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Limits of the possible: diagnostic image quality in coronary angiography with third-generation dual-source CT. Clin Res Cardiol 2017; 106:485-492. [PMID: 28168514 DOI: 10.1007/s00392-017-1077-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 01/10/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND The usage of coronary CT angiography (CTA) is appropriate in patients with acute or chronic chest pain; however the diagnostic accuracy may be challenged with increased Agatston score (AS), increased heart rate, arrhythmia and severe obesity. Thus, we aim to determine the potential of the recently introduced third-generation dual-source CT (DSCT) for CTA in a 'real-life' clinical setting. METHODS Two hundred and sixty-eight consecutive patients (age: 67 ± 10 years; BMI: 27 ± 5 kg/m²; 61% male) undergoing clinically indicated CTA with DSCT were included in the retrospective single-center analysis. A contrast-enhanced volume dataset was acquired in sequential (SSM) (n = 151) or helical scan mode (HSM) (n = 117). Coronary segments were classified in diagnostic or non-diagnostic image quality. A subset underwent invasive angiography to determine the diagnostic accuracy of CTA. RESULTS SSM (96.8 ± 6%) and HSM (97.5 ± 8%) provided no significant differences in the overall diagnostic image quality. However, AS had significant influence on diagnostic image quality exclusively in SSM (B = 0.003; p = 0.0001), but not in HSM. Diagnostic image quality significantly decreased in SSM in patients with AS ≥2,000 (p = 0.03). SSM (sensitivity: 93.9%; specificity: 96.7%; PPV: 88.6%; NPV: 98.3%) and HSM (sensitivity: 97.4%; specificity: 94.3%; PPV: 86.0%; NPV: 99.0%) provided comparable diagnostic accuracy (p = n.s.). SSM yielded significantly lower radiation doses as compared to HSM (2.1 ± 2.0 vs. 5.1 ± 3.3 mSv; p = 0.0001) in age and BMI-matched cohorts. CONCLUSION SSM in third-generation DSCT enables significant dose savings and provides robust diagnostic image quality in patients with AS ≤2000 independent of heart rate, heart rhythm or obesity.
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Canceled coronary computed tomography angiography: Downstream testing and outcomes. Int J Cardiol 2017; 227:457-461. [DOI: 10.1016/j.ijcard.2016.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 11/03/2016] [Indexed: 01/07/2023]
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53
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CT Determination of Fractional Flow Reserve in Coronary Lesions. JOURNAL OF INTERDISCIPLINARY MEDICINE 2016. [DOI: 10.1515/jim-2016-0070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Invasively determined fractional flow reserve (FFR) represents the gold-standard method for the functional evaluation of coronary lesions. Coronary computed tomography angiography (CCTA) provides characterization of the coronary anatomy, with important morphological information on the atherosclerotic plaques, but does not offer a hemodynamic evaluation of coronary artery lesions. CT evaluation of FFR (FFRCT) is a new noninvasive diagnostic method, which provides anatomical and functional assessment of the whole coronary tree, based on computational techniques, with no more radiation or hyperemic agent administration compared with routine CCTA. Recent studies demonstrated the safety and accuracy of FFRCT and its therapeutic use and cost benefits in real-world clinical use.
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Cecere A, Riccioni G, Sforza N, Marano R, Guglielmi G. Coronary artery calcium score and coronary computed tomography angiography for patients with asymptomatic polyvascular (non-coronary) atherosclerosis. Singapore Med J 2016; 58:528-534. [PMID: 27957585 DOI: 10.11622/smedj.2016186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The primary endpoint of this study was to determine the prevalence of coronary artery disease (CAD) and coronary artery calcium score (CACS) using coronary computed tomography angiography (CCTA) among patients with polyvascular atherosclerosis (PVA). Secondary endpoints were to evaluate the prevalence of cardiovascular risk factors and determine the predictors of PVA. METHODS The presence of atherosclerotic disease was assessed using ultrasonographic vascular examination in 515 asymptomatic patients. All patients with presence of stenosis over 50% and moderate-to-severe cardiovascular risk profile underwent CCTA to identify atherosclerotic coronary disease. RESULTS Among 515 participants, 143 patients had no evidence of atherosclerotic plaque. Of the 372 patients with atherosclerotic plaque, 184 patients had single-vessel disease, 111 patients had double-vessel disease and 77 patients had triple-vessel disease; among these patients, those who also presented with stenosis > 50% underwent CCTA. Coronary stenosis categories included: normal (6.4%); haemodynamically insignificant (34.6%); intermediate (28.7%); significant (26.6%); and total artery occlusion (3.7%). Based on the coronary vessel involved, the patients were categorised as having single- (41.0%), double- (42.0%) or triple- (17.0%) coronary disease. CACS was significantly higher in patients with double- or triple-vessel disease when compared to those with single-vessel disease. CONCLUSION Our study confirmed not only the high sensitivity of CCTA for highlighting CAD, but also its negative predictive value for excluding the presence of coronary stenosis or ischaemia. We found good correlation between PVA and CACS, and were able to confirm the risk factors for PVA.
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Affiliation(s)
| | - Graziano Riccioni
- Intensive Cardiology Care Unit, San Camillo de Lellis Hospital, Italy
| | - Nicola Sforza
- Department of Radiology, Scientific Institute Hospital, Casa Sollievo della Sofferenza, Italy
| | - Riccardo Marano
- Department of Bioimaging and Radiological Sciences, Institute of Radiology, Catholic University, Italy
| | - Giuseppe Guglielmi
- Department of Radiology, University of Foggia, Italy.,Department of Radiology, Scientific Institute Hospital, Casa Sollievo della Sofferenza, Italy
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Carrascosa P, Leipsic JA, Deviggiano A, Capunay C, Vallejos J, Goldsmit A, De Zan MC, Rodriguez-Granillo GA. Virtual Monochromatic Imaging in Patients with Intermediate to High Likelihood of Coronary Artery Disease: Impact of Coronary Calcification. Acad Radiol 2016; 23:1490-1497. [PMID: 27622565 DOI: 10.1016/j.acra.2016.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 08/02/2016] [Accepted: 08/04/2016] [Indexed: 01/26/2023]
Abstract
RATIONALE AND OBJECTIVES We sought to explore the image quality and diagnostic performance of virtual monochromatic imaging derived from dual-energy computed tomography coronary angiography (DE-CTCA) in patients with intermediate to high likelihood of coronary artery disease (CAD) and the influence of calcification. MATERIALS AND METHODS Consecutive symptomatic patients with suspected CAD referred for invasive coronary angiography who underwent DE-CTCA and a coronary artery calcium scoring before the invasive procedure comprised the study population. RESULTS Sixty-seven patients were included. Image quality was significantly lower at 45 keV reconstructions (mean Likert score 45 keV 3.57 ± 0.6, 65 keV 4.07 ± 0.5, and 85 keV 4.09 ± 0.6; P < .0001). Patients with moderate calcification showed a trend toward a significant improvement in the diagnostic performance with 65 keV vs 45 keV reconstructions (45 keV, area under the curve 0.92 [95% confidence interval 0.89-0.95] vs 65 keV, area under the curve 0.96 [95% confidence interval 0.93-0.98], P = .06). The diagnostic performance of DE-CTCA was significantly lower in segments with higher coronary artery calcium scoring compared to segments with none or mild calcification, independent of the energy level applied. CONCLUSIONS In patients with intermediate to high likelihood of CAD, DE-CTCA had a good diagnostic performance, although significantly lower in segments with severe calcification.
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Affiliation(s)
- Patricia Carrascosa
- Department of Cardiovascular Imaging, Diagnóstico Maipú, Av Maipú 1668, Vicente López (B1602ABQ), Buenos Aires, Argentina.
| | | | - Alejandro Deviggiano
- Department of Cardiovascular Imaging, Diagnóstico Maipú, Av Maipú 1668, Vicente López (B1602ABQ), Buenos Aires, Argentina
| | - Carlos Capunay
- Department of Cardiovascular Imaging, Diagnóstico Maipú, Av Maipú 1668, Vicente López (B1602ABQ), Buenos Aires, Argentina
| | - Javier Vallejos
- Department of Cardiovascular Imaging, Diagnóstico Maipú, Av Maipú 1668, Vicente López (B1602ABQ), Buenos Aires, Argentina
| | - Alejandro Goldsmit
- Department of Interventional Cardiology, Sanatorio Guemes, Buenos Aires, Argentina
| | - Macarena C De Zan
- Department of Cardiovascular Imaging, Diagnóstico Maipú, Av Maipú 1668, Vicente López (B1602ABQ), Buenos Aires, Argentina
| | - Gaston A Rodriguez-Granillo
- Department of Cardiovascular Imaging, Diagnóstico Maipú, Av Maipú 1668, Vicente López (B1602ABQ), Buenos Aires, Argentina
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Yoshioka K, Tanaka R, Nagata K, Sasaki T, Takeda K, Ueda T, Sugawara T, Ueyama Y, Chiba T, Sasaki A, Kikuchi K. Modified Subtraction Coronary CT Angiography Method for Patients Unable to Perform Long Breath-Holds: A Preliminary Study. Acad Radiol 2016; 23:1170-5. [PMID: 27426980 DOI: 10.1016/j.acra.2016.04.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 04/15/2016] [Accepted: 04/17/2016] [Indexed: 11/28/2022]
Abstract
RATIONALE AND OBJECTIVES Severe calcifications of the coronary arteries are still a major challenge in coronary computed tomography (CT) angiography (CCTA). Subtraction CCTA using a 320-detector row CT scanner has recently been introduced for patients with severe calcifications. However, the conventional subtraction CCTA method requires a long breath-holding time of approximately 20-40 seconds. This is a major problem in clinical practice because many patients may not be able to perform such a long breath-hold. We explored a modified subtraction CCTA method with a short breath-holding time to overcome this problem. MATERIALS AND METHODS This study was approved by our institutional review board, and all patients gave written informed consent. A total of 12 patients with a coronary calcium score of >400 were enrolled in this study. All patients were unable to hold their breath for more than 20 seconds. Modified subtraction CCTA was performed using the bolus-tracking method. The acquisition protocol was adjusted so that the mask scan was acquired 10 seconds after the postcontrast scan during a single breath-hold. The subtraction image was obtained by subtracting the mask image data from the postcontrast image data. The breath-holding times were recorded. Enhancement of the coronary arteries in the subtraction images was assessed. Subjective image quality was evaluated in a total of 32 segments using a 4-point scale. RESULTS The mean breath-holding time was 12.8 ± 0.8 seconds (range, 12-14 seconds). The average CT number in the coronary arteries was 288.6 ± 80.5 Hounsfield units (HU) in the subtraction images. Average image quality was significantly increased from 2.1 ± 0.9 with conventional CCTA to 3.1 ± 0.7 with subtraction CCTA (P < 0.001). With subtraction CCTA, the number of non-diagnostic segments was significantly reduced from 53% to 19% (P = 0.001). CONCLUSIONS This preliminary study has shown that our modified subtraction CCTA method allows the breath-holding time to be shortened to <15 seconds. This may substantially improve the success rate of subtraction CCTA by reducing artifacts and allowing this technique to be applied to patients who are unable to perform a long breath-hold.
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Affiliation(s)
- Kunihiro Yoshioka
- Division of Cardiovascular Radiology, Department of Radiology, Iwate Medical University, 19-1 Uchimaru, Morioka 020-8505, Japan.
| | - Ryoichi Tanaka
- Division of Cardiovascular Radiology, Department of Radiology, Iwate Medical University, 19-1 Uchimaru, Morioka 020-8505, Japan
| | - Kyouhei Nagata
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University, Morioka, Japan
| | - Tadashi Sasaki
- Center for Radiological Science, Iwate Medical University Hospital, Morioka, Japan
| | - Kouta Takeda
- Center for Radiological Science, Iwate Medical University Hospital, Morioka, Japan
| | - Takanori Ueda
- Center for Radiological Science, Iwate Medical University Hospital, Morioka, Japan
| | - Tsuyoshi Sugawara
- Center for Radiological Science, Iwate Medical University Hospital, Morioka, Japan
| | - Yuta Ueyama
- Center for Radiological Science, Iwate Medical University Hospital, Morioka, Japan
| | - Takuya Chiba
- Center for Radiological Science, Iwate Medical University Hospital, Morioka, Japan
| | - Akinobu Sasaki
- Center for Radiological Science, Iwate Medical University Hospital, Morioka, Japan
| | - Kei Kikuchi
- Center for Radiological Science, Iwate Medical University Hospital, Morioka, Japan
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Influence of the coronary calcium score on the ability to rule out coronary artery stenoses by coronary CT angiography in patients with suspected coronary artery disease. J Cardiovasc Comput Tomogr 2016; 10:343-50. [DOI: 10.1016/j.jcct.2016.07.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 07/15/2016] [Indexed: 11/23/2022]
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Budoff MJ, Min JK. FFR Derived From Coronary CT Angiography: Solving the Calcification Dilemma of Coronary CT Angiography. JACC Cardiovasc Imaging 2016; 8:1056-1058. [PMID: 26381767 DOI: 10.1016/j.jcmg.2015.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 06/18/2015] [Indexed: 11/19/2022]
Affiliation(s)
- Matthew J Budoff
- Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California.
| | - James K Min
- Departments of Radiology and Medicine, Weill Cornell Medical College, New York, New York; Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital, New York, New York
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Nakanishi R, Budoff MJ. Noninvasive FFR derived from coronary CT angiography in the management of coronary artery disease: technology and clinical update. Vasc Health Risk Manag 2016; 12:269-78. [PMID: 27382296 PMCID: PMC4922813 DOI: 10.2147/vhrm.s79632] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
After a decade of clinical use of coronary computed tomographic angiography (CCTA) to evaluate the anatomic severity of coronary artery disease, new methods of deriving functional information from CCTA have been developed. These methods utilize the anatomic information provided by CCTA in conjunction with computational fluid dynamics to calculate fractional flow reserve (FFR) values from CCTA image data sets. Computed tomography-derived FFR (CT-FFR) enables the identification of lesion-specific drop noninvasively. A three-dimensional CT-FFR modeling technique, which provides FFR values throughout the coronary tree (HeartFlow FFRCT analysis), has been validated against measured FFR and is now approved by the US Food and Drug Administration for clinical use. This technique requires off-site supercomputer analysis. More recently, a one-dimensional computational analysis technique (Siemens cFFR), which can be performed on on-site workstations, has been developed and is currently under investigation. This article reviews CT-FFR technology and clinical evidence for its use in stable patients with suspected coronary artery disease.
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Affiliation(s)
- Rine Nakanishi
- Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Mathew J Budoff
- Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, CA, USA
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Independent prognostic value of coronary artery calcium score and coronary computed tomography angiography in an outpatient cohort of low to intermediate risk chest pain patients. Neth Heart J 2016; 24:332-42. [PMID: 26879946 PMCID: PMC4840119 DOI: 10.1007/s12471-016-0819-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Limited studies report on the additional prognostic value of coronary computed tomography angiography (CCTA) and the coronary artery calcium score (CACS). Methods For a median of 637 days, 1551 outpatients with chest pain, without known coronary artery disease (CAD) and low or intermediate pre-test probability of CAD, were followed for major adverse cardiac events (MACE), defined as death, myocardial infarction or late revascularisation. Cox proportional hazard regression was used to evaluate the independent prognostic value of CCTA and CACS. Results MACE occurred in 23 patients (1.5 %): death (3, 0.2 %), myocardial infarction (4, 0.3 %) and late revascularisation (16, 1.3 %). Multivariate analysis showed an independent prognostic value of CCTA (p < 0.001), CACS of 100–400 (p = 0.035) and CACS of > 400 (p = 0.021). CCTA showed obstructive CAD in 3.1 % of patients with CACS = 0. No events occurred in patients with CACS = 0 without obstructive CAD at CCTA, whereas 2/23 patients (9 %) with CACS = 0 with obstructive CAD had a MACE. Conclusions Our study shows that both CCTA and higher CACS categories have independent prognostic value in chest pain patients with low to intermediate pre-test probability of obstructive CAD, in which CCTA is appropriate. Furthermore a non-negligible amount of patients with CACS = 0 have obstructive CAD at CCTA. CCTA can be used in these patients to identify those at risk for MACE.
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Yang FB, Guo WL, Sheng M, Sun L, Ding YY, Xu QQ, Xu MG, Lv HT. Diagnostic accuracy of coronary angiography using 64-slice computed tomography in coronary artery disease. Saudi Med J 2016; 36:1156-62. [PMID: 26446324 PMCID: PMC4621719 DOI: 10.15537/smj.2015.10.12415] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Objectives: To conduct a meta-analysis and investigate the diagnostic value of 64-slice computed tomography (CT) angiography for diagnosing coronary artery disease (CAD) in patients. Methods: A comprehensive literature search from March 2005 to August 2014 was performed on the following databases: Cochrane Library; Medline; EmBase; PubMed; and BioMed Central database. As a reference standard, studies that assessed 64-slice CT angiography in detecting coronary artery stenosis (CAS) with invasive coronary angiography were included. Coronary artery stenosis was defined as ≥50% diameter stenosis. Diagnostic value was determined by pooling sensitivity, specificity, positive likelihood ratio (PLR) and negative likelihood ratio (NLR) values at segment-level analysis. Diagnostic accuracy was undertaken using area under the curve (AUC) value and summary receiver operating characteristic (SROC) curves. Publication bias was examined by Deek’s funnel plot asymmetry test. Results: Eight studies were included in the analysis, enrolling a total of 579 patients (7,407 segment coronary vessels). At segment-level, pooled sensitivity value was 90% (95% confidence interval [CI]: 83-95%), specificity was 91% (95% CI: 61-98%), PLR value was 9.7 (95% CI: 1.8-53.3), and NLR value was 0.11 (95% CI: 0.05-0.22) for CAS. Optimal cut-off point of sensitivity was 90%, and specificity under the SROC curve was 91%. The AUC value was 0.94. Conclusion: The 64-slice CT angiography is a reliable tool for detection of CAD when using a cut-off of ≥50% diameter stenosis in elderly population.
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Affiliation(s)
- Fu-Bin Yang
- Radiology Department, Children's Hospital of Soochow University, Suzhou, People's Republic of China. E-mail.
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Cheruvu C, Naoum C, Blanke P, Norgaard B, Leipsic J. Beyond Stenosis With Fractional Flow Reserve Via Computed Tomography and Advanced Plaque Analyses for the Diagnosis of Lesion-Specific Ischemia. Can J Cardiol 2016; 32:1315.e1-1315.e9. [PMID: 27032888 DOI: 10.1016/j.cjca.2016.01.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Revised: 12/14/2015] [Accepted: 01/04/2016] [Indexed: 12/24/2022] Open
Abstract
In the treatment of stable coronary artery disease (CAD), the determination of stenosis severity by invasive coronary angiography (ICA) is a critical procedure, and for borderline lesions, the detection of ischemia through invasive fractional flow reserve (FFR) is the gold standard. With advances in computational fluid dynamics, FFR can now be calculated noninvasively using anatomic data from coronary computed tomographic angiography (CCTA). This technique is known as FFRCT. The purpose of this review is to summarize the science of FFRCT, describe its diagnostic accuracy, discuss its clinical and economic impact, and elucidate factors beyond stenosis severity that may mechanistically relate to lesion-specific ischemia. These factors include adverse atherosclerotic plaque characteristics such as positive remodelling, low-attenuation plaque, and spotty calcification, as well as aggregate plaque volume. These factors can be appreciated noninvasively by CCTA but not by ICA. The diagnostic accuracy of FFRCT, compared with the gold standard of FFR, has been validated in 3 prospective multicentre blinded core laboratory-controlled trials, and as a result FFRCT has been approved by the US Food and Drug Administration for clinical use. FFRCT has also been shown in a clinical utility trial to better identify patients without obstructive CAD when compared with standard noninvasive assessment of stable CAD, thereby avoiding unnecessary angiograms. In addition, the use of FFRCT has been shown to allow for a significant cost savings compared with traditional care. It is therefore important for cardiologists to appreciate the value of this important new methodology.
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Affiliation(s)
- Chaitu Cheruvu
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher Naoum
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Philipp Blanke
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bjarne Norgaard
- Department of Cardiology, Aarhus University Hospital, Aarhus Skejby, Denmark
| | - Jonathon Leipsic
- Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada.
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Amanuma M, Kondo T, Sano T, Takayanagi T, Matsutani H, Sekine T, Arai T, Morita H, Ishizaka K, Arakita K, Iwasa A, Takase S. Assessment of coronary in-stent restenosis: value of subtraction coronary computed tomography angiography. Int J Cardiovasc Imaging 2015; 32:661-70. [PMID: 26662268 DOI: 10.1007/s10554-015-0826-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 12/09/2015] [Indexed: 10/22/2022]
Abstract
In conventional coronary computed tomography angiography (CCTA), metal artifacts are frequently observed where stents are located, making it difficult to evaluate in-stent restenosis. This study was conducted to investigate whether subtraction CCTA can improve diagnostic accuracy in the evaluation of in-stent restenosis. Subtraction CCTA was performed using 320-row CT in 398 patients with previously placed stents who were able to hold their breath for 25 s and in whom mid-diastolic prospective one-beat scanning was possible. Among these patients, 126 patients (94 men and 32 women, age 74 ± 8 years) with 370 stents who also underwent invasive coronary angiography (ICA) were selected as the subjects of this study. With ICA findings considered the gold standard, conventional CCTA was compared against subtraction CCTA to determine whether subtraction can improve diagnostic accuracy in the evaluation of in-stent restenosis. When non-assessable stents were considered to be stenotic, the diagnostic accuracy in the evaluation of in-stent restenosis was 62.7 % for conventional CCTA and 89.5 % for subtraction CCTA. When the non-assessable stents were considered to be non-stenotic the diagnostic accuracy was 90.3 % for conventional CCTA and 94.31 % for subtraction CCTA. When subtraction CCTA was used to evaluate only the 138 stents that were judged to be non-assessable by conventional CCTA, 116 of these stents were judged to be assessable, and the findings for 109 of them agreed with those obtained by ICA. Even for stents with an internal diameter of 2.5-3 mm, the lumen can be evaluated in more than 80 % of patients. Subtraction CCTA provides significantly higher diagnostic accuracy than conventional CCTA in the evaluation of in-stent restenosis.
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Affiliation(s)
- Makoto Amanuma
- Department of Radiology, Takase Clinic, 885-2 Minami-Orui, Takasaki, Gunma, 370-0036, Japan.
| | - Taskeshi Kondo
- Department of Cardiology, Jukokai Central Hospital, Miyoshi, Japan
| | - Tomonari Sano
- Department of Radiation Technology, Takase Clinic, Takasaki, Japan
| | | | | | - Takako Sekine
- Department of Radiation Technology, Takase Clinic, Takasaki, Japan
| | - Takehiro Arai
- Department of Radiation Technology, Takase Clinic, Takasaki, Japan
| | - Hitomi Morita
- Department of Radiation Technology, Takase Clinic, Takasaki, Japan
| | | | - Kazumasa Arakita
- Clinical Application Research Center, Toshiba Medical Corporation, Ōtawara, Japan
| | - Akiko Iwasa
- Application Group of CT Sales Department, Toshiba Medical Corporation, Ōtawara, Japan
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Reliability of a new method for coronary artery calcium or metal subtraction by 320-row cardiac CT. Eur Radiol 2015; 26:3208-14. [DOI: 10.1007/s00330-015-4130-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 11/17/2015] [Accepted: 11/19/2015] [Indexed: 12/14/2022]
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65
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Computed tomography segmental calcium score (SCS) to predict stenosis severity of calcified coronary lesions. Int J Cardiovasc Imaging 2015; 31:1663-75. [DOI: 10.1007/s10554-015-0750-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 07/29/2015] [Indexed: 11/26/2022]
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Nørgaard BL, Gaur S, Leipsic J, Ito H, Miyoshi T, Park SJ, Zvaigzne L, Tzemos N, Jensen JM, Hansson N, Ko B, Bezerra H, Christiansen EH, Kaltoft A, Lassen JF, Bøtker HE, Achenbach S. Influence of Coronary Calcification on the Diagnostic Performance of CT Angiography Derived FFR in Coronary Artery Disease: A Substudy of the NXT Trial. JACC Cardiovasc Imaging 2015; 8:1045-1055. [PMID: 26298072 DOI: 10.1016/j.jcmg.2015.06.003] [Citation(s) in RCA: 130] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 05/26/2015] [Accepted: 06/04/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The goal of this study was to examine the diagnostic performance of noninvasive fractional flow reserve (FFR) derived from coronary computed tomography angiography (CTA) (FFRCT) in relation to coronary calcification severity. BACKGROUND FFRCT has shown promising results in identifying lesion-specific ischemia. The extent to which the severity of coronary calcification affects the diagnostic performance of FFRCT is not known. METHODS Coronary calcification was assessed by using the Agatston score (AS) in 214 patients suspected of having coronary artery disease who underwent coronary CTA, FFRCT, and FFR (FFR examination was performed in 333 vessels). The diagnostic performance of FFRCT (≤0.80) in identifying vessel-specific ischemia (FFR ≤0.80) was investigated across AS quartiles (Q1 to Q4) and for discrimination of ischemia in patients and vessels with a low-mid AS (Q1 to Q3) versus a high AS (Q4). Coronary CTA stenosis was defined as lumen reduction >50%. RESULTS Mean ± SD per-patient and per-vessel AS were 302 ± 468 (range 0 to 3,599) and 95 ± 172 (range 0 to 1,703), respectively. There was no statistical difference in diagnostic accuracy, sensitivity, or specificity of FFRCT across AS quartiles. Discrimination of ischemia by FFRCT was high in patients with a high AS (416 to 3,599) and a low-mid AS (0 to 415), with no difference in area under the receiver-operating characteristic curve (AUC) (0.86 [95% confidence interval (CI): 0.76 to 0.96] vs. 0.92 [95% CI: 0.88 to 0.96]) (p = 0.45). Similarly, discrimination of ischemia by FFRCT was high in vessels with a high AS (121 to 1,703) and a low-mid AS (0 to 120) (AUC: 0.91 [95% CI: 0.85 to 0.97] vs. 0.95 [95% CI: 0.91 to 0.98]; p = 0.65). Diagnostic accuracy and specificity of FFRCT were significantly higher than for stenosis assessment in each AS quartile at the per-patient (p < 0.001) and per-vessel (p < 0.05) level with similar sensitivity. In vessels with a high AS, FFRCT exhibited improved discrimination of ischemia compared with coronary CTA alone (AUC: 0.91 vs. 0.71; p = 0.004), whereas on a per-patient level, the difference did not reach statistical significance (AUC: 0.86 vs. 0.72; p = 0.09). CONCLUSIONS FFRCT provided high and superior diagnostic performance compared with coronary CTA interpretation alone in patients and vessels with a high AS.
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Affiliation(s)
- Bjarne L Nørgaard
- Department of Cardiology, Aarhus University Hospital Skejby, Aarhus, Denmark.
| | - Sara Gaur
- Department of Cardiology, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Jonathon Leipsic
- Department of Radiology, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hiroshi Ito
- Department of Cardiology, Okayama University Hospital, Okayama, Japan
| | - Toru Miyoshi
- Department of Cardiology, Okayama University Hospital, Okayama, Japan
| | - Seung-Jung Park
- Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Ligita Zvaigzne
- Diagnostic Institute of Radiology, Paul Stradins Clinical University Hospital, Riga, Latvia
| | - Nikolaos Tzemos
- Department of Radiology, Golden Jubilee Hospital, Glasgow, Scotland
| | - Jesper M Jensen
- Department of Cardiology, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Nicolaj Hansson
- Department of Cardiology, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Brian Ko
- MonashHeart, Monash Medical Center and Monash University, Victoria, Australia
| | - Hiram Bezerra
- Department of Cardiology, Harrington Heart and Vascular Institute, University Hospitals, Cleveland, Ohio
| | | | - Anne Kaltoft
- Department of Cardiology, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Jens F Lassen
- Department of Cardiology, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Stephan Achenbach
- Department of Cardiology, Erlangen University Hospital, Erlangen, Germany
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67
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Fuchs A, Kühl JT, Chen MY, Helqvist S, Razeto M, Arakita K, Steveson C, Arai AE, Kofoed KF. Feasibility of coronary calcium and stent image subtraction using 320-detector row CT angiography. J Cardiovasc Comput Tomogr 2015; 9:393-8. [PMID: 26091841 DOI: 10.1016/j.jcct.2015.03.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 02/04/2015] [Accepted: 03/30/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND The reader confidence and diagnostic accuracy of coronary CT angiography (CCTA) can be compromised by the presence of calcified plaques and stents causing blooming artifacts. Compared to conventional invasive coronary angiography (ICA), this may cause an overestimation of stenosis severity leading to false-positive results. In a pilot study, we tested the feasibility of a new coronary calcium image subtraction algorithm in relation to reader confidence and diagnostic accuracy. METHODS Forty-three patients underwent clinically indicated ICA and CCTA using a 320-detector row CT. Median Agatston score was 510. Two data sets were reconstructed: a conventional CCTA (CCTAconv) and a subtracted CCTA (CCTAsub), where calcifications detected on noncontrast images were subtracted from the CCTA. Reader confidence and concordance with ICA for identification of >50% stenosis were recorded. We defined target segments on CCTAconv as motion-free coronary segments with calcification or stent and low reader confidence. The effect of CCTAsub was assessed. No approval from the ethics committee was required according to Danish law. RESULTS A total of 76 target segments were identified. The use of coronary calcium image subtraction improved the reader confidence in 66% of these segments. In target segments, specificity (86% vs 65%; P < .01) and positive predictive value (71% vs 51%, P = .03) were improved using CCTAsub compared to CCTAconv without loss in negative predictive value. CONCLUSIONS Our initial experience with coronary calcium image subtraction suggests that it is feasible and could lead to an improvement in reader confidence and diagnostic accuracy for identification of significant coronary artery disease.
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Affiliation(s)
- Andreas Fuchs
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen 2100, Denmark.
| | - J Tobias Kühl
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Marcus Y Chen
- National Heart Lung and Blood Institute, National Institute of Health, Bethesda, MD, USA
| | - Steffen Helqvist
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Marco Razeto
- Toshiba Medical Visualization Systems Europe, Edinburgh, United Kingdom
| | | | | | - Andrew E Arai
- National Heart Lung and Blood Institute, National Institute of Health, Bethesda, MD, USA
| | - Klaus F Kofoed
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen 2100, Denmark; Department of Radiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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68
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Chaikriangkrai K, Velankar P, Schutt R, Alchalabi S, Nabi F, Mahmarian J, Chang SM. Additive prognostic value of coronary artery calcium score over coronary computed tomographic angiography stenosis assessment in symptomatic patients without known coronary artery disease. Am J Cardiol 2015; 115:738-44. [PMID: 25604930 DOI: 10.1016/j.amjcard.2014.12.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 12/23/2014] [Accepted: 12/23/2014] [Indexed: 11/19/2022]
Abstract
The objective of this study was to examine the additive prognostic performance of coronary artery calcium score (CACS) over coronary computed tomography angiography (CCTA) stenosis assessment in symptomatic patients suspected for coronary artery disease (CAD) undergoing CCTA. A total of 805 symptomatic patients without known history of CAD who underwent coronary evaluation by multidetector cardiac CT were analyzed. Mean age of the cohort was 58 ± 13 years. A total of 44% (354 of 805) of the patients had a 0 CACS, 27% (215 of 805) had CACS 1 to 100, 14% (111 of 805) had CACS 101 to 400, and 15% (125 of 805) had CACS >400. CCTA showed normal coronary arteries in 43% (349 of 805) of patients, ≤50% stenosis in 42% (333 of 805), and >50% stenosis in 15% (123 of 805). Patients were followed for 2.3 ± 0.9 years. Major adverse cardiac event (MACE) was defined as cardiac death, nonfatal myocardial infarction, and late coronary revascularization. Overall incidence of MACE was 1.4% per year. Both CACS and CCTA stenosis were independently associated with increased MACE (p <0.05 for both). Addition of CACS into the model with clinical risk factors and CCTA stenosis significantly improved predictive performance for MACE from the model with clinical risk factors and CCTA stenosis only (global chi-square score 108 vs 70; p = 0.019). In conclusion; in symptomatic patients without known CAD, both CACS and CCTA stenosis were independently associated with increased cardiac events, and performing non-contrast-enhanced CACS evaluation in addition to contrast-enhanced CCTA improved predictive ability for future cardiac events compared to CCTA stenosis assessment alone.
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Affiliation(s)
| | - Pradnya Velankar
- Department of Medicine, Houston Methodist Hospital, Houston, Texas
| | - Robert Schutt
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Sama Alchalabi
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Faisal Nabi
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - John Mahmarian
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Su Min Chang
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
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Yoshioka K, Tanaka R, Muranaka K, Sasaki T, Ueda T, Chiba T, Takeda K, Sugawara T. Subtraction coronary CT angiography using second-generation 320-detector row CT. Int J Cardiovasc Imaging 2015; 31 Suppl 1:51-8. [PMID: 25721727 DOI: 10.1007/s10554-015-0630-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 02/17/2015] [Indexed: 11/29/2022]
Abstract
The purpose of this study was to explore the feasibility of subtraction coronary computed tomography angiography (CCTA) by second-generation 320-detector row CT in patients with severe coronary artery calcification using invasive coronary angiography (ICA) as the gold standard. This study was approved by the institutional board, and all subjects provided written consent. Twenty patients with calcium scores of >400 underwent conventional CCTA and subtraction CCTA followed by ICA. A total of 82 segments were evaluated for image quality using a 4-point scale and the presence of significant (>50 %) luminal stenosis by two independent readers. The average image quality was 2.3 ± 0.8 with conventional CCTA and 3.2 ± 0.6 with subtraction CCTA (P < 0.001). The percentage of segments with non-diagnostic image quality was 43.9 % on conventional CCTA versus 8.5 % on subtraction CCTA (P = 0.004). The segment-based diagnostic accuracy for detecting significant stenosis according to ICA revealed an area under the receiver operating characteristics curve of 0.824 (95 % confidence interval [CI], 0.750-0.899) for conventional CCTA and 0.936 (95 % CI 0.889-0.936) for subtraction CCTA (P = 0.001). The sensitivity, specificity, positive predictive value, and negative predictive value for conventional CCTA were 88.2, 62.5, 62.5, and 88.2 %, respectively, and for subtraction CCTA they were 94.1, 85.4, 82.1, and 95.3 %, respectively. As compared to conventional, subtraction CCTA using a second-generation 320-detector row CT showed improvement in diagnostic accuracy at segment base analysis in patients with severe calcifications.
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Affiliation(s)
- Kunihiro Yoshioka
- Division of Cardiovascular Radiology, Department of Radiology, Iwate Medical University, 19-1 Uchimaru, Morioka, 020-8505, Japan,
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70
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Kim YJ, Yong HS, Kim SM, Kim JA, Yang DH, Hong YJ. Korean guidelines for the appropriate use of cardiac CT. Korean J Radiol 2015; 16:251-85. [PMID: 25741189 PMCID: PMC4347263 DOI: 10.3348/kjr.2015.16.2.251] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Accepted: 01/03/2015] [Indexed: 01/07/2023] Open
Abstract
The development of cardiac CT has provided a non-invasive alternative to echocardiography, exercise electrocardiogram, and invasive angiography and cardiac CT continues to develop at an exponential speed even now. The appropriate use of cardiac CT may lead to improvements in the medical performances of physicians and can reduce medical costs which eventually contribute to better public health. However, until now, there has been no guideline regarding the appropriate use of cardiac CT in Korea. We intend to provide guidelines for the appropriate use of cardiac CT in heart diseases based on scientific data. The purpose of this guideline is to assist clinicians and other health professionals in the use of cardiac CT for diagnosis and treatment of heart diseases, especially in patients at high risk or suspected of heart disease.
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Affiliation(s)
- Young Jin Kim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul 120-752, Korea
| | - Hwan Seok Yong
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul 152-703, Korea
| | - Sung Mok Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710, Korea
| | - Jeong A Kim
- Department of Radiology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang 411-706, Korea
| | - Dong Hyun Yang
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, Korea
| | - Yoo Jin Hong
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul 120-752, Korea
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71
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Ortiz-Pérez JT, Bosch X. Comments on exercise echocardiography and multidetector computed tomography for the evaluation of acute chest pain. Response. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2015; 68:165-166. [PMID: 25547376 DOI: 10.1016/j.rec.2014.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 10/17/2014] [Indexed: 06/04/2023]
Affiliation(s)
- José T Ortiz-Pérez
- Servicio de Cardiología, Instituto Clínico del Tórax, Hospital Clínic, IDIBAPS, Universidad de Barcelona, Barcelona, Spain.
| | - Xavier Bosch
- Servicio de Cardiología, Instituto Clínico del Tórax, Hospital Clínic, IDIBAPS, Universidad de Barcelona, Barcelona, Spain
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72
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Comentarios a la evaluación del dolor torácico agudo mediante ecocardiografía de ejercicio y tomografía computarizada multidetectores. Respuesta. Rev Esp Cardiol 2015. [DOI: 10.1016/j.recesp.2014.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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73
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Kauling RM, Post MC, Rensing BJWM, Verzijlbergen JF, Schaap J. Hybrid SPECT/CCTA Imaging in the Work-up of Patients with Suspected Coronary Artery Disease. CURRENT CARDIOVASCULAR IMAGING REPORTS 2015. [DOI: 10.1007/s12410-014-9316-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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74
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Munnur RK, Cameron JD, Ko BS, Meredith IT, Wong DTL. Cardiac CT: atherosclerosis to acute coronary syndrome. Cardiovasc Diagn Ther 2014; 4:430-48. [PMID: 25610801 PMCID: PMC4278045 DOI: 10.3978/j.issn.2223-3652.2014.11.03] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 10/27/2014] [Indexed: 12/17/2022]
Abstract
Coronary computed tomographic angiography (CCTA) is a robust non-invasive method to assess coronary artery disease (CAD). Qualitative and quantitative assessment of atherosclerotic coronary stenosis with CCTA has been favourably compared with invasive coronary angiography (ICA) and intravascular ultrasound (IVUS). Importantly, it allows the study of preclinical stages of atherosclerotic disease, may help improve risk stratification and monitor the progressive course of the disease. The diagnostic accuracy of CCTA in the assessment of coronary artery bypass grafts (CABG) is excellent and the constantly improving technology is making the evaluation of stents feasible. Novel techniques are being developed to assess the functional significance of coronary stenosis. The excellent negative predictive value of CCTA in ruling out disease enables early and safe discharge of patients with suspected acute coronary syndromes (ACS) in the Emergency Department (ED). In addition, CCTA is useful in predicting clinical outcomes based on the extent of coronary atherosclerosis and also based on individual plaque characteristics such as low attenuation plaque (LAP), positive remodelling and spotty calcification. In this article, we review the role of CCTA in the detection of coronary atherosclerosis in native vessels, stented vessels, calcified arteries and grafts; the assessment of plaque progression, evaluation of chest pain in the ED, assessment of functional significance of stenosis and the prognostic significance of CCTA.
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75
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Cho I, Chang HJ, Ó Hartaigh B, Shin S, Sung JM, Lin FY, Achenbach S, Heo R, Berman DS, Budoff MJ, Callister TQ, Al-Mallah MH, Cademartiri F, Chinnaiyan K, Chow BJW, Dunning AM, DeLago A, Villines TC, Hadamitzky M, Hausleiter J, Leipsic J, Shaw LJ, Kaufmann PA, Cury RC, Feuchtner G, Kim YJ, Maffei E, Raff G, Pontone G, Andreini D, Min JK. Incremental prognostic utility of coronary CT angiography for asymptomatic patients based upon extent and severity of coronary artery calcium: results from the COronary CT Angiography EvaluatioN For Clinical Outcomes InteRnational Multicenter (CONFIRM) study. Eur Heart J 2014; 36:501-8. [PMID: 25205531 DOI: 10.1093/eurheartj/ehu358] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIM Prior evidence observed no predictive utility of coronary CT angiography (CCTA) over the coronary artery calcium score (CACS) and the Framingham risk score (FRS), among asymptomatic individuals. Whether the prognostic value of CCTA differs for asymptomatic patients, when stratified by CACS severity, remains unknown. METHODS AND RESULTS From a 12-centre, 6-country observational registry, 3217 asymptomatic individuals without known coronary artery disease (CAD) underwent CACS and CCTA. Individuals were categorized by CACS as: 0-10, 11-100, 101-400, 401-1000, >1000. For CCTA analysis, the number of obstructive vessels-as defined by the per-patient presence of a ≥50% luminal stenosis-was used to grade the extent and severity of CAD. The incremental prognostic value of CCTA over and above FRS was measured by the likelihood ratio (LR) χ(2), C-statistic, and continuous net reclassification improvement (NRI) for prediction, discrimination, and reclassification of all-cause mortality and non-fatal myocardial infarction. During a median follow-up of 24 months (25th-75th percentile, 17-30 months), there were 58 composite end-points. The incremental value of CCTA over FRS was demonstrated in individuals with CACS >100 (LRχ(2), 25.34; increment in C-statistic, 0.24; NRI, 0.62, all P < 0.001), but not among those with CACS ≤100 (all P > 0.05). For subgroups with CACS >100, the utility of CCTA for predicting the study end-point was evident among individuals whose CACS ranged from 101 to 400; the observed predictive benefit attenuated with increasing CACS. CONCLUSION Coronary CT angiography provides incremental prognostic utility for prediction of mortality and non-fatal myocardial infarction for asymptomatic individuals with moderately high CACS, but not for lower or higher CACS.
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Affiliation(s)
- Iksung Cho
- Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Yonsei University Health System, 250 Seongsanno Seodaemungu, Seoul, South Korea Department of Radiology, NewYork-Presbyterian Hospital and the Weill Cornell Medical College, New York, NY, USA
| | - Hyuk-Jae Chang
- Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Yonsei University Health System, 250 Seongsanno Seodaemungu, Seoul, South Korea
| | - Bríain Ó Hartaigh
- Department of Radiology, NewYork-Presbyterian Hospital and the Weill Cornell Medical College, New York, NY, USA
| | - Sanghoon Shin
- Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Yonsei University Health System, 250 Seongsanno Seodaemungu, Seoul, South Korea
| | - Ji Min Sung
- Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Yonsei University Health System, 250 Seongsanno Seodaemungu, Seoul, South Korea
| | - Fay Y Lin
- Department of Medicine, NewYork-Presbyterian Hospital and Weill Cornell Medical College, New York, NY, USA
| | | | - Ran Heo
- Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel S Berman
- Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Matthew J Budoff
- Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA, USA
| | | | - Mouaz H Al-Mallah
- Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI, USA
| | - Filippo Cademartiri
- Cardiovascular Imaging Unit, Giovanni XXIII Hospital, Monastier, Treviso, Italy Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Benjamin J W Chow
- Department of Medicine and Radiology, University of Ottawa, Ottawa, ON, Canada
| | | | | | - Todd C Villines
- Department of Medicine, Walter Reed Medical Center, Washington, DC, USA
| | - Martin Hadamitzky
- Division of Cardiology, Deutsches Herzzentrum Munchen, Munich, Germany
| | - Joerg Hausleiter
- Medizinische Klinik I der Ludwig-Maximilians-Universität München, Munich, Germany
| | - Jonathon Leipsic
- Department of Medicine and Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Leslee J Shaw
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | | | | | - Gudrun Feuchtner
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Yong-Jin Kim
- Seoul National University Hospital, Seoul, South Korea
| | - Erica Maffei
- Cardiovascular Imaging Unit, Giovanni XXIII Hospital, Monastier, Treviso, Italy Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Gianluca Pontone
- Department of Clinical Sciences and Community Health, University of Milan, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Daniele Andreini
- Department of Clinical Sciences and Community Health, University of Milan, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - James K Min
- Department of Radiology, NewYork-Presbyterian Hospital and the Weill Cornell Medical College, New York, NY, USA
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Alani A, Nakanishi R, Budoff MJ. Recent improvement in coronary computed tomography angiography diagnostic accuracy. Clin Cardiol 2014; 37:428-33. [PMID: 24756932 DOI: 10.1002/clc.22286] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 03/13/2014] [Indexed: 01/07/2023] Open
Abstract
Although invasive coronary angiography has been the gold standard for evaluating coronary artery disease (CAD), it should not be routinely performed as an initial test to assess CAD in subjects with suspected CAD by the recent guidelines, due to cost, invasiveness, and measurable risk. Coronary computed tomography angiography (CCTA) is a rapidly growing, noninvasive imaging modality that developed quickly over the last decade, and its role for evaluation of CAD becomes of great promise with high diagnostic accuracy. Although artifact issues have created some challenges for CCTA, recent advances-including the introduction of more detectors, leading to broader coverage, and faster and higher-definition scanners-allow improved precision and fewer uninterpretable studies. This review article summarizes the current key literature regarding the diagnostic accuracy of CCTA in native coronary arteries, stents, coronary artery bypass grafts, lesions with high calcification, and the functional assessment of CAD.
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Affiliation(s)
- Anas Alani
- Department of Cardiology, Harbor-UCLA Medical Center, Los Angeles, California
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77
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Sano T. [6. Diagnosis of ischemic heart disease by multidetector computed tomography]. Nihon Hoshasen Gijutsu Gakkai Zasshi 2013; 69:1444-1454. [PMID: 24366565 DOI: 10.6009/jjrt.2013_jsrt_69.12.1444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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78
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Improved evaluation of calcified segments on coronary CT angiography: a feasibility study of coronary calcium subtraction. Int J Cardiovasc Imaging 2013; 29 Suppl 2:75-81. [PMID: 24158235 DOI: 10.1007/s10554-013-0316-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 10/16/2013] [Indexed: 10/26/2022]
Abstract
We explore the feasibility of coronary calcium subtraction computed tomography angiography (CCTA) in patients with high calcium scores using invasive coronary angiography as the gold standard. Eleven patients with calcium scores of >400 underwent CCTA using a subtraction protocol followed by invasive coronary angiography. In addition to standard reconstructions, subtracted images were obtained using a dedicated subtraction algorithm. A total of 55 calcified segments were evaluated for image quality [using a 4-point scale ranging from 1 (uninterpretable) to 4 (good)] and the presence of significant (≥ 50 %) luminal stenosis. Conventional and subtracted CCTA were compared using quantitative coronary angiography (QCA) as the gold standard. The average image quality of conventional CCTA was 2.5 ± 0.6 versus 3.1 ± 0.6 on subtraction CCTA (P < 0.001). The percentage of segments with a score 1 or 2 was reduced from 41.8 to 12.7 % after coronary calcium subtraction (P = 0.002). On QCA, significant stenosis was observed in 16 segments. The area under the receiver operating characteristics curve to detect ≥ 50 % stenosis on QCA increased from 0.741 [95 % confidence interval (CI) 0.598-0.885] for conventional CCTA to 0.905 (95 % CI 0.791-1.000) for subtraction CCTA (P = 0.003). In patients with extensive calcifications undergoing CCTA, coronary calcium subtraction may improve the evaluation of calcified segments.
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79
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Use of multi-slice computed tomography in patients with chest-pain submitted to the emergency department. Int J Cardiovasc Imaging 2013; 30:145-53. [DOI: 10.1007/s10554-013-0292-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 09/05/2013] [Indexed: 10/26/2022]
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80
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Accuracy and predictive value of coronary computed tomography angiography for the detection of obstructive coronary heart disease in patients with an Agatston calcium score above 400. J Comput Assist Tomogr 2013; 37:387-94. [PMID: 23674010 DOI: 10.1097/rct.0b013e318282d61c] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE We assessed the accuracy of coronary computed tomography angiography (CTA) in patients with an Agatston calcium score (ACS) of greater than 400 by comparing it with invasive coronary angiography (ICA), and we evaluated the predictive value of CTA for obstructive coronary heart disease (CHD) compared with traditional clinical risk assessment. METHODS A total of 253 patients who had an ACS of greater than 400 were enrolled in this study. The degree of coronary stenosis was visually and quantitatively estimated by postprocessing imaging using 15-segment coronary models. All patients underwent ICA after a mean (SD) of 34 (24) days, and the degree of coronary stenosis was compared with the results of CTA. RESULTS Computed tomography angiography accurately diagnosed significant stenosis in 204 (99.0%) of 206 patients and in 649 (83.5%) of 777 segments. When the patients were considered based on their ACS (group A, 400 < ACS ≤ 1000, vs group B, ACS > 1000), group B showed lower specificity (9.1% vs 41.7%) and poorer agreement (k = 0.149 vs 0.495) than for ICA. By segment-based analysis, the agreement between CTA and ICA was good (k = 0.729), and there was no significant difference between groups A (k = 0.728) and B (k = 0.727). Computed tomography angiography was the most powerful predictor (odds ratio = 52.645, P < 0.001), whereas the 10-year CHD risk and pretest probability were not significantly correlated with obstructive CHD. CONCLUSIONS Despite good overall diagnostic accuracy, coronary CTA in this group of patients was limited by low specificity. However, CTA was a better predictor of obstructive CHD compared with clinical predictors, and it avoided unnecessary ICA, even in patients with extensive coronary artery calcification.
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Significance of coronary calcification for prediction of coronary artery disease and cardiac events based on 64-slice coronary computed tomography angiography. BIOMED RESEARCH INTERNATIONAL 2013; 2013:472347. [PMID: 23586041 PMCID: PMC3613090 DOI: 10.1155/2013/472347] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Accepted: 02/04/2013] [Indexed: 12/13/2022]
Abstract
This work aims to validate the clinical significance of coronary artery calcium score (CACS) in predicting coronary artery disease (CAD) and cardiac events in 100 symptomatic patients (aged 37-87 years, mean 62.5, 81 males) that were followed up for a mean of 5 years. Our results showed that patients with CAD and cardiac events had significantly higher CACS than those without CAD and cardiac events, respectively. The corresponding data were 1450.42 ± 3471.24 versus 130 ± 188.29 (P < 0.001) for CAD, and 1558.67 ± 513.29 versus 400.46 ± 104.47 (P = 0.031) for cardiac events. Of 72 patients with CAD, cardiac events were found in 56 (77.7%) patients. The prevalence of cardiac events in our cohort was 13.3% for calcium score 0, 50% for score 11-100, 56% for score 101-400, 68.7% for score 401-1,000, and 75.0% for score >1000. Increased CACS (>100) was also associated with an increased frequency of multi-vessel disease. Nonetheless, 3 (20%) out of 15 patients with zero CACS had single-vessel disease. Significant correlation (P < 0.001) was observed between CACS and CAD on a vessel-based analysis for coronary arteries. It is concluded that CACS is significantly correlated with CAD and cardiac events.
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Sun Z, Almoudi M. Coronary computed tomography angiography: an overview of clinical applications. Interv Cardiol 2013. [DOI: 10.2217/ica.12.79] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Coronary Calcium Scan Acquisition Before Coronary CT Angiography: Limited Benefit or Useful Addition? AJR Am J Roentgenol 2013; 200:66-73. [DOI: 10.2214/ajr.12.8643] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Larsen LH, Kofoed KF, Dalsgaard M, Kristensen T, Elming H, Steinbrüchel DA, Køber L, Kelbæk H, Hassager C. Assessment of coronary artery disease using coronary computed tomography angiography in patients with aortic valve stenosis referred for surgical aortic valve replacement. Int J Cardiol 2012; 168:126-31. [PMID: 23073274 DOI: 10.1016/j.ijcard.2012.09.057] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Revised: 06/22/2012] [Accepted: 09/14/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND In patients referred for aortic valve replacement (AVR) a pre-surgical assessment of coronary artery disease is mandatory to determine the possible need for additional coronary artery bypass grafting. The diagnostic accuracy of coronary computed tomography angiography (coronary CTA) was evaluated in patients with aortic valve stenosis referred for surgical AVR. METHODS Between March 2008 and March 2010 a total of 181 consecutive patients were included. All patients underwent pre-surgical coronary CTA (64- or 320-detector CT scanner) and invasive coronary angiography (ICA). The analyses were performed blinded to each other. RESULTS The mean ± SD age of the included patients was 71 ± 9 years and 59% were male. The prevalence of significant coronary artery stenosis >70% by ICA was 36%. Average heart rate during coronary CTA was 65 ± 16 b pm. In a patient based analysis 94% of the patients (171/181) were considered fully evaluable. Coronary CTA had a sensitivity of 68%, a specificity of 91%, a positive predictive value of 81%, and a negative predictive value of 83%. Advanced age, obstructive lung disease, NYHA function class III/IV, and high Agatston score were found to be significantly associated with disagreement between ICA and coronary CTA in univariate analysis. CONCLUSION In patients with aortic valve stenosis referred for surgical AVR the diagnostic accuracy of coronary CTA to identify significant coronary artery disease is moderate. Coronary CTA may be used successfully in a subset of patients with low age, no chronic obstructive lung disease, NYHA function class<III and low coronary Agatston score.
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Affiliation(s)
- L Hornbech Larsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark.
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den Dekker MAM, de Smet K, de Bock GH, Tio RA, Oudkerk M, Vliegenthart R. Diagnostic performance of coronary CT angiography for stenosis detection according to calcium score: systematic review and meta-analysis. Eur Radiol 2012; 22:2688-98. [PMID: 22797978 DOI: 10.1007/s00330-012-2551-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Revised: 05/15/2012] [Accepted: 05/17/2012] [Indexed: 11/29/2022]
Affiliation(s)
- Martijn A M den Dekker
- Center for Medical Imaging - North East Netherlands, Department of Radiology, University of Groningen/University Medical Center Groningen, Hanzeplein 1, P.O. Box 30001, 9700 RB, Groningen, The Netherlands
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