ON THE COVER Triple Rule In. Advocates have hailed 64-slice multidetector CT as a method to identify the 3 most important lethal causes of chest pain in the emergency room: myocardial ischemia, aortic dissection, and pulmonary embolism. This has been referred to as the "triple rule-out." A 77-year-old man with coronary artery disease presented with a 2-week history of worsening dyspnea on exertion following a 4-h episode of chest pain. On presentation, the patient was noted to be hypertensive with a systolic blood pressure of 160/100 mm Hg, a pulse of 110 beats/min, and respirations of 30. Left carotid pulses were faint compared to right carotid pulses, and both femoral pulses were weak. Chest radiography revealed cardiomegaly with a prominent aortic arch and widened mediastinum. He was referred for urgent thoracic CT with contrast. The patient had evidence of an extensive Stanford Type A aortic dissection and severe 3-vessel coronary artery disease with 4 patent grafts, all arising from the true lumen, as shown in A, a 3-D volume-rendered image. There was also evidence of an acute pulmonary embolism, with a filling defect seen in the right main pulmonary artery (arrow in B). Both true and false lumens are demonstrated (TL and FL). (C) Axial CT slice demonstrating extensive coronary artery disease in the left anterior descending coronary artery (arrow). The patient underwent lower extremity duplex ultrasound which showed evidence of deep venous thrombosis in the right common femoral vein. He eventually underwent placement of an inferior vena cava filter and had uneventful surgical repair of the aortic dissection. Images provided by Swaminatha V. Gurudevan, MD, Farhood Saremi, MD, Shaista Malik, MD, PhD, Jeffrey C. Milliken, MD, Jagat Narula, MD, PhD, from the Division of Cardiology, University of California, Irvine School of Medicine, Irvine, California

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