الفهرس 
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Abstract
Evaluation of chest pain in the emergency department (ED) is a public health issue of great consequence, and the differential diagnosis of chest pain is another complex challenge.
Numerous vascular and non-vascular chest problems, such as pulmonary embolism (PE), aortic dissection or acute coronary syndrome, as well as pulmonary, pleural, or osseous lesions, must be taken into account.
Nowadays, contrast-enhanced multidetector-row computed tomography (CT) has replaced previous invasive diagnostic procedures and currently represents the imaging modality of choice when the clinical suspicion of pulmonary embolism or acute aortic syndrome is raised.
Triple rule-out CT denominates an ECG-gated protocol that allows for the depiction of the pulmonary arteries, thoracic aorta, and coronary arteries within a single examination. This can be accomplished through the use of a dedicated contrast media administration regimen resulting in simultaneous attenuation of the three vessel territories.
The detection of non-coronary lesions that explain the presenting complaint, is a major advantage of the TRO CT examination over nuclear stress testing. TRO studies are most appropriate and cost-effective when there is a suspicion for acute coronary syndrome along with other diagnoses such as pulmonary embolism, acute aortic syndrome, or nonvascular disease in the thorax.
The aim of this study was assessing the validity and efficacy of triple rule-out CT in diagnosis of different vascular causes of chest pain in the emergency department.
We retrospectively reviewed the data of consecutive 50 patients who presented with acute chest pain to our emergency department at Sohag University Hospitals and at Misr Radiology Centre in new cairo during the period between January and December 2021. We included patients classified to have an intermediate risk for acute coronary syndrome (ACS) according to the TIMI score (scores between 3 and 5) (14). Contrarily, we excluded patients with high risk (TIMI score > 5), pregnancy, high creatinine level (> 1.3 mg/dl), and who reported previous allergy to the contrast media. Patients with traumatic chest pain were also excluded.
All patients were subjected to detailed history taking, physical examination and routine laboratory investigations. The triple out CT protocol in the current study was performed via a 128-multislice CT device using a 0.5 mm Detector-row dimension, 0.35 s gantry rotation, 160 mm beam width, and 175 s temporal resolution for each cross-section image.
Our results showed that:
The most common risk factor found in our studied patients was dyslipidemia that was found in 34 (68%) cases followed by hypertension in 33 (66%) cases then smoking in 28 (56%) cases and DM in 22 (44%) cases.
Regarding clinical history 14% had previous history of catheterization; one case had previous history of open-heart surgery and case had previous history of CABG. Calcium scoring was done post CABG in one stent for stent in six cases. The mean calcium scoring was 477.79± 620.8.
Regarding the cause of chest pain, 30% of cases had negative examination results without a significant coronary diagnosis to explain the acute chest pain. Half patients (50%) had a significant coronary lesion (> 70% stenosis) that could explain their presentation and 32 (64%) of them had non-significant coronary lesions. Twenty patients (40%) had a non-coronary diagnosis that could explain chest pain. Three patients (6%) had both significant coronary artery disease and a non-coronary diagnosis that could account for presentation of acute chest pain.
Sliding hernia accounted for the largest portion of non-coronary diagnoses (8/50 cases [16%]). Five patients had pulmonary artery disease. In addition, there were five cases of myocardial bridging. Other non-coronary diagnoses included aortic pathologic findings (one case had aortic dissection and one case had aortic aneurysm).
Chest examination and investigation revealed that four cases (8%) had previous COVID; one case had effusion and pneumonia, one case had moderate right pleural effusion and case had pericardial effusion.
Finally we can say that multi-detector CT (MCT) is an ideal technique to be implemented in ER departments for Triple rule out examination (chest pain protocol) and it was proved to have a very high NPV (negative predictive value) and very high sensitivity for detection all causes of chest pain as coronary artery diseases, aortic dissection, aortic aneurysm, pulmonary embolism, sliding hernias and different lung diseases as proved in this study.
Limitation
The present study has several limitations, including its retrospective nature. In addition, the results represent the patient population at two institution and may not be generalizable to patient populations at other centers. The criteria for ordering TRO CT at our institution are not standardized, and complete indications for the studies were not available for review. In particular, a complete tabulation of the risk factors and pre-test probabilities for ACS and various non-coronary diagnoses in our population was not available. Last, patient outcomes were not evaluated, limiting the conclusions that can be made about the safety and accuracy of TRO CT in our population, as well as the impact of the numerous incidental findings.
Conclusion
CT is a well-established and frequently used imaging modality to quickly diagnose various diseases in an interdisciplinary ED after filling the criteria of chest pain in new guidlines. In industrialized countries, the most common reasons for CT examination in an emergency setting are acute chest pain, CAD, and acute stroke. To address these clinical questions, standardized, symptom-oriented cardiac CT images with corresponding reconstructions are required. Many cases had a previous history of catheterization and all patients complained of chest pain with and without significant coronary disease. Chest findings show COVID 19 and effusion with pneumonia and pericardial effusion. CT is the best way for diagnosis of the cause of chest pain in the emergency department.
Recommendation
TRO-CT should therefore be considered as a valuable investigation method in the ER to diagnosis of the cause of chest pain in the emergency department.
Future studies with larger sample size and with a prospective study design needed to proven its added value.