% or a non-evaluable coronary segment. SOC and 3 month follow up data were used to determine an adjudicated clinical diagnosis. The diagnostic ability of obstructive CAD on CT to identify clinical diagnoses was determined. Patients were followed up for 1 year for cardiac events. Seven (7%) patients were diagnosed with ACS. CT sensitivity to detect obstructive CAD in ACS patients was 100% (95% CI 65%, 100%), negative predictive value 100% (96%, 100%), specificity 88% (80%, 94%), and positive predictive value 39% (17%, 64%). Pulmonary embolism and acute aortic syndrome were not identified in any patients. No cardiac events occurred in patients without obstructive CAD over 1 year. CONCLUSIONS Whole chest CT has high sensitivity and negative predictive value for ACS with excellent one year prognosis in patients without obstructive CAD on CT. The frequency of pulmonary embolism or acute aortic syndrome and the higher radiation dose suggest whole chest CT should be limited to select patients. ClinicalTrials.org #: NCT00855231.
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Affiliation(s)
- Kelley R Branch
- Division of Cardiology, University of Washington, Seattle, Washington, United States of America.
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Chandra S, Sarkar PK, Chandra D, Ginsberg NE, Cohen RI. Finding an alternative diagnosis does not justify increased use of CT-pulmonary angiography. BMC Pulm Med 2013; 13:9. [PMID: 23388541 PMCID: PMC3570493 DOI: 10.1186/1471-2466-13-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 01/30/2013] [Indexed: 11/17/2022] Open
Abstract
Background The increased use of computed tomography pulmonary angiography (CTPA) is often justified by finding alternative diagnoses explaining patients’ symptoms. However, this has not been rigorously examined. Methods We retrospectively reviewed CTPA done at our center over an eleven year period (2000 – 2010) in patients with suspected pulmonary embolus (PE). We then reviewed in detail the medical records of a representative sample of patients in three index years – 2000, 2005 and 2008. We determined whether CTPA revealed pulmonary pathology other than PE that was not readily identifiable from the patient’s history, physical examination and prior chest X-ray. We also assessed whether the use of pre-test probability guided diagnostic strategy for PE. Results A total of 12,640 CTPA were performed at our center from year 2000 to 2010. The number of CTPA performed increased from 84 in 2000 to 2287 in 2010, a 27 fold increase. Only 7.6 percent of all CTPA and 3.2 percent of avoidable CTPAs (low or intermediate pre-test probability and negative D-dimer) revealed previously unknown findings of any clinical significance. When we compared 2008 to 2000 and 2005, more CTPAs were performed in younger patients (mean age (years) for 2000: 67, 2005: 63, and 2008: 60, (p=0.004, one–way ANOVA)). Patients were less acutely ill with fewer risk factors for PE. Assessment of pre-test probability of PE and D-dimer measurement were rarely used to select appropriate patients for CTPA (pre-test probability of PE documented in chart (% total) in year 2000: 4.1%, 2005: 1.6%, 2008: 3.1%). Conclusions Our data do not support the argument that increased CTPA use is justified by finding an alternative pulmonary pathology that could explain patients’ symptoms. CTPA is being increasingly used as the first and only test for suspected PE.
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Affiliation(s)
- Subani Chandra
- Division of Pulmonary, Critical Care and Sleep Medicine, The Long Island Jewish Medical Center, The Hofstra North Shore-LIJ School of Medicine, New Hyde Park, New York, NY 11040, USA
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Krissak R, Henzler T, Prechel A, Reichert M, Gruettner J, Sueselbeck T, Schoenberg SO, Fink C. Triple-rule-out dual-source CT angiography of patients with acute chest pain: Dose reduction potential of 100kV scanning. Eur J Radiol 2012; 81:3691-6. [PMID: 21163600 DOI: 10.1016/j.ejrad.2010.11.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Accepted: 11/17/2010] [Indexed: 10/18/2022]
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Foster TA, Shapiro MD. The ‘Triple Rule Out’ CT Angiogram for Acute Chest Pain: Should it be Done, and If So, How? CURRENT CARDIOVASCULAR IMAGING REPORTS 2012. [DOI: 10.1007/s12410-012-9152-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Kang EJ, Lee KN, Kim DW, Kim BS, Choi S, Park BH, Oh JY. Triple rule-out acute chest pain evaluation using a 320-row-detector volume CT: a comparison of the wide-volume and helical modes. Int J Cardiovasc Imaging 2012; 28 Suppl 1:7-13. [DOI: 10.1007/s10554-012-0072-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2012] [Accepted: 05/10/2012] [Indexed: 11/27/2022]
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Ross SG, Thali MJ, Bolliger S, Germerott T, Ruder TD, Flach PM. Sudden death after chest pain: feasibility of virtual autopsy with postmortem CT angiography and biopsy. Radiology 2012; 264:250-9. [PMID: 22570504 DOI: 10.1148/radiol.12092415] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine the potential of minimally invasive postmortem computed tomographic (CT) angiography combined with image-guided tissue biopsy of the myocardium and lungs in decedents who were thought to have died of acute chest disease and to compare this method with conventional autopsy as the reference standard. MATERIALS AND METHODS The responsible justice department and ethics committee approved this study. Twenty corpses (four female corpses and 16 male corpses; age range, 15-80 years), all of whom were reported to have had antemortem acute chest pain, were imaged with postmortem whole-body CT angiography and underwent standardized image-guided biopsy. The standard included three biopsies of the myocardium and a single biopsy of bilateral central lung tissue. Additional biopsies of pulmonary clots for differentiation of pulmonary embolism and postmortem organized thrombus were performed after initial analysis of the cross-sectional images. Subsequent traditional autopsy with sampling of histologic specimens was performed in all cases. Thereafter, conventional histologic and autopsy reports were compared with postmortem CT angiography and CT-guided biopsy findings. A Cohen κ coefficient analysis was performed to explore the effect of the clustered nature of the data. RESULTS In 19 of the 20 cadavers, findings at postmortem CT angiography in combination with CT-guided biopsy validated the cause of death found at traditional autopsy. In one cadaver, early myocardial infarction of the papillary muscles had been missed. The Cohen κ coefficient was 0.94. There were four instances of pulmonary embolism, three aortic dissections (Stanford type A), three myocardial infarctions, three instances of fresh coronary thrombosis, three cases of obstructive coronary artery disease, one ruptured ulcer of the ascending aorta, one ruptured aneurysm of the right subclavian artery, one case of myocarditis, and one pulmonary malignancy with pulmonary artery erosion. In seven of 20 cadavers, CT-guided biopsy provided additional histopathologic information that substantiated the final diagnosis of the cause of death. CONCLUSION Postmortem CT angiography combined with image-guided biopsy, because of their minimally invasive nature, have a potential role in the detection of the cause of death after acute chest pain.
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Affiliation(s)
- Steffen G Ross
- Centre for Forensic Imaging and Virtopsy, Institute of Forensic Medicine, University of Berne, Bern, Switzerland
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David S, Beddy P, Babar J, Devaraj A. Evolution of CT pulmonary angiography: referral patterns and diagnostic yield in 2009 compared with 2006. Acta Radiol 2012; 53:39-43. [PMID: 22114018 DOI: 10.1258/ar.2011.110186] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND CT pulmonary angiography (CTPA) is an increasingly popular imaging test for assessing patients with acute chest pain. PURPOSE To evaluate the number of CTPA performed in 2009 compared with 2006 and assess the frequency of pulmonary embolus (PE) versus alternative diagnoses. MATERIAL AND METHODS Numbers of CTPA and V/Q scans performed in a six-month period of 2006 and 2009 were established by review of the hospital radiology information system. CTPAs were evaluated by two radiologists in consensus and the incidence of pulmonary embolism and alternative diagnoses in 2006 and 2009 were recorded. RESULTS The final study groups were 99 patients who underwent CTPA in 2006 and 149 patients in 2009. There was a significant fall in the incidence of PE identified on CTPA in 2009 compared to 2006 (11% versus 21%, P = 0.04). There was a non-significant rise in the incidence of alternative diagnoses in 2009 compared to 2006 (45% versus 40%, P = 0.48). Nine types of alternative radiological diagnoses were made on CTPA, the most common of which was pneumonia in both time periods (17% and 12%). Eighty-seven V/Q scans were performed in the study period in 2006, compared to 109 in 2009. The incidence of PE identified on V/Q scanning remained stable (8% in 2009 versus 12% in 2006, P = 0.44). CONCLUSION The numbers of CTPAs being performed has increased in three years. The incidence of PE identified has fallen and there has been a modest increase in the number of alternative diagnoses.
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Affiliation(s)
- Sarojini David
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge
| | - Peter Beddy
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge
| | - Judith Babar
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge
| | - Anand Devaraj
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge
- Department of Radiology, St George's Hospital, London, UK
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Sun Z, Choo GH, Ng KH. Coronary CT angiography: current status and continuing challenges. Br J Radiol 2012; 85:495-510. [PMID: 22253353 DOI: 10.1259/bjr/15296170] [Citation(s) in RCA: 102] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Coronary CT angiography has been increasingly used in the diagnosis of coronary artery disease owing to rapid technological developments, which are reflected in the improved spatial and temporal resolution of the images. High diagnostic accuracy has been achieved with multislice CT scanners (64 slice and higher), and in selected patients coronary CT angiography is regarded as a reliable alternative to invasive coronary angiography. With high-quality coronary CT imaging increasingly being performed, patients can benefit from an imaging modality that provides a rapid and accurate diagnosis while avoiding an invasive procedure. Despite the tremendous contributions of coronary CT angiography to cardiac imaging, study results reported in the literature should be interpreted with caution as there are some limitations existing within the study design or related to patient risk factors. In addition, some attention must be given to the potential health risks associated with the ionising radiation received during cardiac CT examinations. Radiation dose associated with coronary CT angiography has raised serious concerns in the literature, as the risk of developing malignancy is not negligible. Various dose-saving strategies have been implemented, with some of the strategies resulting in significant dose reduction. The aim of this review is to present an overview of the role of coronary CT angiography on cardiac imaging, with focus on coronary artery disease in terms of the diagnostic and prognostic value of coronary CT angiography. Various approaches for dose reduction commonly recommended in the literature are discussed. Limitations of coronary CT angiography are identified. Finally, future directions and challenges with the use of coronary CT angiography are highlighted.
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Affiliation(s)
- Z Sun
- Department of Imaging and Applied Physics, Curtin University, Perth, Australia
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Cury RC, Feuchtner G, Mascioli C, Fialkow J, Andrulonis P, Villanueva T, Pena CS, Janowitz WR, Katzen BT, Ziffer JA. Cardiac CT in the emergency department: convincing evidence, but cautious implementation. J Nucl Cardiol 2011; 18:331-41. [PMID: 21359497 DOI: 10.1007/s12350-011-9356-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
In clinical practice, assessment of chest pain patients presenting to the emergency department is difficult and the work-up can be lengthy and costly. There is growing evidence supporting the use of coronary computed tomography angiography (CTA) in early assessment of patients presenting with acute chest pain to the emergency department. CTA appears to be a faster and more accurate way to diagnosis or rule out coronary stenosis, leading to reduced hospital admissions, decreased time in the ED and lower costs. The focus of this article is to review the current literature of the use of Coronary CTA and "triple rule out" protocols in the emergency department setting and to provide a chest pain algorithm, showing how Coronary CTA can be implemented effectively in clinical practice. Potential pitfalls and requirements for implementation will also be discussed.
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Affiliation(s)
- Ricardo C Cury
- Baptist Hospital of Miami and Baptist Cardiac and Vascular Institute, 8900 North Kendall Drive, Miami, FL, USA.
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Madder RD, Raff GL, Hickman L, Foster NJ, McMurray MD, Carlyle LM, Boura JA, Chinnaiyan KM. Comparative diagnostic yield and 3-month outcomes of "triple rule-out" and standard protocol coronary CT angiography in the evaluation of acute chest pain. J Cardiovasc Comput Tomogr 2011; 5:165-71. [PMID: 21511557 DOI: 10.1016/j.jcct.2011.03.008] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2010] [Revised: 02/12/2011] [Accepted: 03/09/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUND "Triple rule-out" CT angiography simultaneously evaluates coronary artery disease, pulmonary embolism, and aortic dissection in a single imaging examination. However, the clinical outcomes of this approach are unknown. OBJECTIVE Using standard cardiac CT angiography as a reference, this study was performed to describe the diagnostic yield and clinical outcomes of patients undergoing triple rule-out in clinical practice. METHODS We identified consecutive patients at 2 institutions undergoing triple rule-out or cardiac CT angiography for acute chest pain. The primary outcome was a composite diagnostic yield consisting of coronary artery diameter stenosis >50%, pulmonary embolism, and aortic dissection. Other reported outcomes included radiation dose, downstream resource use, and 90-day clinical outcomes. RESULTS Among 2068 patients (272 triple rule-out and 1796 cardiac CT angiograms), the composite diagnostic yield was 14.3% with triple rule-out and 16.3% with cardiac CT (P = 0.41) and was driven by the diagnosis of obstructive coronary artery disease (13.2% triple rule-out versus 16.1% cardiac CT, P = 0.22). The diagnostic yield for pulmonary embolism was low (1.1% triple rule-out and 0.2% cardiac CT, P = 0.052) and no aortic dissections were found in either group. Compared with cardiac CT, the triple rule-out approach was associated with higher radiation exposure (12.0 ± 5.6 mSv versus 8.2 ± 4.0 mSv, P < 0.0001), a greater incidence of subsequent emergency center cardiac evaluations (5.9% versus 2.5%, P = 0.0017), and more downstream pulmonary embolism-protocol CT angiography (3.3% versus 0.9%, P = 0.0034). CONCLUSIONS Among patients with acute chest pain, a triple rule-out approach resulted in higher radiation exposure compared with cardiac CT, but was not associated with improved diagnostic yield, reduced clinical events, or diminished downstream resource use.
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Affiliation(s)
- Ryan D Madder
- Department of Cardiovascular Medicine, William Beaumont Hospital, 3601 W. 13 Mile Road, Royal Oak, MI 48073, USA.
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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; 21:1416-23. [PMID: 21347640 DOI: 10.1007/s00330-011-2088-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2010] [Revised: 01/13/2011] [Accepted: 01/25/2011] [Indexed: 11/26/2022]
Affiliation(s)
- Tahir Durmus
- Department of Radiology, Charité-University Hospital Berlin, Campus Mitte, 10117 Berlin, Germany.
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Coronary CT Angiography in Acute Chest Pain Syndromes. CURRENT CARDIOVASCULAR IMAGING REPORTS 2010. [DOI: 10.1007/s12410-010-9052-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Hartmann IJ, Wittenberg R, Schaefer-Prokop C. Imaging of acute pulmonary embolism using multi-detector CT angiography: An update on imaging technique and interpretation. Eur J Radiol 2010; 74:40-9. [DOI: 10.1016/j.ejrad.2010.02.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2010] [Accepted: 02/09/2010] [Indexed: 11/27/2022]
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Henzler T, Krissak R, Reichert M, Sueselbeck T, Schoenberg SO, Fink C. Volumetric analysis of pulmonary CTA for the assessment of right ventricular dysfunction in patients with acute pulmonary embolism. Acad Radiol 2010; 17:309-15. [PMID: 20152725 DOI: 10.1016/j.acra.2009.10.022] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Revised: 10/21/2009] [Accepted: 10/25/2009] [Indexed: 10/19/2022]
Abstract
RATIONALE AND OBJECTIVES To retrospectively determine the value of a volumetric ventricle analysis for the assessment of right ventricular dysfunction in patients with suspected pulmonary embolism (PE) by using image data from non-electrocardiographically (ECG)-gated multidetector computed tomography angiography (CTA). MATERIALS AND METHODS Hypothesizing that the presence of PE and the embolus location correlated with right ventricular dysfunction, we retrospectively analyzed 100 non-ECG-gated pulmonary CTA datasets of patients with central, peripheral, and without PE. Right ventricle/left ventricle (RV/LV) diameter ratio measured in transverse sections (RV/LV(trans)), four-chamber view (RV/LV(4ch)), and RV/LV volume ratio (RV/LV(vol)) were assessed on CT images. The results were correlated with the embolus location, the 30-day mortality rate, and the necessity of intensive care treatment. RESULTS All CT parameters showed statistically significant differences between all patients groups depended on embolus location. The receiver operating characteristic analysis RV/LV(vol) showed the strongest discriminatory power to differ between patients with central and without PE and between patients with central and peripheral PE (central PE vs. no PE: RV/LV(vol) = 0.932, RV/LV(trans) = 0.880, and RV/LV(4ch) = 0.811, central PE vs. peripheral PE: RV/LV(vol) = 0.950, RV/LV(trans) = 0.849, and RV/LV(4ch) = 0.881), indicating a correlation with embolus location predisposing for RVD. For the identification of high-risk patients with PE all three CT parameters showed statistically significant values (P < .0001), whereas in the receiver operating characteristic analysis, RV/LV(vol) had the strongest discriminatory power (RV/LV(vol) = 0.819, RV/LV(trans) = 0.799, and RV/LV(4ch) = 0.758). CONCLUSION Ventricle volumetry of non-ECG-gated CTA allows the assessment of right ventricular dysfunction in patients with acute PE. Compared to unidimensional measurements, a volumetric analysis seems to be slightly superior to identify high-risk patients with adverse clinical outcome. However, the method is more time consuming and requires dedicated software tools compared to unidimensional parameters, which is disadvantageous in an emergency setting.
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Saving Dose in Triple-Rule-Out Computed Tomography Examination Using a High-Pitch Dual Spiral Technique. Invest Radiol 2010; 45:64-71. [PMID: 20027121 DOI: 10.1097/rli.0b013e3181c15842] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Litt H. Are three diagnoses always better than one? Acad Radiol 2009; 16:1037-8. [PMID: 19660709 DOI: 10.1016/j.acra.2009.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2009] [Revised: 07/11/2009] [Accepted: 07/12/2009] [Indexed: 12/01/2022]
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