Triple rule-out computed tomography for risk stratification of patients with acute chest pain Minjung Kathy Chae, Eun Kyoung Kim, Ka-Young Jung, Tae.

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Triple rule-out computed tomography for risk stratification of patients with acute chest pain Minjung Kathy Chae, Eun Kyoung Kim, Ka-Young Jung, Tae Gun Shin, Min Seob Sim, Ik-Joon Jo, Keun Jeong Song, Sung-A. Chang, Young Bin Song, Joo-Yong Hahn, Seung Hyuk Choi, Hyeon-Cheol Gwon, Sang-Hoon Lee, Sung Mok Kim, Hong Eo, Yeon Hyeon Choe, Jin-Ho Choi Journal of Cardiovascular Computed Tomography Volume 10, Issue 4, Pages 291-300 (July 2016) DOI: 10.1016/j.jcct.2016.06.002 Copyright © 2016 Society of Cardiovascular Computed Tomography Terms and Conditions

Fig. 1 Representative triple rule-out CT cases. Case 1: A 78 year old female with hypertension and diabetes complained of severe substernal chest pain. No specific finding in chest X-ray, ECG, and cardiac biomarkers. TRO-CT revealed absence of significantly obstructed coronary arteries (Panels A–C) and aortic or pulmonary artery disease (Panel D). Yellow arrows indicate non-obstructive calcified plaque in the distal RCA and mitral annulus calcification, respectively. Endoscopic examination identified gastroesophageal reflux, which was relieved by antacid medication. Case 2: A 44 year old male complained of sudden chest pain and vomiting. No risk factor except smoking. No specific finding in ECG and cardiac biomarkers. TRO-CT revealed multiple non-obstructive coronary plaques (yellow arrows), one tight stenosis in the ostial PDA (single red arrow) and a totally occluded PL branch (three red arrows). Urgent percutaneous coronary intervention (PCI) was performed. Case 3: A 76 year old female with progressive severe chest pain. She has undergone PCI 4 years ago. Chest X-ray showed haziness in the right lower lung field. TRO-CT showed a mild stenosis in proximal RCA (yellow arrow in panel I) and a patent stent in the mid LAD (blue arrows in panel J). Multiple pulmonary thrombi were found (magenta arrows in panel L). Intravenous thrombolytic therapy was performed. Case 4: A 74 year old female complained of severe substernal chest pain. She had undergone coronary artery bypass surgery 9 years ago. No specific finding in chest X-ray and ECG except evidence of prior sternotomy. LAD was not obstructive (panel M) and the internal thoracic artery graft was occluded (yellow arrows in panel J). A LCX graft was patent (blue arrows in panel O). A vein graft to RCA was obliterated (panel Q) but RCA was patent (panel P). An acute intramural hematoma (magenta arrows) with small dissection (asterisk) in posterior wall of ascending aorta was found (panel R). Emergency aortic surgery with Bentall’s procedure was performed. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.) Journal of Cardiovascular Computed Tomography 2016 10, 291-300DOI: (10.1016/j.jcct.2016.06.002) Copyright © 2016 Society of Cardiovascular Computed Tomography Terms and Conditions

Fig. 2 Distribution of clinical risk scores. According to the definition of each risk scoring systems, clinically low risk groups were defined by TIMI risk <3, GRACE <108, Diamond-Forrester <30%, or HEART <4 and are shown in light colors (skyblue or pink). Clinically intermediate risk groups are shown in dense colors (blue or magenta). Clinical risk scores showed wide and inhomogeneous distributions and were poorly matched with TRO-CT findings. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.) Journal of Cardiovascular Computed Tomography 2016 10, 291-300DOI: (10.1016/j.jcct.2016.06.002) Copyright © 2016 Society of Cardiovascular Computed Tomography Terms and Conditions

Fig. 3 Receiver characteristics curve analysis of clinical risk scores and triple rule-out CT for prediction of 30-day clinical event. p-value shows pairwise comparison of ROC curves. Journal of Cardiovascular Computed Tomography 2016 10, 291-300DOI: (10.1016/j.jcct.2016.06.002) Copyright © 2016 Society of Cardiovascular Computed Tomography Terms and Conditions

Fig. 4 Reclassification of clinical risk scores by triple rule-out CT. The height of center and the area of circles indicates the 30-day MACE risk and the number of patients in each group, respectively. The cutoff values of the clinically low risk group were TIMI score <3, GRACE score <108, HEART score <4, and Diamond-Forrester risk <30% in each risk scoring system. Panels A, C, E, and G: The results of clinical risk scoring systems are shown in gray-colored circles. The 30-day MACE risk was 7.4%–12.1% in low risk group, and 14.4%–23.8% in intermediate to high risk group. p < 0.001 for clinically low risk versus intermediate-to-high risk, all. Panels B, D, F, and H: TRO-CT reclassified the 30-day MACE risk made by clinical risk scoring systems, which is illustrated in the red (positive TRO-CT) and blue circles (negative TRO-CT) separated from gray-colored circles with dotted line (clinical risk). The net portion of patients reclassified by TRO-CT was 16.3% in TIMI risk score, 24.4% in GRACE score, 36.2% in HEART score, and 54.4% in Diamond-Forrester. p < 0.001, for positive TRO-CT versus negative TRO-CT, all. Journal of Cardiovascular Computed Tomography 2016 10, 291-300DOI: (10.1016/j.jcct.2016.06.002) Copyright © 2016 Society of Cardiovascular Computed Tomography Terms and Conditions

Fig. 5 Impact of triple rule-out CT on the stay time at emergency department. Journal of Cardiovascular Computed Tomography 2016 10, 291-300DOI: (10.1016/j.jcct.2016.06.002) Copyright © 2016 Society of Cardiovascular Computed Tomography Terms and Conditions