• Thomas Schertler, Thomas Frauenfelder, Paul Stolzmann, Hans Scheffel, Lotus Desbiolles, Borut Marincek, Vladimir Kaplan, Nils Kucher, and Hatem Alkadhi.
• Institute of Diagnostic Radiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland.
• Acad Radiol. 2009 Jun 1;16(6):708-17.

Rationale And ObjectivesThe aim of this study was to prospectively investigate the diagnostic value of triple rule-out computed tomography (CT) in patients suspected of having acute pulmonary embolism (PE).Materials And MethodsA total of 125 patients with suspicion of PE, of whom 14 patients had the additional clinical suspicion of acute aortic syndrome, underwent electrocardiogram-gated triple rule-out dual-source CT. The contrast media application protocol was adjusted to obtain a homogenous attenuation of the pulmonary arteries, thoracic aorta, and coronary arteries. The diagnostic performance of triple rule-out CT was assessed by using adjudicated discharge diagnoses as reference standards.ResultsA total of 161 adjudicated cardiovascular discharge diagnoses were made in the 125 patients (including all true-positive and true-negative findings): acute PE was found in 26 (21%) and was excluded by CT in 99 (79%), coronary artery disease was found in 3 (3%) and was excluded by catheter angiography in 9 (6%), left ventricular systolic dysfunction was found in 2 (2%) and was excluded by echocardiography in 8 (6%), and acute aortic syndrome was found in 5 (4%) and was excluded by CT in 9 (7%) patients. Nonvascular chest disease was found in 34 (27%) and included pneumonia (n = 17), neoplasms (n = 5), fractures/osteolysis (n = 3), pericarditis (n = 2), and post-pneumonectomy syndrome (n = 1). Triple rule-out CT was normal in 53 (42%) patients. Overall sensitivity, specificity, and positive and negative predictive value of triple rule-out CT for cardiovascular disease were 100% (95% confidence interval [CI] 90-100%), 98% (95%CI 94-100%), 95% (95%CI 82-99%), and 100% (95%CI 97-100%, respectively).ConclusionsTriple rule-out CT is feasible in patients with suspicion of PE, reveals a wide range of vascular and non-vascular chest disease, and offers an excellent overall diagnostic performance.

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