Computed Tomographic Angiography for Risk Stratification in Patients with Acute Chest Pain - The Triple Rule-out Concept in the Emergency Department

Author(s): Marton-Popovici Monica*, Béla Merkely, Bálint Szilveszter, Zsófia Dora Drobni, Pál Maurovich-Horvat

Journal Name: Current Medical Imaging
Formerly: Current Medical Imaging Reviews

Volume 16 , Issue 2 , 2020

Become EABM
Become Reviewer
Call for Editor

Graphical 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.

Keywords: Acute coronary syndromes, chest pain, aortic dissection, pulmonary embolism, triple rule-out, cardiac computed tomography.

Pitts SR, Niska RW, Xu J, Burt CW. National hospital ambulatory medical care survey: 2006 emergency department summary. Natl Health Stat Rep 2008; 6(7): 1-38.
[PMID: 18958996]
Pope JH, Selker HP. Acute coronary syndromes in the emergency department: diagnostic characteristics, tests, and challenges. Cardiol Clin 2005; 23(4): 423-51.
[] [PMID: 16278116]
Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med 2000; 342(16): 1163-70.
[] [PMID: 10770981]
Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA 2005; 294(20): 2623-9.
[] [PMID: 16304077]
Gruettner J, Henzler T, Sueselbeck T, Fink C, Borggrefe M, Walter T. Clinical assessment of chest pain and guidelines for imaging. Eur J Radiol 2012; 81(12): 3663-8.
[] [PMID: 21396792]
Sheikh AS, Ali K, Mazhar S. Acute aortic syndrome. Circulation 2013; 128(10): 1122-7.
[] [PMID: 24002714]
Coady MA, Rizzo JA, Elefteriades JA. Pathologic variants of thoracic aortic dissections. Penetrating atherosclerotic ulcers and intramural hematomas. Cardiol Clin 1999; 17(4): 637-57.
[] [PMID: 10589337]
Pape LA, Awais M, Woznicki EM, et al. Presentation, diagnosis, and outcomes of acute aortic dissection: 17-year trends from the international registry of acute aortic dissection. J Am Coll Cardiol 2015; 66(4): 350-8.
[] [PMID: 26205591]
Kruip MJ, Slob MJ, Schijen JH, van der Heul C, Büller HR. Use of a clinical decision rule in combination with D-dimer concentration in diagnostic workup of patients with suspected pulmonary embolism: a prospective management study. Arch Intern Med 2002; 162(14): 1631-5.
[] [PMID: 12123408]
Suzuki T, Distante A, Zizza A, et al. IRAD-Bio investigators. Diagnosis of acute aortic dissection by D-dimer: the International Registry of Acute Aortic Dissection substudy on Biomarkers (IRAD-Bio) experience. Circulation 2009; 119(20): 2702-7.
[] [PMID: 19433758]
Yoon YE, Wann S. Evaluation of acute chest pain in the emergency department: “triple rule-out” computed tomography angiography. Cardiol Rev 2011; 19(3): 115-21.
[] [PMID: 21464639]
Amsterdam EA, Kirk JD, Bluemke DA, et al. Testing of low-risk patients presenting to the emergency department with chest pain. Circulation 2010; 122(17): 1756-76.
[] [PMID: 20660809]
Yoo SM, Rho JY, Lee HY, Song IS, Moon JY, White CS. Current concepts in cardiac ct angiography for patients with acute chest pain. Korean Circ J 2010; 40(11): 543-9.
[] [PMID: 21217929]
Katz DA, Williams GC, Brown RL, et al. Emergency physicians’ fear of malpractice in evaluating patients with possible acute cardiac ischemia. Ann Emerg Med 2005; 46(6): 525-33.
[] [PMID: 16308068]
Budoff MJ, Dowe D, Jollis JG, et al. Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial. J Am Coll Cardiol 2008; 52(21): 1724-32.
[] [PMID: 19007693]
Meijboom WB, Meijs MF, Schuijf JD, et al. Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study. J Am Coll Cardiol 2008; 52(25): 2135-44.
[] [PMID: 19095130]
Rogers IS, Banerji D, Siegel EL, et al. Usefulness of comprehensive cardiothoracic computed tomography in the evaluation of acute undifferentiated chest discomfort in the emergency department (CAPTURE). Am J Cardiol 2011; 107(5): 643-50.
[] [PMID: 21247533]
Schoepf UJ, Costello P. CT angiography for diagnosis of pulmonary embolism: state of the art. Radiology 2004; 230(2): 329-37.
[] [PMID: 14752178]
Kalender WA, Seissler W, Klotz E, Vock P. Spiral volumetric CT with single-breath-hold technique, continuous transport, and continuous scanner rotation. Radiology 1990; 176(1): 181-3.
[] [PMID: 2353088]
Ohnesorge B, Flohr T, Becker C, et al. Cardiac imaging by means of electrocardiographically gated multisection spiral CT: initial experience. Radiology 2000; 217(2): 564-71.
[] [PMID: 11058661]
Gallagher MJ, Raff GL. Use of multislice CT for the evaluation of emergency room patients with chest pain: the so-called “triple rule-out”. Catheter Cardiovasc Interv 2008; 71(1): 92-9.
[] [PMID: 18098208]
Hsiao EM, Rybicki FJ, Steigner M. CT coronary angiography: 256-slice and 320-detector row scanners. Curr Cardiol Rep 2010; 12(1): 68-75.
[] [PMID: 20425186]
Ropp A, Lin CT, White CS. Coronary computed tomography angiography for the assessment of acute chest pain in the emergency department: evidence, guidelines, and tips for implementation. J Thorac Imaging 2015; 30(3): 169-75.
[] [PMID: 25730553]
Halpern EJ, Levin DC, Zhang S, Takakuwa KM. Comparison of image quality and arterial enhancement with a dedicated coronary CTA protocol versus a triple rule-out coronary CTA protocol. Acad Radiol 2009; 16(9): 1039-48.
[] [PMID: 19523852]
Schertler T, Frauenfelder T, Stolzmann P, et al. Triple rule-out CT in patients with suspicion of acute pulmonary embolism: findings and accuracy. Acad Radiol 2009; 16(6): 708-17.
[] [PMID: 19427980]
Shapiro MD. Is the “triple rule-out” study an appropriate indication for cardiovascular CT? J Cardiovasc Comput Tomogr 2009; 3(2): 100-3.
[] [PMID: 19201674]
Frauenfelder T, Appenzeller P, Karlo C, et al. Triple rule-out CT in the emergency department: protocols and spectrum of imaging findings. Eur Radiol 2009; 19(4): 789-99.
[] [PMID: 19015860]
Kontos MC, Diercks DB, Kirk JD. Emergency department and office-based evaluation of patients with chest pain. Mayo Clin Proc 2010; 85(3): 284-99.
[] [PMID: 20194155]
Soliman HH. Value of triple rule-out CT in the emergency department. EJRNM 2015; 46(3): 621-7.
van der Wall EE, Schuijf JD, Bax JJ. Triple rule-out CT coronary angiography: three of a kind? Int J Cardiovasc Imaging 2009; 25(3): 327-30.
[] [PMID: 19002601]
Litt HI, Gatsonis C, Snyder B, et al. CT angiography for safe discharge of patients with possible acute coronary syndromes. N Engl J Med 2012; 366(15): 1393-403.
[] [PMID: 22449295]
Chang AM, Shofer FS, Weiner MG, et al. Actual financial comparison of four strategies to evaluate patients with potential acute coronary syndromes. Acad Emerg Med 2008; 15(7): 649-55.
[] [PMID: 18691213]
Gruettner J, Fink C, Walter T, et al. Coronary computed tomography and triple rule out CT in patients with acute chest pain and an intermediate cardiac risk profile. Part 1: impact on patient management. Eur J Radiol 2013; 82(1): 100-5.
[] [PMID: 22749769]
Savino G, Herzog C, Costello P, Schoepf UJ. 64 slice cardiovascular CT in the emergency department: concepts and first experiences. Radiol Med (Torino) 2006; 111(4): 481-96.
[] [PMID: 16779535]
Min JK, Shaw LJ, Devereux RB, et al. Prognostic value of multidetector coronary computed tomographic angiography for prediction of all-cause mortality. J Am Coll Cardiol 2007; 50(12): 1161-70.
[] [PMID: 17868808]
Chae MK, Kim EK, Jung KY, et al. Triple rule-out computed tomography for risk stratification of patients with acute chest pain. J Cardiovasc Comput Tomogr 2016; 10(4): 291-300.
[] [PMID: 27375202]
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(5): 677-82.
[] [PMID: 26587090]
Madder RD, Raff GL, Hickman L, et al. 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(3): 165-71.
[] [PMID: 21511557]
Takakuwa KM, Halpern EJ. 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. Radiology 2008; 248(2): 438-46.
[] [PMID: 18641247]
Chang SA, Choi SI, Choi EK, et al. Usefulness of 64-slice multidetector computed tomography as an initial diagnostic approach in patients with acute chest pain. Am Heart J 2008; 156(2): 375-83.
[] [PMID: 18657674]
Wnorowski AM, Halpern EJ. Diagnostic yield of triple-rule-out CT in an emergency setting. AJR Am J Roentgenol 2016; 207(2): 295-301.
[] [PMID: 27186867]
Lucassen W, Geersing GJ, Erkens PM, et al. Clinical decision rules for excluding pulmonary embolism: a meta-analysis. Ann Intern Med 2011; 155(7): 448-60.
[] [PMID: 21969343]
Kline JA, Stubblefield WB. Clinician gestalt estimate of pretest probability for acute coronary syndrome and pulmonary embolism in patients with chest pain and dyspnea. Ann Emerg Med 2014; 63(3): 275-80.
[] [PMID: 24070658]
Rogers AM, Hermann LK, Booher AM, et al. IRAD investigators. Sensitivity of the aortic dissection detection risk score, a novel guideline-based tool for identification of acute aortic dissection at initial presentation: results from the international registry of acute aortic dissection. Circulation 2011; 123(20): 2213-8.
[] [PMID: 21555704]
Chase M, Robey JL, Zogby KE, Sease KL, Shofer FS, Hollander JE. Prospective validation of the thrombolysis in myocardial infarction risk score in the emergency department chest pain population. Ann Emerg Med 2006; 48(3): 252-9.
[] [PMID: 16934646]
Visser A, Wolthuis A, Breedveld R, ter Avest E. HEART score and clinical gestalt have similar diagnostic accuracy for diagnosing ACS in an unselected population of patients with chest pain presenting in the ED. Emerg Med J 2015; 32(8): 595-600.
[] [PMID: 25217099]
Than M, Flaws D, Sanders S, et al. Development and validation of the emergency department assessment of chest pain score and 2 h accelerated diagnostic protocol. Emerg Med Australas 2014; 26(1): 34-44.
[] [PMID: 24428678]
Lee HY, Yoo SM, White CS. Coronary CT angiography in emergency department patients with acute chest pain: triple rule-out protocol versus dedicated coronary CT angiography. Int J Cardiovasc Imaging 2009; 25(3): 319-26.
[] [PMID: 18853277]
Kumar A, Cannon CP. Acute coronary syndromes: diagnosis and management, part I. Mayo Clin Proc 2009; 84(10): 917-38.
[] [PMID: 19797781]
Burris AC II, Boura JA, Raff GL, Chinnaiyan KM. Triple rule out versus coronary CT angiography in patients with acute chest pain: results from the ACIC consortium. JACC Cardiovasc Imaging 2015; 8(7): 817-25.
[] [PMID: 26093928]
Fernández del Valle A, Delgado Sánchez-Gracián C, Oca Pernas R, et al. High pitch CT in triple rule-out studies: radiation dose and image quality compared to multidetector CT. Radiologia (Madr) 2015; 57(5): 412-8.
[] [PMID: 25443435]
Kidoh M, Nakaura T, Nakamura S, et al. Contrast material and radiation dose reduction strategy for triple-rule-out cardiac CT angiography: feasibility study of non-ECG gated low kVp scan of the whole chest following coronary CT antiography. Acta Radiol 2014; 55(5): 1186-96.
[] [PMID: 23969265]
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(7): 1416-23.
[] [PMID: 21347640]
Goldstein JA, Chinnaiyan KM, Abidov A, et al. CT-STAT investigators. The CT-STAT (coronary computed tomographic angiography for systematic triage of acute chest pain patients to treatment) trial. J Am Coll Cardiol 2011; 58(14): 1414-22.
[] [PMID: 21939822]
Hoffmann U, Bamberg F, Chae CU, et al. Coronary computed tomography angiography for early triage of patients with acute chest pain: the ROMICAT (Rule Out Myocardial Infarction using Computer Assisted Tomography) trial. J Am Coll Cardiol 2009; 53(18): 1642-50.
[] [PMID: 19406338]
Halpern EJ. Triple-rule-out CT angiography for evaluation of acute chest pain and possible acute coronary syndrome. Radiology 2009; 252(2): 332-45.
[] [PMID: 19703877]
Arbab-Zadeh A, Miller JM, Rochitte CE, et al. Diagnostic accuracy of CT coronary angiography according to pretest probability of coronary artery disease and severity of coronary arterial calcification: The CorE-64 international, multicenter study. J Am Coll Cardiol 2012; 59(4): 379-87.
[] [PMID: 22261160]
Manheimer ED, Peters MR, Wolff SD, et al. Comparison of radiation dose and image quality of triple-rule-out computed tomography angiography between conventional helical scanning and a strategy incorporating sequential scanning. Am J Cardiol 2011; 107(7): 1093-8.
[] [PMID: 21306693]
Sabarudin A, Sun Z. Beta-blocker administration protocol for prospectively ECG-triggered coronary CT angiography. World J Cardiol 2013; 5(12): 453-8.
[] [PMID: 24392189]
Takx RA, Suchá D, Park J, Leiner T, Hoffmann U. Sublingual nitroglycerin administration in coronary computed tomography angiography: a systematic review. Eur Radiol 2015; 25(12): 3536-42.
[] [PMID: 25994194]
Cademartiri F, Mollet NR, Lemos PA, et al. Higher intracoronary attenuation improves diagnostic accuracy in MDCT coronary angiography. AJR Am J Roentgenol 2006; 187(4)W430-3
[] [PMID: 16985117]
Karády J, Panajotu A, Kolossváry M, et al. The effect of four-phasic versus three-phasic contrast media injection protocols on extravasation rate in coronary CT angiography: a randomized controlled trial. Eur Radiol 2017; 27(11): 4538-43.
[] [PMID: 28540480]
Dodd JD, Kalva S, Pena A, et al. Emergency cardiac CT for suspected acute coronary syndrome: qualitative and quantitative assessment of coronary, pulmonary, and aortic image quality. AJR Am J Roentgenol 2008; 191(3): 870-7.
[] [PMID: 18716121]
Cornea AM, McCullough BJ, Mitsumori LM, Gunn ML. Enhancement of the pulmonary arteries and thoracic aorta: comparison of a biphasic contrast injection and fixed delay protocol with a monophasic injection and a timing bolus protocol. Emerg Radiol 2015; 22(3): 231-7.
[] [PMID: 25228282]
Mihl C, Kok M, Wildberger JE, et al. Coronary CT angiography using low concentrated contrast media injected with high flow rates: Feasible in clinical practice. Eur J Radiol 2015; 84(11): 2155-60.
[] [PMID: 26277498]
Schussler JM, Smith ER. Sixty-four-slice computed tomographic coronary angiography: will the “triple rule out” change chest pain evaluation in the ED? Am J Emerg Med 2007; 25(3): 367-75.
[] [PMID: 17349915]
Takakuwa KM, Halpern EJ. Radiation dose in a “triple rule-out” and standard protocol of emergency department patients using 64-MDCT: the impact of ECG-based tube current modulation on age, sex and body mass index. AJR Am J Roentgenol 2009; 192(4): 866-72.
[] [PMID: 19304688]
Hameed TA, Teague SD, Vembar M. Low radiation dose ECG-gated chest CT angiography on a 256 slice multidetector CT scanner. Int J Cardiovasc Imaging 2009; 25: 267-78.
Einstein AJ, Henzlova MJ, Rajagopalan S. Estimating risk of cancer associated with radiation exposure from 64-slice computed tomography coronary angiography. JAMA 2007; 298(3): 317-23.
[] [PMID: 17635892]
Paul JF, Abada HT. Strategies for reduction of radiation dose in cardiac multislice CT. Eur Radiol 2007; 17(8): 2028-37.
[] [PMID: 17318604]
Takx RAP, Krissak R, Fink C, et al. Low-tube-voltage selection for triple-rule-out CTA: relation to patient size. Eur Radiol 2017; 27(6): 2292-7.
[] [PMID: 27686566]
Lee CH, Goo JM, Ye HJ, et al. Radiation dose modulation techniques in the multidetector CT era: from basics to practice. Radiographics 2008; 28(5): 1451-9.
[] [PMID: 18794318]
Chen HL, Chen TW, Qiu LH, Diao XM, Zhang C, Chen L. Application of flash dual-source CT at low radiation dose and low contrast medium dose in triple-rule-out (tro) examination. Int J Clin Exp Med 2015; 8(11): 21898-905.
[PMID: 26885160]
Hein PA, Romano VC, Lembcke A, May J, Rogalla P. Initial experience with a chest pain protocol using 320-slice volume MDCT. Eur Radiol 2009; 19(5): 1148-55.
[] [PMID: 19137311]
Hirai N, Horiguchi J, Fujioka C, et al. Prospective versus retrospective gating with dual source coronary computed tomography angiography: development of selection criteria and initial experience. J Cardiovasc Comput Tomogr 2008; 248(2): 424-30.
Ghafourian K, Younes D, Simprini LA, Weigold WG, Weissman G, Taylor AJ. Scout view X-ray attenuation versus weight-based selection of reduced peak tube voltage in cardiac CT angiography. JACC Cardiovasc Imaging 2012; 5(6): 589-95.
[] [PMID: 22698527]
Li JL, Huang MP, Liang CH, et al. Individualized radiation dose control in 256-slice CT Coronary Angiography (CTCA) in retrospective ECG-triggered helical scans: using a measure of body size to adjust tube current selection. Eur J Radiol 2012; 81(11): 3146-53.
[] [PMID: 22677617]
Bischoff B, Hein F, Meyer T, et al. Impact of a reduced tube voltage on CT angiography and radiation dose: results of the PROTECTION I study. JACC Cardiovasc Imaging 2009; 2(8): 940-6.
[] [PMID: 19679281]
Feuchtner GM, Jodocy D, Klauser A, et al. Radiation dose reduction by using 100-kV tube voltage in cardiac 64-slice computed tomography: a comparative study. Eur J Radiol 2010; 75(1): e51-6.
[] [PMID: 19671491]
Krissak R, Henzler T, Prechel A, et al. Triple-rule-out dual-source CT angiography of patients with acute chest pain: dose reduction potential of 100 kV scanning. Eur J Radiol 2012; 81(12): 3691-6.
[] [PMID: 21163600]
Cao JX, Wang YM, Lu JG, Zhang Y, Wang P, Yang C. Radiation and contrast agent doses reductions by using 80-kV tube voltage in coronary computed tomographic angiography: a comparative study. Eur J Radiol 2014; 83(2): 309-14.
[] [PMID: 24315475]
Sommer WH, Schenzle JC, Becker CR, et al. Saving dose in triple-rule-out computed tomography examination using a high-pitch dual spiral technique. Invest Radiol 2010; 45(2): 64-71.
[] [PMID: 20027121]
Chinnaiyan KM, Bilolikar AN, Walsh E, et al. CT dose reduction using prospectively triggered or fast-pitch spiral technique employed in cardiothoracic imaging (the CT dose study). J Cardiovasc Comput Tomogr 2014; 8(3): 205-14.
[] [PMID: 24939069]
Kohn MA, Kwan E, Gupta M, Tabas JA. Prevalence of acute myocardial infarction and other serious diagnoses in patients presenting to an urban emergency department with chest pain. J Emerg Med 2005; 29(4): 383-90.
[] [PMID: 16243193]
Kim HS, Kim SM, Cha MJ, et al. Triple rule-out CT angiography protocol with restricting field of view for detection of pulmonary thromboembolism and aortic dissection in emergency department patients: simulation of modified CT protocol for reducing radiation dose. Acta Radiol 2017; 58(5): 521-7.
[] [PMID: 27552981]
Sun K, Han RJ, Ma LJ, Wang LJ, Li LG, Chen JH. Prospectively electrocardiogram-gated high-pitch spiral acquisition mode dual-source CT coronary angiography in patients with high heart rates: comparison with retrospective electrocardiogram-gated spiral acquisition mode. Korean J Radiol 2012; 13(6): 684-93.
[] [PMID: 23118566]
Kröpil P, Rojas CA, Ghoshhajra B, et al. Prospectively ECG-triggered high-pitch spiral acquisition for cardiac CT angiography in routine clinical practice: initial results. J Thorac Imaging 2012; 27(3): 194-201.
[] [PMID: 21964497]
Koplay M, Celik M, Avcı A, et al. Comparison between prospectively electrocardiogram-gated high-pitch mode and retrospectively electrocardiogram-gated mode for dual-source CT coronary angiography. Pol J Radiol 2015; 80: 561-8.
[] [PMID: 26767072]
Litmanovich D, Zamboni GA, Hauser TH, Lin PJ, Clouse ME, Raptopoulos V. ECG-gated chest CT angiography with 64-MDCT and tri-phasic IV contrast administration regimen in patients with acute non-specific chest pain. Eur Radiol 2008; 18(2): 308-17.
[] [PMID: 17763855]
Ayaram D, Bellolio MF, Murad MH, et al. Triple rule-out computed tomographic angiography for chest pain: a diagnostic systematic review and meta-analysis. Acad Emerg Med 2013; 20(9): 861-71.
[] [PMID: 24050793]
Bartorelli AL, Marenzi G. Contrast-induced nephropathy. J Interv Cardiol 2008; 21(1): 74-85.
[] [PMID: 18086132]
Nakayama Y, Awai K, Funama Y, et al. Abdominal CT with low tube voltage: preliminary observations about radiation dose, contrast enhancement, image quality, and noise. Radiology 2005; 237(3): 945-51.
[] [PMID: 16237140]
Bae KT. Intravenous contrast medium administration and scan timing at CT: considerations and approaches. Radiology 2010; 256(1): 32-61.
[] [PMID: 20574084]
Schoellnast H, Deutschmann HA, Berghold A, Fritz GA, Schaffler GJ, Tillich M. MDCT angiography of the pulmonary arteries: influence of body weight, body mass index, and scan length on arterial enhancement at different iodine flow rates. AJR Am J Roentgenol 2006; 187(4): 1074-8.
[] [PMID: 16985159]
Tatsugami F, Husmann L, Herzog BA, et al. Evaluation of a body mass index-adapted protocol for low-dose 64-MDCT coronary angiography with prospective ECG triggering. AJR Am J Roentgenol 2009; 192(3): 635-8.
[] [PMID: 19234258]
Behrendt FF, Bruners P, Keil S, et al. Impact of different vein catheter sizes for mechanical power injection in CT: in vitro evaluation with use of a circulation phantom. Cardiovasc Intervent Radiol 2009; 32(1): 25-31.
[] [PMID: 18521665]
Zheng M, Liu Y, Wei M, Wu Y, Zhao H, Li J. Low concentration contrast medium for dual-source computed tomography coronary angiography by a combination of iterative reconstruction and low-tube-voltage technique: feasibility study. Eur J Radiol 2014; 83(2): e92-9.
[] [PMID: 24332352]
Funama Y, Taguchi K, Utsunomiya D, et al. Combination of a low-tube-voltage technique with hybrid iterative reconstruction (iDose) algorithm at coronary computed tomographic angiography. J Comput Assist Tomogr 2011; 35(4): 480-5.
[] [PMID: 21765305]
Im DJ, Kim Y-H, Choo KS, et al. Comparison of coronary computed tomography angiography image quality with high- and low-concentration contrast agents (CONCENTRATE): study protocol for a randomized controlled trial. Trials 2016; 17(1): 315.
[] [PMID: 27418333]
Bae KT, Seeck BA, Hildebolt CF, et al. Contrast enhancement in cardiovascular MDCT: effect of body weight, height, body surface area, body mass index, and obesity. AJR Am J Roentgenol 2008; 190(3): 777-84.
[] [PMID: 18287452]
Husmann L, Alkadhi H, Boehm T, et al. Influence of cardiac hemodynamic parameters on coronary artery opacification with 64-slice computed tomography. Eur Radiol 2006; 16(5): 1111-6.
[] [PMID: 16607499]
Johnson TR, Nikolaou K, Wintersperger BJ, et al. Optimization of contrast material administration for electrocardiogram-gated computed tomographic angiography of the chest. J Comput Assist Tomogr 2007; 31(2): 265-71.
[] [PMID: 17414765]
Dobra M, Bordi L, Nyulas T, et al. Computed tomography - an emerging tool for triple rule-out in the emergency department. A review. J Cardiovasc Emerg 2017; 3(1): 36-40.
Abbara S, Arbab-Zadeh A, Callister TQ, et al. SCCT guidelines for performance of coronary computed tomographic angiography: a report of the society of cardiovascular computed tomography guidelines committee. J Cardiovasc Comput Tomogr 2009; 3(3): 190-204.
[] [PMID: 19409872]
Halliburton SS, Abbara S, Chen MY, et al. Society of cardiovascular computed tomography. SCCT guidelines on radiation dose and dose-optimization strategies in cardiovascular CT. J Cardiovasc Comput Tomogr 2011; 5(4): 198-224.
[] [PMID: 21723512]
Goldman LW. Principles of CT: radiation dose and image quality. J Nucl Med Technol 2007; 35(4): 213-25.
[] [PMID: 18006597]
Donnino R, Jacobs JE, Doshi JV, et al. Dual-source versus single-source cardiac CT angiography: comparison of diagnostic image quality. AJR Am J Roentgenol 2009; 192(4): 1051-6.
[] [PMID: 19304713]
Duarte R, Miranda D, Fernández-Pérez G, Costa JC. Coronariografía mediante tomografía computarizada con sincronización prospectiva. Comparación de la calidad de imagen y dosis de radiación con equipos de 128 detectores de fuente única y doble fuente. Radiologia (Madr) 2013; 55(4): 315-2.
Kligerman SJ, White CS. Image quality and feasibility of an ultralow-dose high-pitch helical triple-rule-out computed tomography angiography acquired in the caudocranial direction. J Thorac Imaging 2014; 29(1): 50-9.
[] [PMID: 24247084]
Rahmani N, Jeudy J, White CS. Triple rule-out and dedicated coronary artery CTA: comparison of coronary artery image quality. Acad Radiol 2009; 16(5): 604-9.
[] [PMID: 19282205]
Hoffmann U, Truong QA, Schoenfeld DA, et al. ROMICAT-II Investigators. Coronary CT angiography versus standard evaluation in acute chest pain. N Engl J Med 2012; 367(4): 299-308.
[] [PMID: 22830462]
den Dekker MA, de Smet K, de Bock GH, Tio RA, Oudkerk M, Vliegenthart R. Diagnostic performance of coronary CT angiography for stenosis detection according to calcium score: systematic review and meta-analysis. Eur Radiol 2012; 22(12): 2688-98.
[] [PMID: 22797978]
Qahtani SA, Kandeel AY, Breault S, Jouannic A-M, 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(8): 627-31.
[] [PMID: 26124909]
Landry A, Koyfman A. Should triple rule-out CT angiography be used in patients with suspected acute coronary artery disease, aortic dissection, or pulmonary embolus? Ann Emerg Med 2015; 65(2): 216-7.
[] [PMID: 24836704]
Motoyama S, Ito H, Sarai M, et al. Plaque characterization by coronary computed tomography angiography and the likelihood of acute coronary events in mid-term follow-up. J Am Coll Cardiol 2015; 66(4): 337-46.
[] [PMID: 26205589]
Benedek T, Jako B, Benedek I. Plaque quantification by coronary CT and intravascular ultrasound identifies a low CT density core as a marker of plaque instability in acute coronary syndromes. Int Heart J 2014; 55(1): 22-8.
[] [PMID: 24463925]
Benedek T, Bucur O, Pascanu I, Benedek I. Analysis of coronary plaque morphology by 64-multislice computed tomography coronary angiography and calcium scoring in patients with type 2 diabetes mellitus. Acta Endo (Buc) 2011; 7(1): 59-68.
Benedek T, Maurovich-Horváth P, Ferdinandy P, Merkely B. The use of biomarkers for the early detection of vulnerable atherosclerotic plaques and vulnerable patients. A review. J Cardiovasc Emerg 2016; 2: 106-13.
Maurovich-Horvat P, Ferencik M, Voros S, Merkely B, Hoffmann U. Comprehensive plaque assessment by coronary CT angiography. Nat Rev Cardiol 2014; 11(7): 390-402.
[] [PMID: 24755916]
Benedek T, Gyöngyösi M, Benedek I. Multislice computed tomographic coronary angiography for quantitative assessment of culprit lesions in acute coronary syndromes. Can J Cardiol 2013; 29(3): 364-71.
[] [PMID: 23333164]
Maurovich-Horvat P, Schlett CL, Alkadhi H, et al. The napkin-ring sign indicates advanced atherosclerotic lesions in coronary CT angiography. JACC Cardiovasc Imaging 2012; 5(12): 1243-52.
[] [PMID: 23236975]
Machaalany J, Yam Y, Ruddy TD, et al. Potential clinical and economic consequences of noncardiac incidental findings on cardiac computed tomography. J Am Coll Cardiol 2009; 54(16): 1533-41.
[] [PMID: 19815125]
Iribarren C, Hlatky MA, Chandra M, et al. Incidental pulmonary nodules on cardiac computed tomography: prognosis and use. Am J Med 2008; 121(11): 989-96.
[] [PMID: 18954846]
Onuma Y, Tanabe K, Nakazawa G, et al. Noncardiac findings in cardiac imaging with multidetector computed tomography. J Am Coll Cardiol 2006; 48(2): 402-6.
[] [PMID: 16843193]

Rights & PermissionsPrintExport Cite as

Article Details

Year: 2020
Published on: 03 June, 2018
Page: [98 - 110]
Pages: 13
DOI: 10.2174/1573405614666180604095120
Price: $65

Article Metrics

PDF: 32