The conclusions of this study are either ludicrous, or rather significant; the authors are either daft, or prescient. It depends fundamentally on your position regarding the utility of CT coronary angiograms.
This article describes a retrospective review of all the “Triple-Rule-Out” angiograms performed at a single center, Thomas Jefferson University Hospital, between 2006 and 2015. There were no specific circumstances under which the TRO were performed, but, grossly, the intended population were those who were otherwise being evaluated for an acute coronary syndrome but “was suspected of having additional noncoronary causes of chest pain”.
This “ACS-but-maybe-not” cohort totaled 1,192 patients over their 10 year study period. There were 970 (81.4%) with normal coronary arteries and no significant alternative diagnosis identified. The remaining, apparently to these authors, had “either a coronary or noncoronary diagnosis that could explain their presentation”, including 139 (11.7%) with moderate or severe coronary artery disease. In a mostly low-risk, troponin-negative population, it may be a stretch to attribute their symptoms to the coronary artery disease – but I digress.
The non-coronary diagnoses, the 106 (8.6%) with other findings, range from “important” to “not at all”. There were, at least, a handful of aortic dissections and pulmonary emboli picked up – though we can debate the likelihood of true positives based on pretest odds. However, these authors also credit the TRO with a range of sporadic findings as diverse as endocarditis, to diastasis of the sternum, and 24 cases of “aortic aneurysm” which were deemed important mostly because there were no priors for comparison.
The authors finally then promote TRO scans based on these noncoronary findings – stating that, if a traditional CTCA were performed, many of these diagnosis would likely be missed. Thus, the paradox. If you are already descending the circles of hell, and are using CTCA in the Emergency Department – then, yes, it is reasonable to suggest the TRO is a valid extension of the CTCA. Then again, if CTCA in the acute setting is already outside the scope of practice, and TRO is an abomination – carry on as if this study never existed.
“Diagnostic Yield of Triple-Rule-Out CT in an Emergency Setting”
http://www.ncbi.nlm.nih.gov/pubmed/27186867
Sorry I use this thread , but comments are closed on the appropriate ones (HEART Score) .
I’ a bit puzzled that some scores HEARt for instance, includes traditional chronic risk factors for coronary disease, which ave been reported roughly useless (1,2), and yet performs well.
What do you think about that discrepancy ?
The risk factors in HEART are
Hypercholesterolemia
Hypertension
Diabetes Mellitus
Cigarette smoking
Positive family history
Obesity
History of atherosclerotic is another story and plays as a heavyweight in the score.
1- https://www.ncbi.nlm.nih.gov/pubmed/17145112
2- https://www.ncbi.nlm.nih.gov/pubmed/18691797
I agree – traditional risk factors are great for predicting CAD, but not as good for predicting an ACS. CAD, after all, comes in many forms with regard to plaque stability and flow limitation. When Erlanger did their HEARTS3 score, they un-weighted those elements in deference to other issues like abnormal EKGs, HPI elements, and troponin (and serial troponin) testing. EDACS seems to hew more closely to the JAMA Rational Clinical Exam for ACS, which is why I ultimately expect that might eventually replace HEART.