Triple Rule-out Computed Tomographic Angiography for Chest Pain: A Diagnostic Systematic Review and Meta-Analysis

The objective was to compare the image quality, diagnostic accuracy, radiation exposure, and contrast volume of “triple rule-out” (TRO) computed tomography (CT) to other diagnostic modalities commonly used to evaluate patients with nontraumatic chest pain (dedicated coronary, pulmonary embolism [PE], and aortic dissection CT; invasive coronary angiography; and nuclear stress testing). Four electronic databases were searched, along with reference lists and contacted content experts, for relevant studies from inception until October 2012. Eligible studies enrolled patients with nontraumatic chest pain, shortness of breath, suspected acute coronary syndrome (ACS), PE, or aortic dissection; used at least 64-slice CT technology; and compared TRO CT to another diagnostic modality. Eleven studies enrolling 3,539 patients (791 TRO and 2,748 non-TRO) were included (one randomized controlled trial and 10 observational). There was no significant difference in image quality between TRO and dedicated CT scans. TRO CT had the following pooled diagnostic accuracy estimates for coronary artery disease: sensitivity of 94.3% (95% confidence interval [CI] = 89.1% to 97.5%), specificity of 97.4% (95% CI = 96.1% to 98.4%), positive likelihood ratio (LR+) of 17.71 (95% CI = 3.92 to 79.96), and negative likelihood ratio (LR–) of 0.08 (95% CI = 0.02 to 0.27). There were insufficient numbers of patients with PE or aortic dissection to generate diagnostic accuracy estimates for these conditions. Use of TRO CT involved greater radiation exposure (mean difference [MD] = 4.84 mSv, 95% CI = 1.65 to 8.04 mSv) and contrast exposure (MD = 38.0 mL, 95% CI = 28.1 to 48.0 mL) compared to non-TRO CT patients. Triple rule-out CT is highly accurate for detecting coronary artery disease. Given the low (<1%) prevalence of PE and aortic dissection in the included studies, and the increased radiation and contrast exposure, there are insufficient data to recommend use of TRO CT in the diagnosis of these conditions. Comparar la calidad de imagen, la certeza diagnóstica, la exposición a radiación y el volumen de contraste de la tomografía computarizada (TC) para “triple descarte” (TD) con otras modalidades diagnósticas utilizadas frecuentemente para evaluar a los pacientes con dolor torácico no traumático (TC dirigida a coronarias, embolismo pulmonar (EP) y disección aórtica; angiografía coronaria invasiva; pruebas de estrés isotópicas). Se buscaron los estudios relevantes publicados hasta octubre de 2012 en cuatro bases de datos electrónicas, en las listas de la bibliografía y en los expertos de contenido contactados. Los estudios elegibles incluyeron pacientes con dolor torácico no traumático, disnea, sospecha de síndrome coronario agudo, EP o disección aórtica; utilizaron TC con tecnología de al menos 64 cortes; y compararon la TC TD con otra modalidad diagnóstica. Se incluyeron once estudios (uno aleatorizado y 10 observacionales) con 3.599 pacientes (791 TD y 2.748 no TD). No hubo diferencias significativas en la calidad de la imagen entre TC TD y los dirigidos. La TC TD tuvo las siguientes estimaciones de certeza diagnóstica para la enfermedad de las arterias coronarias: sensibilidad 94,3% (intervalo de confianza [IC] 95% = 89,1% a 97,5%), especificidad 97,4% (IC 95% = 96,1% a 98,4%), razón de probabilidad positiva 17,71 (IC 95% = 3,92 a 79,96), y razón de probabilidad negativa 0,08 (IC 95% = 0,02 a 0,27). No hay suficiente número de pacientes con EP o disección aórtica para generar estimaciones de certeza diagnóstica para estas enfermedades. La utilización de la TC TD supuso una mayor exposición a la radiación (diferencia de la media [DM] 4,84 mSv, IC 95% = 1,65 a 8.04 mSv) y al contraste (DM 38,0 mL, IC 95% = 28,1 a 48,0 mL) en comparación con los pacientes con una TC no TD. La TC TD es altamente certera para detectar la enfermedad coronaria. Dada la baja prevalencia (<1%) de EP y de disección aórtica en los estudios incluidos, y el incremento de radiación y exposición a contraste, no hay suficientes datos para recomendar el uso de TC TD en el diagnóstico de estas dos enfermedades. Chest pain is the second most common reason patients present to emergency departments (EDs) across the United States and accounts for over 6 million annual visits.1 Information obtained from the history, physical examination, electrocardiogram (ECG), and cardiac biomarkers is often insufficient for clinicians to safely distinguish patients who require further testing or hospital admission from those who can be safely discharged from the ED. This leads to high rates of testing and negative inpatient cardiac evaluations in low-risk patients,2 with admission rates as high as 96% reported in a recent investigation.3 “Triple rule-out” (TRO) coronary computed tomography (CT) angiography has recently emerged as a technology that noninvasively evaluates the coronary arteries and simultaneously visualizes the pulmonary arteries, thoracic aorta, and other intrathoracic structures. TRO CT, which has potential to identify both coronary and other life-threatening etiologies of chest pain such as coronary stenosis, pulmonary embolism (PE), and aortic dissection, is emerging as a diagnostic modality in some clinical settings for patients at low to moderate risk for acute coronary syndromes (ACS) in whom PE or aortic dissection are also being considered in the differential diagnosis. To perform TRO CT, either ECG-gated 64-slice multidetector or dual-source CT technology is required.4 Dual-source CT uses two x-ray tubes and two detectors arranged at 90° angles, allowing reconstruction of cross-sectional images at one-quarter of the gantry rotation time and improving the temporal resolution and diagnostic image quality of coronary artery examinations without requiring preexamination β-blockade.5 Currently, there is a paucity of data comparing the performance of the TRO CT to other diagnostic imaging modalities commonly used to evaluate patients with chest pain such as nuclear perfusion imaging, coronary CT angiography, or dedicated PE or aortic dissection CT. As TRO CT becomes increasingly available as a diagnostic imaging modality to evaluate patients with chest pain, it will be critical for emergency physicians to know its potential utility in practice. The objective of this study was to compare the image quality, diagnostic accuracy, radiation exposure, and contrast volume of TRO CT to other diagnostic modalities commonly used to evaluate patients with nontraumatic chest pain. This was a systematic review and meta-analysis, and it adheres to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) as applicable to diagnostic accuracy reviews.6 We included original research studies that enrolled adults with nontraumatic chest pain; shortness of breath; or symptoms suggestive of ACS, PE, or aortic dissection that used 64-slice CT technology (or greater) to compare TRO CT to another diagnostic modality. Studies that enrolled patients under 18 years of age or trauma patients were excluded. An expert librarian (PJE) designed a comprehensive search strategy with input from the clinical lead author (EPH). The electronic search included Ovid MEDLINE, Ovid EMBASE, Web of Science, and Scopus from inception until October 2012 (see Data Supplement S1, available as supporting information in the online version of this paper, for the MEDLINE search strategy). We made adjustments to the search strategy to account for differences in indexing between databases. Web of Science and Scopus depend heavily on text words, so acronyms were included in the strategies. We did not apply a language restriction to the search strategy. We also reviewed the “related citations” section of PubMed and reference lists of included studies and contacted a content expert (JEH) to identify additional articles for review. Two investigators (DA, MFB) independently screened the titles and abstracts of all records identified from the search strategy (phase I). If either reviewer thought the study might be eligible, we obtained the full report. The same two investigators then independently assessed the eligibility of each full report (phase II). We used Cohen's unweighted kappa to measure chance corrected agreement between reviewers for each phase of study selection. Any disagreements were discussed with the clinical lead author (EPH) and resolved by consensus. Data regarding study quality were abstracted for each study by one author (MFB). We assessed the quality of randomized clinical trials with the Cochrane Collaboration's tool for assessing risk of bias.7 The quality of case–control and cohort studies was assessed with the Newcastle-Ottawa quality assessment scale,8 and the quality of studies of diagnostic accuracy with the revised Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool.9 One author (DA) extracted data from each included article using a standardized data extraction form. Data were reviewed for accuracy by another author (MFB). We extracted the following data from each study: study design, patient demographics, imaging technology and parameters, and the clinical setting. Data were also extracted for both TRO CT and control study populations to assess diagnostic accuracy, image quality, radiation exposure, contrast volume, imaging time, cost, length of stay (LOS), and admission rate. When data were not sufficiently reported, we contacted the corresponding study author by e-mail twice over a period of 2 weeks to acquire missing information. Image quality was assessed using different scales across the studies. Therefore, we standardized these scores by dividing the difference in means by its standard deviation (i.e., made the scales unitless). The standardized difference in means10 is comparable across studies and can be expressed as an odds ratio (OR) and pooled using a random effects model11 as implemented in comprehensive meta-analysis (version 2, Biostat, Englewood, NJ). Results are presented as ORs with values over 1.00 indicating better image quality with TRO. Diagnostic accuracy measures were pooled using random-effect meta-analysis as implemented in MetaDiSc12 and also tested in a bivariate mixed effects regression model.13 Continuous outcomes were pooled as a difference in means using a random-effects model as implemented in RevMan (version 5.1, Cochrane Collaboration).14 Heterogeneity was assessed using the I2 statistic.15 Figure 1 shows the study selection process. The search strategy yielded 733 records. Of these, 692 were not relevant to the study question and were excluded. Review of the titles and abstracts in phase I identified 41 potentially relevant studies for further review. Of the 41 articles, 38 were in English, two were in Chinese,16, 17 and one was in German.18 The Chinese articles were reviewed for eligibility by a physician who was fluent in Chinese (see acknowledgements). After further review of the title and abstract, the German article was found to include a subset of the same cohort published in another article19 and was excluded. Seven articles were excluded because they compared different CT protocols instead of comparing TRO CT to a separate diagnostic modality.20-26 Nine studies did not compare the TRO CT to another control group.16, 17, 27-33 Four articles did not involve TRO CT but focused on CT for PE or coronary artery imaging instead.34-37 A total of 11 studies were included in the systematic review. Observed agreement for phase II of the review was 92.7% with a kappa of 0.81 (95% CI = 0.60 to 1.02). Table 1 describes the 11 included studies, which enrolled 3,539 patients (791 TRO CT [intervention] and 2,748 patients receiving another diagnostic modality [control]). Seven studies had case–control designs, three had cohort designs, and one was a randomized clinical trial. In six studies,38-43 the cohort consisted of patients at low to intermediate risk for ACS; in four studies,44-47 the patients had undifferentiated chest pain with suspicion for PE, aortic dissection, or ACS; and in one study,42 the cohort consisted of a subset of patients who underwent both TRO CT and invasive angiography (see Data Supplement S2, available as supporting information in the online version of this paper, for a complete description of the eligibility criteria for each of the included studies). The diagnostic modalities to which TRO CT was compared included nuclear stress testing,38 dedicated PE CT, aortic dissection CT,44, 45, 47 dedicated coronary CT,40, 43, 45, 46 and coronary angiography.19, 39, 41, 48 Four studies compared the diagnostic accuracy of TRO CT to coronary angiography,19, 39, 41, 42 and the remaining seven studies reported a number of outcomes including utilization (LOS, cost, and admission rate) and technology-specific outcomes (image quality, radiation exposure, and volume of contrast administered). One study evaluated a composite yield for the diagnosis of coronary artery disease (CAD), PE, or aortic dissection.47 Six studies used 64-slice CT technology, four studies used dual-source CT,19, 39, 43, 44 and one study included 64-slice CT technology and dual-source CT.47 Four of the six studies that used 64-slice CT technology used beta blockers to slow the heart rate and improve image quality. One study performed D-dimer measurements in all the patients and performed TRO CT instead of coronary CT angiography in those with elevated D-dimer.43 There were 13.9% in the TRO group and no patients in the coronary CT angiography group with PE. Table 2 shows patient demographics by intervention and control arm. Patients were predominantly men with a mean age of 49 to 67 years. The intervention and control groups were well balanced in regard to age, sex, and body mass index, where reported. The one randomized clinical trial included in the review did not report blinding of the participants or outcome assessors, but otherwise met criteria for appropriate sequence generation, allocation concealment, and outcome reporting.44 Table 3 shows the quality assessment for the case–control and cohort studies according to the Newcastle-Ottawa scale for case–control and cohort studies (maximum score of 9). The studies by Shapiro and colleagues,45 Madder and colleagues,47 and Gruettner and colleagues43 received scores of 6*, and the study by Takakuwa and colleagues38 a score of 5*; the remaining studies received scores of 2*, suggesting a substantial risk for bias. Table 4 shows the QUADAS-2 scores for the four diagnostic accuracy studies. All the studies were at a high risk of in and because not all the patients received the reference standard a group of patients TRO CT also underwent coronary Two studies did not report blinding to the of the reference standard the of the of the four studies the patient cohort and were at low risk of 39, 42 of the studies were as low risk for regarding the of the studies. Four studies evaluated the image quality of TRO CT compared to dedicated CT Image quality was not different between the two groups = 95% CI = to I2 = When the two studies with the quality scores were from the 46 the pooled was Four studies evaluated the diagnostic accuracy of TRO CT using coronary angiography as the standard for the of 39, 41, 42 In each of these studies a subset of the cohort underwent TRO CT by coronary angiography, with each patient as or The pooled diagnostic accuracy estimates were sensitivity of 94.3% (95% CI = 89.1% to I2 = specificity of 97.4% (95% CI = 96.1% to I2 = positive likelihood ratio (LR+) of 17.71 (95% CI = 3.92 to I2 = and negative likelihood ratio (LR–) of 0.08 (95% CI = 0.02 to I2 = and specificity estimates obtained using a bivariate regression model estimates with 95% One reported no difference in the of patients with with TRO CT compared to coronary angiography = but did not report diagnostic accuracy estimates comparing the two There were patients with 43, 44 In each patients were considered to PE without by dedicated CT for PE or invasive pulmonary angiography standard so diagnostic accuracy data were not reported. There were no patients with aortic dissection the included studies. studies data on radiation exposure that were to meta-analysis A total of patients were patients in the TRO CT group and patients in the control Patients who underwent TRO CT were to radiation (mean difference [MD] = 4.84 mSv, 95% CI = 1.65 to 8.04 this was with significant = the of that TRO CT was with radiation exposure in all studies. When the study with the quality was from the the pooled was and the was studies data on contrast volume A total of patients were patients in the TRO group and patients in the control Patients TRO CT received greater of contrast (MD = 38.0 mL, 95% CI = 28.1 to 48.0 this was with significant = the of that TRO CT was with a greater volume of contrast in all studies. When the study with the quality was from the the pooled was Two of the 11 studies reported data on 44 Takakuwa and colleagues38 reported compared to patients who underwent nuclear stress TRO CT patients had mean of stay (MD = 95% CI = to and who compared TRO CT to dedicated PE, aortic dissection, or coronary CT, did not a significant difference in the for TRO CT compared to dedicated CT = Two studies reported data on 44 TRO CT an of compared to for nuclear stress testing and reported a for TRO CT, the difference was not significant for TRO CT for dedicated CT; = One study an comparing the use of TRO CT to a that involved hospital admission and invasive coronary angiography for of coronary artery in patients at intermediate risk for The of patient was in the TRO CT group compared to the standard group In the of patients with significant coronary artery stenosis, the TRO CT group had a of the standard group Takakuwa and reported that patients receiving TRO CT were to be to the hospital compared to patients receiving nuclear stress testing 95% CI = to and did not a significant difference in the rate of hospital admission for TRO compared to dedicated CT = there were insufficient data reported on cost, and admission rate to Triple rule-out CT was found to be highly accurate for the diagnosis of emergency physicians be most in the diagnosis of ACS, a TRO CT is obtained in a patient with nontraumatic chest pain and no significant coronary are is The is not a patient with a potentially significant coronary on TRO CT require invasive coronary angiography to the coronary which additional radiation and contrast We greater radiation exposure with TRO CT in with a of this of additional radiation is the radiation exposure from commonly performed CT from 2 to for a and it is not for radiation to the with risk in radiation exposure can over imaging that use radiation be there is a to A of can be to additional contrast it is an additional 38 of contrast the risk of the of with chest CT is not and be made to the of contrast to patients to the risk of The number of of PE and aortic dissection in each of the studies was low to compare the diagnostic accuracy of TRO to dedicated CT. the data in this review that the image quality between TRO and dedicated CT is at this in time there are insufficient data to the use of TRO CT for the diagnosis of PE or aortic the increased radiation and contrast exposure and of diagnostic accuracy data for PE and aortic dissection, there are no to recommend use of TRO CT in the diagnosis of these conditions. The of the studies included in the review enrolled patients with chest pain at low to moderate risk for four of the 10 studies enrolled patients with chest pain suspected to be to PE or aortic dissection, and the prevalence of these was To the utility of TRO CT in clinical studies will to the prevalence of each of these three to the study to to compare the diagnostic accuracy of TRO CT to dedicated PE and aortic dissection CT. In to patient trials a number of outcomes of such as diagnostic accuracy, cost, of and the clinical yield and of to outcomes will to be to generate relevant to patients. Diagnostic randomized controlled trials in which patients are randomized to TRO CT or to a diagnostic modality commonly used in to outcomes the diagnostic accuracy measures such as sensitivity and and on an to will be critical to the of diagnostic on outcomes that to such as and The of this review included a search strategy that involved four electronic the of the included articles, and with a content expert and of the included studies. This the potential for bias. We contacted study to data not included in the original We also used in the including assessment of for study selection. was This systematic review and meta-analysis was by the number of studies included in the review. The of reported in each of the studies with regard to patient was as of the studies were published in the and were focused on technology patient In some studies a subset of control patients underwent reference standard diagnostic the risk of bias. Two control 46 were of quality. As by the of the of and sensitivity be these studies. If the pooled and the such studies be excluded. In the of this meta-analysis were to these the body of and a there was in the of radiation and contrast exposure, estimates in each of the studies were in the same supporting greater radiation and contrast exposure with TRO CT. There were patients with PE the included 43, 44 and no of aortic dissection, to generate regarding the diagnostic accuracy of TRO CT for PE or aortic Triple rule-out computed tomography is highly accurate for detecting coronary artery disease. Given the low (<1%) prevalence of pulmonary embolism and aortic dissection in the included studies, and the increased radiation and contrast exposure, there are insufficient data to recommend use of rule-out computed tomography in the diagnosis of these conditions. The in the Chinese articles identified in the of the review. The is not for the content or of supporting information by the Any missing be to the corresponding author for the

Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.