The impact of cardiac CT on the appropriate utilization of catheter coronary angiography

IMPACT OF COMPUTED TOMOGRAPHY CORONARY ANGIOGRAPHY ON OTHER DIAGNOSTIC TESTS

Objectives: Information on the impact of computed tomography coronary angiography (CTCA) on patterns of care is scarce. In particular, it is not clear if, and to what extent, its adoption actually leads to a reduction in the use of other diagnostics tools. The aim of this study was to evaluate whether the adoption of CTCA in Emilia-Romagna (an Italian region with a population of 4.4 million) had any effect on utilization rates of myocardial perfusion scintigraphy (MPS) and coronary angiography (CA).

Methods: Interrupted time series (ITS) were applied to monthly volumes of MPS and CA tests performed from 2003 to 2010, to assess trends in usage rates for those procedures before and after CTCA was adopted by all the healthcare organizations operating in the region.

Results: After an increase in the first year of CTCA introduction, its use remained stable over the study period. After September 2006, a significant decrease in MPS volumes (31 percent; p < .0001) and a much less tangible decrease in CA volumes (5 percent; p < .0001), were detected by ITS analyses.

Conclusions: This study demonstrates that the use of CTCA had a greater impact on MPS usage rates than on CA.

Can Computer Tomography Predict Compromise of Cardiac Structures After Percutaneous Closure of Interatrial Septal Defects?

BACKGROUND

Erosion of a cardiac structure after device closure of an interatrial septal communication (IASC-C), although rare, is a major and severe adverse event which may be underreported. On the other hand, unexplained episodes of transient chest pain occur more often and may be quite distressing. We sought to define the parameters relating the devices to the adjacent cardiac structures and to determine whether computer tomography (CT) could predict erosion of atrial or aortic wall or precordial pain symptoms occurring in the first months after device implantation.

METHODS

Retrospective observational study of 20 patients who underwent CT for de novo chest pain occurring after IASC-C or as a diagnostic test for suspected or proven coronary artery disease (CAD). Clinical follow up was for 20.5 ± 17.6 (6-84) months. CT was done 18 ± 10 (2-28) weeks after IASC-C.

RESULTS

Indentation of the aortic root was found in 11 (55%) patients, the left atrial wall in 13 (65%) and the right atrial wall in eight (40%) of patients. Contact without indentation was found in nine (45%), 6 (30%) and 11 (55%) of patients respectively.

CONCLUSIONS

Device indenting of the left and right atrial, as well as the aortic wall, occured in the majority of the patients examined after IASC-C. This finding may explain bouts of chest pain after the intervention in some patients, but does not predict clinically relevant erosion of a cardiac structure.

The diagnostic performance of multi-slice coronary computed tomographic angiography: a systematic review

BACKGROUND

The use of coronary computed tomographic angiography (CCTA) for evaluation of patients with suspected coronary artery disease (CAD) is growing rapidly, yet questions remain regarding its diagnostic accuracy and its impact on clinical decision-making and patient outcomes.

METHODS

A systematic literature review was conducted to identify studies examining (a) CCTA's diagnostic accuracy; and (b) the impact of CCTA on clinical decision-making and/or patient outcomes. Diagnostic accuracy estimates were limited to patient-based analyses of occlusion; outcome studies were eligible for inclusion if they involved patients at low-to-intermediate risk of CAD. Pooled accuracy estimates were derived using bivariate random effects models; non-diagnostic CCTA results were conservatively assumed to be false positives.

RESULTS

A total of 42 diagnostic accuracy studies and 11 patient outcome studies were identified. The pooled mean sensitivity for CCTA in primary analyses was 98% (95% CI: 96%, 99%); specificity was 85% (81%, 89%). A small number of outcome studies set primarily in the emergency department found triage of low-risk patients using CCTA produced no serious adverse outcomes and was time-saving relative to standard triage care. Outcome studies in the outpatient setting were limited to four case series that did not directly compare patient care or outcomes with those of contemporaneous patients evaluated without CCTA.

CONCLUSIONS

CCTA appears to have high diagnostic accuracy in patients with suspected CAD, but its potential impact on clinical decision-making and patient outcomes is less well-understood, particularly in non-emergent settings.