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She also tells you it was accompanied by shortness of breath. The episode resolved while she was being transported to the emergency department (ED). Her vital signs are: temperature 37.1 °C (98.8 °F), blood pressure 140/95 mm Hg, pulse rate 87 beats/minute, and respiration rate is 16/minute. Electrocardiography shows a mild right heart strain pattern with ST-T changes that may indicated ischemia; initial troponin level and D-dimer levels are both borderline. You are uncertain about pursuing a cardiac ischemia vs pulmonary embolism vs aortic dissection work-up. Which of the following imaging studies should you consider in this situation? - triple rule-out computed tomography (CT) angiogram to image the coronary arteries, pulmonary vasculature, and the aorta - computed tomography (CT) angiogram of the aorta; if negative, then admission to the observation unit for serial electrocardiography (ECG) and biomarker testing - ventilation/perfusion (V/Q) scan with aortic follow-through; if negative, then admission to the observation unit for serial electrocardiography (ECG) and biomarker testing - coronary computed tomography (CT) angiogram, followed by ventilation/perfusion (V/Q) scan if CT findings are negative The correct answer is: triple rule-out computed tomography (CT) angiogram to image the coronary arteries, pulmonary vasculature, and the aorta   **Educational Objective:** Put into practice the 2015 imaging guidelines for chest pain. **Key Point:** Sometimes patients present with such complex patterns that it is unsafe to pursue any one of the 3 classic life-threatening chest pain diagnoses (acute coronary syndrome, acute aortic syndrome, pulmonary embolism) at the exclusion of the others. In these cases, a new approach, the triple-rule out- CT angiogram, is recommended. **Explanation:** Patients who present to the ED with chest pain and a complex pattern of signs, symptoms, and clinical data (eg, difficult-to-interpret laboratory assessment, ECG findings) are traditionally placed into 1 of 3 diagnostic pathways for including/excluding 1 of 3 life-threatening problems: - Acute coronary syndrome (ACS) - Pulmonary embolism (PE) - Acute aortic syndrome (AAS) In this approach, an alternative pathway with additional imaging studies may be necessary if the initial, tentative diagnosis is unconfirmed. For this reason, such complex patients often undergo more than 1 imaging study to arrive at a diagnosis or to exclude all diagnoses considered to be life threatening. The 2015 American Heart Association guidelines on imaging patients with chest pain in the ED recommend triple rule-out CT angiography in these patients to simultaneously evaluate for ACS, PE, and AAS in a single study. Initial, small, single-center studies have reported an negative predictive value between 99.4% and 100.0%, with both image quality and diagnostic accuracy being equivalent to the dedicated individual studies (coronary CT angiogram, CT pulmonary angiogram, and CT aortogram). Triple rule-out CT angiography is obtained by starting with a coronary CT protocol and then imaging more of the chest (either from the aortic arch to the base or the entire chest) while using additional contrast to maintain pulmonary artery enhancement. This approach results in an increase in radiation dose from 25% to 150% and in contrast volume from 20% to 50%. For these reasons, dedicated CT imaging of the specific organ is still preferred over triple rule-out CT angiography when the differential diagnosis can be narrowed. The guidelines state that triple rule-out CT angiography is appropriate when the overall likelihood of ACS, PE, or AAS is not low. However, the increased diagnostic yield of triple rule-out CT angiography over dedicated coronary CT is quite small; therefore, triple rule-out CT angiography is rarely considered  appropriate (coronary CT angiogram is preferable) when the overall likelihood of both PE and AAS is low. **Reference:** Rybicki FJ, Udelson JE, Peacock WF, et al. 2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS appropriate utilization of cardiovascular imaging in emergency department patients with chest pain: a joint report of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. *J Am Coll Cardiol*. 2016;67(7):853-879.   This question appears in [Med-Challenger Emergency Nurse Practitioner Exam Review with CME](https://challengercme.com/emergency-nurse-practitioner-exam-review-cne-course) [Try for free and save](https://fuse.challengercme.com/fulltrial/187). 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The article states the 2015 imaging guidelines recommend triple-rule-out CT angiography in patients whose overall likelihood of ACS, PE, or AAS is not low and whose presentation is complex; it can evaluate all three diagnoses in a single study but increases radiation dose and contrast volume compared with dedicated imaging." }, "name" : "Which imaging study should be considered for a complex chest pain presentation when ACS, PE, and AAS cannot be excluded?", "text" : "A 79-year-old woman had a 10-minute episode of chest pain that was maximal and tearing at onset with shortness of breath; the episode resolved in transport. Vitals: T 37.1 °C, BP 140/95 mm Hg, pulse 87/min, RR 16/min. ECG shows a mild right heart strain pattern with ST-T changes that may indicate ischemia; initial troponin and D-dimer are borderline. You are uncertain about pursuing a work-up for cardiac ischemia vs pulmonary embolism vs aortic dissection. Which imaging study should you consider in this situation?" } } ``` ```json { "@context" : "https://schema.org", "@type" : "ItemList", "description" : "Exam-style review questions based on this article’s teaching points.", "itemListElement" : [ { "@type" : "ListItem", "item" : { "@type" : "Question", "acceptedAnswer" : { "@type" : "Answer", "text" : "Triple rule-out CT angiography to image coronary arteries, pulmonary vasculature, and the aorta in a single study." }, "name" : "Which imaging study is recommended for simultaneous evaluation of ACS, PE, and AAS in a complex chest pain presentation?" }, "position" : 1 }, { "@type" : "ListItem", "item" : { "@type" : "Question", "acceptedAnswer" : { "@type" : "Answer", "text" : "When the overall likelihood of ACS, PE, or AAS is not low and the patient’s clinical pattern is complex enough that excluding only one diagnosis is unsafe." }, "name" : "When do the 2015 imaging guidelines consider triple rule-out CT angiography appropriate?" }, "position" : 2 }, { "@type" : "ListItem", "item" : { "@type" : "Question", "acceptedAnswer" : { "@type" : "Answer", "text" : "Triple rule-out CT increases radiation dose (25%–150%) and contrast volume (20%–50%) compared with dedicated studies, though initial small studies report high negative predictive value and comparable image quality." }, "name" : "What are the main trade-offs of using triple rule-out CT angiography versus dedicated single-organ CT studies?" }, "position" : 3 }, { "@type" : "ListItem", "item" : { "@type" : "Question", "acceptedAnswer" : { "@type" : "Answer", "text" : "Acute coronary syndrome (ACS), pulmonary embolism (PE), and acute aortic syndrome (AAS)." }, "name" : "What are the three classic life-threatening diagnoses considered in ED chest pain pathways?" }, "position" : 4 } ], "name" : "Practice Questions", "numberOfItems" : 4 } ```