Incidental extracardiac findings at cardiac CT angiography: comparison of prevalence and clinical significance between precontrast low-dose whole thoracic scan and postcontrast retrospective ECG-gated cardiac scan

Prevalence of pulmonary nodules detected incidentally on noncancer-related imaging: a review

Pulmonary nodules are common incidental findings requiring surveillance. Follow-up recommendations vary depending on risk factors, size and solid or subsolid characteristics. This review aimed to evaluate the prevalence of clinically significant nodules detected on noncancer-dedicated imaging and the prevalence of part-solid and ground-glass nodules. We conducted a systematic search of literature and screened texts for eligibility. Clinically significant nodules were noncalcified nodules >4-6 mm. Prevalence estimates were calculated for all studies and risk of bias was assessed by one reviewer. Twenty-four studies were included, with a total of 30 887 participants, and 21 studies were cross-sectional in design. Twenty-two studies used computed tomography (CT) imaging with cardiac-related CT being the most frequent. Prevalence of significant nodules was highest in studies with large field of view of the chest and low size thresholds for reporting nodules. The prevalence of part-solid and ground-glass nodules was only described in two cardiac-related CT studies. The overall risk of bias was low in seven studies and moderate in 17 studies. While current literature frequently reports incidental nodules on cardiovascular-related CT, there is minimal reporting of subsolid characteristics. Unclear quantification of smoking history and heterogeneity of imaging protocol also limits reliable evaluation of nodule prevalence in nonscreening cohorts.

German Radiological Society and the Professional Association of German Radiologists Position Paper on Coronary computed tomography: Clinical Evidence and Quality of Patient Care in Chronic Coronary Syndrome

This position paper is a joint statement of the German Radiological Society (DRG) and the Professional Association of German Radiologists (BDR), which reflects the current state of knowledge about coronary computed tomography. It is based on preclinical and clinical studies that have investigated the clinical relevance as well as the technical requirements and fundamentals of cardiac computed tomography. CITATION FORMAT: · Langenbach MC, Sandstede J, Sieren M et al. DRG and BDR Position Paper on Coronary CT: Clinical Evidence and Quality of Patient Care in Chronic Coronary Syndrome. Fortschr Röntgenstr 2023; 195: 115 - 133.

[German Radiological Society and the Professional Association of German Radiologists position paper on coronary computed tomography: clinical evidence and quality of patient care in chronic coronary syndrome]

This position paper is a joint statement of the German Radiological Society (DRG) and the Professional Association of German Radiologists (BDR), which reflects the current state of knowledge about coronary computed tomography (CT). It is based on preclinical and clinical studies that have investigated the clinical relevance as well as the technical requirements and fundamentals of cardiac computed tomography.

Extracardiac findings on cardiac computed tomography in patients undergoing atrial fibrillation catheter ablation

Abstract Background and Aim

To assess the prevalence of incidental extracardiac findings in patients who underwent cardiac CT for the evaluation of left atrial (LA) anatomy before atrial fibrillation (AF) catheter ablation. We also aimed to determine the independent predictors of relevant extracardiac alterations.

Patients and Methods

We studied consecutive patients who underwent cardiac CT with a 256-slice scanner for the visualization of LA anatomy before AF ablation. Prevalence of clinically significant and not significant extracardiac findings were recorded. Moreover, we determined the variables associated with relevant extracardiac alterations with uni- and multivariate logistic regression analyses.

Results

In total, 1,952 consecutive patients who underwent cardiac CT examination between 2010 and 2020 were included in our study (mean age 61.2±10.6 years; 66.2% male). Incidental extracardiac findings were detected in 820 (42.0%; 95%CI=0.40-0.44%) patients, while clinically significant alterations were reported in 416 (21.3%; 95%CI=20.0-23.2%) patients. When analyzing the predictors of clinically relevant alterations, age (OR=1.04; 95%CI=1.03- 1.05), male sex (OR=1.39; 95%CI=1.12-1.73), chest pain (OR=1.46; 95%CI=1.09-1.93), hypertension (OR=1.42; 95%CI=1.12-1.81), heart failure (OR=1.68; 95%CI=1.09-2.53), obstructive CAD (OR=1.56; 95%CI=1.16-2.09) and prior stroke/TIA (OR=1.56; 95%CI=1.04- 2.30) showed association with clinically significant incidental findings in the univariate analysis (all p<0.05). In the multivariate analysis, age (OR=1.04; 95%CI=1.02-1.06; p<0.001) proved to be the only significant predictor of clinically relevant extracardiac finding.

Conclusion

Cardiac CT performed before AF ablation is not only helpful in understanding LA anatomy, but might also identify clinically significant pathologies. These incidental findings might have further diagnostic or therapeutic consequences.

Detection of relevant extracardiac findings on coronary computed tomography angiography vs. invasive coronary angiography

OBJECTIVES

To compare the detection of relevant extracardiac findings (ECFs) on coronary computed tomography angiography (CTA) and invasive coronary angiography (ICA) and evaluate the potential clinical benefit of their detection.

METHODS

This is the prespecified subanalysis of ECFs in patients presenting with a clinical indication for ICA based on atypical angina and suspected coronary artery disease (CAD) included in the prospective single-center randomized controlled Coronary Artery Disease Management (CAD-Man) study. ECFs requiring immediate therapy and/or further workup including additional imaging were defined as clinically relevant. We evaluated the scope of ECFs in 329 patients and analyzed the potential clinical benefit of their detection.

RESULTS

ECFs were detected in 107 of 329 patients (32.5%; CTA: 101/167, 60.5%; ICA: 6/162, 3.7%; p < .001). Fifty-nine patients had clinically relevant ECFs (17.9%; CTA: 55/167, 32.9%; ICA: 4/162, 2.5%; p < .001). In the CTA group, ECFs potentially explained atypical chest pain in 13 of 101 patients with ECFs (12.9%). After initiation of therapy, chest pain improved in 4 (4.0%) and resolved in 7 patients (6.9%). Follow-up imaging was recommended in 33 (10.0%; CTA: 30/167, 18.0%; ICA: 3/162, 1.9%) and additional clinic consultation in 26 patients (7.9%; CTA: 25/167, 15.0%; ICA: 1/162, 0.6%). Malignancy was newly diagnosed in one patient (0.3%; CTA: 1/167, 0.6%; ICA: 0).

CONCLUSIONS

In this randomized study, CTA but not ICA detected clinically relevant ECFs that may point to possible other causes of chest pain in patients without CAD. Thus, CTA might preclude the need for ICA in those patients.

TRIAL REGISTRATION

NCT Unique ID: 00844220 KEY POINTS: • CTA detects ten times more clinically relevant ECFs than ICA. • Actionable clinically relevant ECFs affect patient management and therapy and may thus improve chest pain. • Detection of ECFs explaining chest pain on CTA might preclude the need for performing ICA.

Clinical significance of incidental findings on coronary CT angiography: Insights from a randomized controlled trial

BACKGROUND

The effect of incidental findings from coronary computed tomography angiography (CCTA) on management has not been rigorously investigated. This study uses a control group to explore this relationship.

METHODS

Analysis of data from a randomized controlled trial of acute chest pain patients admitted to telemetry was performed. Patients were randomized to undergo either CCTA (n = 200) or radionuclide myocardial perfusion imaging (MPI) (n = 200). Incidental findings were determined from imaging reports. Records were reviewed to determine subsequent management and imaging during and after hospitalization. Comparisons were performed using Fischer's exact tests.

RESULTS

386 incidental findings were found among 187 CCTA studies. No extra-cardiac incidental findings were noted in the MPI arm, which served as an effective control group. There were significantly more non-coronary medical workups during admission in the CCTA group compared to the MPI group [20% (39) vs. 12% (23), P = 0.038]. CCTA patients underwent significantly more resting echocardiography during the inpatient workup compared to the MPI group [38% (75) vs. 18% (55), P = 0.042]. CCTA patients underwent significantly more non-contrast chest CT exams in the year following admission compared to MPI patients [14% (27) vs. 7% (13) P = 0.029].

CONCLUSIONS

Incidental findings on inpatient CCTAs performed for chest pain have a significant impact on treatment and imaging during and following hospital admission.

Coronavirus disease 2019 (COVID-19) pneumonia incidentally detected on coronary CT angiogram: a do-not-miss diagnosis

Coronary CT angiograms are commonly performed for the evaluation of coronary artery disease and coronary arterial anatomy. However, extracardiac findings are frequently detected on these examinations and often can explain patients’ underlying symptoms, having a significant impact on patient management. Here in, we discuss three cases of incidentally detected novel COVID-19-infected pneumonia (NCIP). This case series highlights the image findings in NCIP and emphasizes the importance of evaluating all organs in the field of view on coronary CT angiograms. In addition, with the ongoing outbreak of COVID-19 and exponentially increasing incidence throughout the world, this report stresses the need for including NCIP in the differential diagnosis of patients with typical image findings in at-risk populations, as early diagnosis is crucial for appropriate patient management and post-exposure recommendations.

Extracardiac findings on coronary computed tomography angiography in patients without significant coronary artery disease

OBJECTIVE

To analyse extracardiac findings in patients without significant coronary artery disease (CAD) in general and in symptomatic patients in particular.

METHODS

We searched the Radiology Information System database for coronary computed tomography angiographies (CTA) performed from 2000-2014 and retrospectively enrolled 3,898 patients without significant CAD (coronary stenosis < 50%) in CTA. In 2,330 symptomatic patients, we analysed the spectrum of extracardiac findings and identified pathologies potentially explaining chest pain. Finally, we investigated variables affecting the number of extracardiac findings detected in CTA.

RESULTS

Overall extracardiac findings were found in 1,177 patients (30.2%; 95%CI, 28.8-31.7%). 94 patients (2.4%; 95%CI, 2.0-2.9%) had extracardiac findings with a recommendation for follow-up, sixteen patients (0.4%; 95%CI, 0.3-0.7%) had incidental urgent, and another three patients (0.1%; 95%CI, 0.1-0.2%) had incidental malignant extracardiac findings. 185 of 2,330 symptomatic patients (7.9%; 95%CI, 6.9-9.1%) revealed extracardiac findings potentially explaining chest pain after exclusion of significant CAD. The number of extracardiac findings increased significantly with patient age (p < 0.001) and the cumulative experience of the CT reader (p < 0.001).

CONCLUSION

30.2% of patients undergoing CTA for exclusion of CAD had ECF, and 7.9% of symptomatic patients without significant CAD on their examination had findings that could potentially explain their symptoms.

KEY POINTS

• Of patients undergoing CTA, 2.8% have relevant incidental extracardiac findings. • CTA could identify the differential diagnosis of chest pain when excluding significant CAD. • Patient age and reader's professional experience influence the number of detected ECFs.

Extracardiac findings at cardiac MR imaging: a single-centre retrospective study over 14 years

OBJECTIVES

To determine the prevalence and significance of extracardiac findings (ECF) in a large set of cardiac magnetic resonance (MR) imaging examinations.

METHODS

The institutional review board (IRB) of the Charité approved this retrospective, single-centre study. A total of 4376 cardiac MR imaging reports of 3553 patients (age 37.4 ± 20 years, 60.8 % male) examined from 2000 to 2014 were included. Findings with a recommendation for follow-up were considered "major ECF". To analyse the association of indication, age and gender with ECF, Poisson regression and computed incidence rate ratios (IRR) were evaluated.

RESULTS

The overall prevalence of ECF was 34% (95% confidence interval [CI] 32.5-35.6%). Major ECF were present in 3.4% (95% CI 2.9-4.1%) while findings that changed patient management were found in 0.9% (95% CI 0.7-1.3%). In the cases of congenital heart disease, ECF prevalence was higher compared to myocarditis (IRR, 6.0; 95% CI 5.1-7.1%; p < 0.001), while the prevalence of major ECF was lower (IRR, 0.2; 95% CI 0.02-0.51%; p < 0.05). Older patient age was associated with more nonvascular ECF (p < 0.001). Female patients had the same probability of having an ECF as male patients (IRR, 1.04; 95% CI 0.95-1.1%; p = 0.43).

CONCLUSION

ECF in cardiac MR imaging are present in about every third patient while relevant ECF that change patient management can be found in about one out of 100 patients. Our data suggest that it is important to involve well-trained radiologists in reading cardiac MR images, which often reveal ECF if congenital heart disease is the clinical indication.

KEY POINTS

• Extracardiac findings are present in about every third patient. • Relevant ECF changing patient management are found in one out of 100 findings. • Chance of ECF is high in patients with CHD and vascular indications.

Incidental extra-cardiac findings on 13N-ammonia myocardial perfusion PET/CT

BACKGROUND

The objective of this study was to describe the prevalence of incidental extra-cardiac findings (IECFs) on myocardial perfusion PET/CTs and the prevalence of potentially clinically relevant and clinically irrelevant IECFs, as well as detection rate of previously unknown malignancies.

METHODS AND RESULTS

From September 2013 until February 2016, a total of 1397 consecutive patients referred for the evaluation of possible ischemia by 13NH3 PET/CT were prospectively included in a database. IECFs were categorized into three groups: potentially clinically relevant IECFs, IECFs that could potentially cause chest pain, and clinically irrelevant IECFs. Additionally, the prevalence of previously unknown malignancies was determined. In 717 (51%) of these patients, 775 IECFs were reported and 115 IECFs were categorized as potentially clinically relevant in 109 (8%) patients. A total of 145 IECFs that could potentially cause chest pain were detected in 139 (10%) patients and 515 clinically irrelevant IECFs were detected in 469 (34%) of the patients. An unknown primary malignancy was histologically proven in 19 patients (1.4%).

CONCLUSIONS

IECFs are detected on myocardial perfusion PET/CT in approximately half of the patients. In the present study, IECFs were potentially clinically relevant in 8% of the patients and in 1.4% an unknown malignancy was found, most of which were lung cancers.

Incidental pulmonary nodules in emergent coronary CT angiography for suspected acute coronary syndrome: Impact of revised 2017 Fleischner Society Guidelines

BACKGROUND

Pulmonary nodules (PN) are frequently detected incidentally during coronary computed tomography angiography (CTA). We evaluated whether the 2017 Fleischner Society guidelines may result in a decrease of follow-up testing of incidental PN as compared to prior guidelines in patients undergoing coronary CTA.

METHODS

We conducted a retrospective study of a registry of emergency department patients who underwent coronary CTA for acute coronary syndrome assessment between 2012 and 2017. Based on guidelines, patients <35 years, history of cancer, or prior exams showing stability of PN were excluded. Patients >60 years, history of smoking, irregular/spiculated PN morphology, or PN size >20 mm were classified as high-risk for lung cancer. Radiological findings pertaining to PN were identified (PN size, morphology, quantity) through review of radiology reports. PN follow-up recommendations were established using 2017 Fleischner Society Guidelines and compared with prior guidelines for solid (2005) and subsolid (2013) PN. Data were analyzed with Student's t-test.

RESULTS

The registry included 2066 patients (female 45.1%, 52.9 ± 11.0 years), of which 578 (28.0%) reported PN. 438 of those (21.2%) were eligible for guideline-based follow-up evaluation. 205 (4 6.8%) were classified as high-risk for lung cancer. 2017 guidelines reduced the number of individuals requiring follow-up by 64.5%, from 264 (12.8%) to 94 patients (4.5%) when compared to prior guidelines (p < 0.001). The minimum number of follow-up chest CTs decreased by 55.8% from 430 to 190 (p < 0.001).

CONCLUSION

Application of the 2017 Fleischner Society Guidelines resulted in a significant decrease of follow-up testing for incidental PN in patients undergoing coronary CTA for suspected acute coronary syndrome.

Cost-effectiveness of follow-up of pulmonary nodules incidentally detected on cardiac computed tomographic angiography in patients with suspected coronary artery disease

BACKGROUND

Pulmonary nodules (PNs) are often detected incidentally during coronary computed tomographic (CT) angiography, which is increasingly being used to evaluate patients with chest pain symptoms. However, the efficiency of following up on incidentally detected PN is unknown.

METHODS AND RESULTS

We determined demographic and clinical characteristics of stable symptomatic patients referred for coronary CT angiography in whom incidentally detected PNs warranted follow-up. A validated lung cancer simulation model was populated with data from these patients, and clinical and economic consequences of follow-up per Fleischner guidelines versus no follow-up were simulated. Of the 3665 patients referred for coronary CT angiography, 591 (16%) had PNs requiring follow-up. The mean age of patients with PNs was 59±10 years; 66% were male; 67% had ever smoked; and 21% had obstructive coronary artery disease. The projected overall lung cancer incidence was 5.8% in these patients, but the majority died of coronary artery disease (38%) and other causes (57%). Follow-up of PNs was associated with a 4.6% relative reduction in cumulative lung cancer mortality (absolute mortality: follow-up, 4.33% versus non-follow-up, 4.54%), more downstream testing (follow-up, 2.34 CTs per patient versus non-follow-up, 1.01 CTs per patient), and an average increase in quality-adjusted life of 7 days. Costs per quality-adjusted life-year gained were $154 700 to follow up the entire cohort and $129 800 per quality-adjusted life-year when only smokers were included.

CONCLUSIONS

Follow-up of PNs incidentally detected in patients undergoing coronary CT angiography for chest pain evaluation is associated with a small reduction in lung cancer mortality. However, significant downstream testing contributes to limited efficiency, as demonstrated by a high cost per quality-adjusted life-year, especially in nonsmokers.

The prevalence and clinical importance of incidentally detected noncoronary cardiovascular findings with coronary multidetector CT angiography

OBJECTIVE

The purpose of this study was to determine the prevalence and clinical importance of incidental findings of noncoronary cardiac structures and mediastinal great vessels in patients who underwent coronary computed tomography angiography (CCTA).

METHODS

The study included 2,096 consecutive patients (1,472 men and 624 women, with a mean age of 55 years). Cardiovascular findings were categorized into three groups according to the clinical importance: group 1 included findings necessitating immediate treatment or intervention; group 2 included findings requiring clinical awareness, follow-up, or further clinical and/or radiological investigations; and group 3 included findings not requiring any follow-up or further tests. We also evaluated whether there was any previous diagnosis of cardiovascular findings.

RESULTS

A total of 174 abnormalities (8.3 %) were detected in 170 patients. Of these abnormalities, 21 findings (12 %) were considered as group 1, 121 (69.5 %) as group 2, and 32 (18.5 %) as group 3. The majority of cardiovascular findings (140 of 174, 80.5 %) were unknown by the reporter during the interpretation of CCTA examinations and regarded as incidental findings.

CONCLUSION

Noncoronary incidental cardiovascular findings in patients who underwent CCTA are common. It is important to be aware of these findings necessitating immediate treatment or intervention, and follow-up or further investigations, and careful attention must be paid to all the structures included in the images.

Detection of cardiac myxomas with non-contrast chest CT

BACKGROUND

Cardiac myxomas are sources of systemic embolism. Currently a large volume of chest CT and calcium-scoring CT scans are performed without contrast injection.

PURPOSE

To evaluate the diagnostic capability of non-contrast CT covering heart in detecting cardiac myxomas.

MATERIAL AND METHODS

This retrospective study included 36 non-contrast CT scans of 36 consecutive patients (16 men, 20 women) who underwent CT scan before surgery for left atrial myxomas and 20 patients without myxoma as a control group. Two independent readers who were blinded to medical information reviewed non-contrast CT scans of 36 patients with cardiac myxomas and 20 scans in the control group patients. They determined the presence of lesions suspicious of myxomas using a five-point scale. The other reader measured attenuation number in the non-calcific areas of the tumors and sizes of the masses on the non-contrast CT images.

RESULTS

The average attenuation of cardiac myxoma (22.5 Hounsfield units [HU]; range, 8.9-32.9 HU) and adjacent unopacified blood (44.6 HU; range, 31.5-57 HU) were significantly different (P < 0.001). Twelve cardiac myxomas (31.6%) had internal calcification and all of them were detected by both of readers. Cardiac myxomas were measured smaller on non-contrast CT (mean, 3.5 cm; range, 1.1-9.7 cm) than on pathologic specimens (mean, 4.1 cm, 1.4-10.0 cm) (P < 0.001). Considering grade 3-5 on a five-grade scale as the detectability, the sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of non-contrast CT in detecting cardiac myxomas were 88.8%/86.1%, 95.0%/100%, 96.9%/100%, 82.6%/80.0%, and 91.1%/91.1%, by reader 1 and reader 2, respectively and there was good inter-observer reliability (kappa value = 0.92, P = 0.157).

CONCLUSION

Non-contrast CT scan is useful for detecting cardiac myxomas. Therefore, radiologists should be familiar with imaging findings of cardiac myxomas on non-contrast CT.

Malignant incidental extracardiac findings on cardiac CT: systematic review and meta-analysis

OBJECTIVE

The objective of our study was to systematically review the evidence on incidental extracardiac findings on cardiac CT with a focus on previously unknown malignancies.

MATERIALS AND METHODS

A systematic search was performed (PubMed, EMBASE, Cochrane databases) for studies reporting incidental extracardiac findings on cardiac CT. Among 1099 articles initially found, 15 studies met the inclusion criteria. The references of those articles were hand-searched and 14 additional studies were identified. After review of the full text, 10 articles were excluded. Nineteen studies including 15,877 patients (64% male) were analyzed. A three-level analysis was performed to determine the prevalence of patients with incidental extracardiac findings, the prevalence of patients with major incidental extracardiac findings, and the prevalence of patients with a proven cancer. Heterogeneity was explored for multiple variables. Pooled prevalence and 95% CI were calculated.

RESULTS

The prevalence of both incidental extracardiac findings and major incidental extracardiac findings showed a high heterogeneity (I2>95%): The pooled prevalence was 44% (95% CI, 35-54%) and 16% (95% CI, 14-20%), respectively. No significant explanatory variables were found for using or not using contrast material, the size of the FOV, and study design (I2>85%). The pooled cancer prevalence for 10 studies including 5082 patients was 0.7% (95% CI, 0.5-1.0%), with an almost perfect homogeneity (I2<0.1%). Of 29 reported malignancies, 21 (72%) were lung cancers; three, thyroid cancers; two, breast cancers; two, liver cancers; and one, mediastinal lymphoma.

CONCLUSION

Although the prevalence of reported incidental extracardiac finding at cardiac CT was highly variable, a homogeneous prevalence of previously unknown malignancies was reported across the studies, for a pooled estimate of 0.7%; more than 70% of these previously unknown malignancies were lung cancers. Extracardiac findings on cardiac CT require careful evaluation and reporting.

Unrequested findings on cardiac computed tomography: looking beyond the heart

Objectives

To determine the prevalence of clinically relevant unrequested extra-cardiac imaging findings on cardiac Computed Tomography (CT) and explanatory factors thereof.

Methods

A systematic review of studies drawn from online electronic databases followed by meta-analysis with meta-regression was performed. The prevalence of clinically relevant unrequested findings and potentially explanatory variables were extracted (proportion of smokers, mean age of patients, use of full FOV, proportion of men, years since publication).

Results

Nineteen radiological studies comprising 12922 patients met the inclusion criteria. The pooled prevalence of clinically relevant unrequested findings was 13% (95% confidence interval 9–18, range: 3–39%). The large differences in prevalence observed were not explained by the predefined (potentially explanatory) variables.

Conclusions

Clinically relevant extra-cardiac findings are common in patients undergoing routine cardiac CT, and their prevalence differs substantially between studies. These differences may be due to unreported factors such as different definitions of clinical relevance and differences between populations. We present suggestions for basic reporting which may improve the interpretability and comparability of future research.

Incidental cardiac findings on computed tomography imaging of the thorax

Background

Investigation of pulmonary pathology with computed tomography also allows visualisation of the heart and major vessels. We sought to explore whether clinically relevant cardiac pathology could be identified on computed tomography pulmonary angiograms (CTPA) requested for the exclusion of pulmonary embolism (PE). 100 consecutive CT contrast-enhanced pulmonary angiograms carried out for exclusion of PE at a single centre were assessed retrospectively by two cardiologists.

Findings

Evidence of PE was reported in 5% of scans. Incidental cardiac findings included: aortic wall calcification (54%), coronary calcification (46%), cardiomegaly (41%), atrial dilatation (18%), mitral annulus calcification (15%), right ventricular dilatation (11%), aortic dilatation (8%) and right ventricular thrombus (1%). Apart from 3 (3%) reports describing cardiomegaly, no other cardiac findings were described in radiologists' reports. Other reported pulmonary abnormalities included: lung nodules (14%), lobar collapse/consolidation (8%), pleural effusion (2%), lobar collapse/consolidation (8%), emphysema (6%) and pleural calcification (4%).

Conclusions

CTPAs requested for the exclusion of PE have a high yield of cardiac abnormalities. Although these abnormalities may not have implications for acute clinical management, they may, nevertheless, be important in long-term care.

Cardiovascular disease: prediction with ancillary aortic findings on chest CT scans in routine practice

PURPOSE

To predict cardiovascular disease (CVD) in a clinical care population by using prevalent subclinical ancillary aortic findings detected on chest computed tomographic (CT) images.

MATERIALS AND METHODS

The study was approved by the medical ethics committee of the primary participating facility and the institutional review boards of all other participating centers. From a total of 6975 patients who underwent diagnostic contrast material-enhanced chest CT for noncardiovascular indications, a representative sample population of 817 patients plus 347 patients who experienced a cardiovascular event during a mean follow-up period of 17 months were assigned visual scores for ancillary aortic abnormalities--on a scale of 0-8 for calcifications, a scale of 0-4 for plaques, a scale of 0-4 for irregularities, and a scale of 0-1 for elongation. Four Cox proportional hazard models incorporating different sum scores for the aortic abnormalities plus age, sex, and chest CT indication were compared for discrimination and calibration. The prediction model that performed best was chosen and externally validated.

RESULTS

Each aortic abnormality was highly predictive, and all models performed well (c index range, 0.70-0.72; goodness-of-fit P value range, .45-.76). The prediction model incorporating the sum score for aortic calcifications was chosen owing to its good performance (c index, 0.72; goodness-of-fit P = .47) and its applicability to nonenhanced CT scanning. Validation of this model in an external data set also revealed good performance (c index, 0.71; goodness-of-fit P = .25; sensitivity, 46%; specificity, 76%).

CONCLUSION

A derived prediction model incorporating ancillary aortic findings detected on routine diagnostic CT images complements established risk scores and may help to identify patients at high risk for CVD. Timely application of preventative measures may ultimately reduce the number or severity of CVD events.

Incidental extracardiac findings at coronary CT: clinical and economic impact

OBJECTIVE

The purpose of this study was to evaluate the prevalence of incidental extracardiac findings on coronary CT, to determine the associated downstream resource utilization, and to estimate additional costs per patient related to the associated diagnostic workup.

MATERIALS AND METHODS

This retrospective study examined incidental extracardiac findings in 151 consecutive adults (69.5% men and 30.5% women; mean age, 54 years) undergoing coronary CT during a 7-year period. Incidental findings were recorded, and medical records were reviewed for downstream diagnostic examinations for a follow-up period of 1 year (minimum) to 7 years (maximum). Costs of further workup were estimated using 2009 Medicare average reimbursement figures.

RESULTS

There were 102 incidental extracardiac findings in 43% (65/151) of patients. Fifty-two percent (53/102) of findings were potentially clinically significant, and 81% (43/53) of these findings were newly discovered. The radiology reports made specific follow-up recommendations for 36% (19/53) of new significant findings. Only 4% (6/151) of patients actually underwent follow-up imaging or intervention for incidental findings. One patient was found to have a malignancy that was subsequently treated. The average direct costs of additional diagnostic workup were $17.42 per patient screened (95% CI, $2.84-$32.00) and $438.39 per patient with imaging follow-up (95% CI, $301.47-$575.31).

CONCLUSION

Coronary CT frequently reveals potentially significant incidental extracardiac abnormalities, yet radiologists recommend further evaluation in only one-third of cases. An even smaller fraction of cases receive further workup. The failure to follow-up abnormal incidental findings may result in missed opportunities to detect early disease, but also limits the short-term attributable costs.

Clinical impact of computerised tomographic angiography performed for preoperative evaluation before coronary artery bypass grafting

OBJECTIVE

In our institution, computerised tomographic (CT) angiography has been performed as a near-routine test before coronary artery bypass grafting (CABG) to evaluate the aorta and its branches. We aimed to determine its impact on operative procedure and perioperative management.

METHODS

From January 2006 through December 2008, neck-to-leg systemic arteries were evaluated by 64-slice multidetector CT scan in 284 patients before CABG. For them, medical records and cardiac surgery database were retrospectively reviewed to investigate the incidence of pathologic lesions of the aorta and its major branches, other incidental lesions and procedure- or management-related decision affected by CT angiography.

RESULTS

In 36 patients (12.7%), cannulation and clamping of the ascending aorta were thought too dangerous because of severe atherosclerotic change. The use of cardiopulmonary bypass was inevitable in 10 of them, and postoperative mortality rate was significantly higher (3/10, 30%) than in the remaining patients (2/274, 0.7%). Conduit selection or grafting strategy was changed due to severe left subclavian artery stenosis or leg vein varicosity in 18 patients (6.3%). For the following problems, surgical interventions were performed in 34 patients (12.0%) concomitantly or during the same admission with CABG; > or = 90% stenosis in carotid (5.6%), iliofemoral (11.6%) or renal (4.6%) arteries, aortic aneurysm (14.4%, six of them met surgical indication) and incidental malignant neoplasm (2.8%). Counting all of the above, preoperative CT angiography affected risk assessment, CABG procedure itself, perioperative management or follow-up plan in 142 patients (50%).

CONCLUSIONS

Because preoperative CT angiography considerably affected management in one half of patients, we recommend its use as a routine test before CABG, unless contraindicated.

Incidental non-cardiac findings of a coronary angiography with a 128-slice multi-detector CT scanner: should we only concentrate on the heart?

Objective

To evaluate the spectrum, prevalence, and significance of incidental non-cardiac findings (INCF) in patients referred for a non-invasive coronary angiography using a 128-slice multi-detector CT (MDCT).

Materials and Methods

The study subjects included 1,044 patients; 774 males (mean age, 59.9 years) and 270 females (mean age, 63 years), referred for a coronary CT angiography on a 128-slice MDCT scanner. The scans were acquired from the level of the carina to just below the diaphragm. To evaluate INCFs, images were reconstructed with a large field of view (> 300 mm) covering the entire thorax. Images were reviewed in the axial, coronal, and sagittal planes, using the mediastinal, lung, and bone windows. The INCFs were classified as severe, indeterminate, and mild, based on their clinical importance, and as thoracic or abdominal based on their locations.

Results

Incidental non-cardiac findings were detected in 56% of patients (588 of 1,044), including 435 males (mean age, 65.6 years) and 153 females (mean age, 67.9 years). A total of 729 INCFs were observed: 459 (63%) mild (58% thoracic, 43% abdominal), 96 (13%) indeterminate (95% thoracic, 5% abdominal), and 174 (24%) severe (87% thoracic, 13% abdominal). The prevalence of severe INCFs was 15%. Two severe INCFs were histologically verified as lung cancers.

Conclusion

The 128-slice MDCT coronary angiography, in addition to cardiac imaging, can provide important information on the pathology of the chest and upper abdomen. The presence of severe INCFs is not rare, especially in the thorax. Therefore, all organs in the scan should be thoroughly evaluated in daily clinical practice.