Triple Rule-Out' CT Scan For Acute Coronary Syndrome

Ruzanna Harutyunyan's picture

Chest pain is the second most common complaint when patients go to the emergency room, accounting for six million visits annually. Determining the cause of patients’ symptoms whether it be a heart attack or some other life-threatening entity like a blood clot in the lungs is challenging since the symptoms often overlap. Thomas Jefferson University Hospital is at the forefront of institutions evaluating a “triple rule-out” protocol with coronary computed tomographic angiography (CCTA) for low-to-moderate risk patients presenting with symptoms suspicious for acute coronary syndrome (ACS). The “triple rule-out” CCTA provides a non-invasive, rapid and accurate approach for the proper diagnosis or exclusion of ACS.

Results from the first 200 emergency room patients evaluated with “triple rule-out” CCTA at Jefferson – available online now( and set to be published in the August issue of Radiology – show that the triple scan, used to evaluate coronary disease, pulmonary embolism, aortic dissection, may expedite care of patients who come to the emergency department with symptoms of a heart attack. The triple rule-out protocol showed that 76 percent of the patients with symptoms mimicking heart disease were not caused by ACS.


Eleven percent of patients had a non-cardiac cause of their symptoms which included some life-threatening diagnoses such as pulmonary embolism and aortic dissection. With regards to coronary artery disease, five percent of patients had severe disease and six percent had moderate disease that was immediately recognized by CCTA. These results demonstrate the potential of the “triple rule-out” CCTA to reduce costs, limit the amount of inpatient observation and evaluation for suspected ACS, and allow better treatment with more time-sensitive diagnoses.

“Triple rule-out coronary CT angiography provides noninvasive visualization of coronary arteries with simultaneous evaluation of the pulmonary arteries, thoracic aorta, and other intra-thoracic structures that might explain signs and symptoms that overlap with ACS,” said Ethan Halpern, M.D. director of Cardiac CT at Jefferson Medical College of Thomas Jefferson University, and co-author of the study. “Furthermore, the examination time and radiation exposure are less than that required for a conventional nuclear stress test which is most often used to evaluate these patients.”

“Standard medical practice tends to be very cautious when a patient presents with symptoms suggesting ACS by performing a battery of tests and sometimes lengthy hospital stays to determine the source of pain,” adds Kevin Takakuwa, M.D., assistant professor, Department of Emergency Medicine at Jefferson Medical College of Thomas Jefferson University, and co-author of the study. “This traditional approach in diagnosis wastes millions of dollars in unnecessary health care costs, but if we can find a way to rapidly rule out ACS as early as possible and more accurately diagnose patients’ problems we can potentially save millions of dollars and a lot of time.”

Triple rule-out using coronary CT scans helped to appropriately triage patients who presented to the Jefferson Chest Pain Center, and allowed them to be discharged from the hospital earlier, with no adverse events at thirty day follow-up. This protocol to evaluate both coronary and non-coronary disease using the triple rule-out CCTA provides a new cost effective and streamlined alternative diagnostic evaluation process for potential ACS patients.