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cardiac computed tomography angiography; coronary computed tomography angiography; CT angiography (CCTA)

Multislice computed tomography using a scanner with 16 detector rows compared well with conventional coronary angiography. Indications: 1) non-invasive imaging modality to assess patency of coronary arteries, i.e. coronary artery disease* - evaluation of chest pain in an emergency department [12] - lessens need for coronary angiography in intermediate risk patients with chest pain [20] - improved clinical outcomes at 5 years in patients with chest pain [23] 2) aortic disease 3) cardiac masses 4) pericardial disease * prognostic value similar to myocardial perfusion scintigraphy [18] * associated with lower risk for myocardial infarction but not mortality compared with exercise stress testing [22] * associated with more invasive coronary angiography procedures (12% vs 9%), revascularizations (7% vs 5%), CAD diagnoses (18% vs 8%), & aspirin & statin prescriptions than exercise stress testing [22] Advantages: 1) high-resolution tomographic images 2) enables 3-D reconstructions of aortic & cardiac anatomy 3) coronary artery vessel lumen & atherosclerotic lesions can be visualized in detail* - CCTA can capture adverse geometric characteristics including lesion location & vessel geometry associated with risk of future acute coronary syndrome [26] - adverse geometric characteristics include - shorter distance from ostium - localized to bifurcation - more tortuous vessel segments [26] 4) identifies anomalous coronary arteries * patients exposed to less radiation & rate the procedure more favorable with coronary CT angiography than with myocardial perfusion scintigraphy [18] - a new technique lowers radiation exposure to below 1 mSv [17] * - better outcomes in patients with diabetes who underwent initial testing with coronary CT angiography than functional testing (cardiac stress testing) [24] Disadvantages: 1) contrast injection 2) radiation exposure 3) requires high-resolution (64-slice) CT instruments 4) does not provide detailed images of distal vessel anatomy 5) catheterization is still needed for intervention (PCI) if coronary artery disease is present Problems include: 1) motion artifacts 2) irregular or rapid heart rates 3) difficulty visualizing segments with stents or graft anastomoses 4) coronary artery calcification in the elderly (may be interpreted as obstructive plaque) [16] 5) accuracy varies widely by center Procedure: * sensitivity: 98%, specificity: 65% 30% of scans uninterpretable [5] sensitivity 100%, specificity 92% [8] * for identifying CAD with > 50% stenosis - triple-rule-out CT - includes thoracic aorta, pulmonary arteries & coronary arteries - requires large contrast bolus & high radiation doses [21] Clinical significance: - coronary artery calcium is associated with increased all-cause mortality [2] - no patients with <50% stenosis by CCTA experienced cardiac death or myocardial infarction within 30 days [12] - positive cardiac CT angiography in women more predictive of adverse cardiovascular events than in men [19] - using triple-rule-out CT, 81% with negative study, 12% with coronary artery stenosis of > 50%, 9% with non coronary artery finding as source of chest pain (pulmonary embolism, pneumonia, aortic aneurysm) [21] Adverse effects: - radiation exposure: - exposure may be diminished without loss of quality [1] - radition exposure [9] a) radiation dose from a single scan varies from 0.8-10.5 mSv depending on the protocol b) excess lifetime risk of cancer from radiation exposure (assuming scans every 5 years) 0.4-0.6/1000 patients [9] Notes: - CCTA is associated with higher cost & more follow up procedures than myocardial perfusion & viability scintigraphy [11]; mortality is similar; rehospitalization may be lower with CCTA [10] - CCTA with simular 2-year outcomes to cardiac stress testing [14] - CCTA with slightly higher cost ($500), but fewer patients undergoing invasive cardiac catheterization with normal findings (28% vs. 53%) [14] - CCTA in addition to exercise stress testing improves diagnostic accuracy but does not affect clinical outcome [15]

Related

coronary artery coronary artery calcification coronary artery calcium (CAC testing) coronary artery disease; coronary atherosclerosis (CAD)

General

CT of heart coronary angiography computed tomography angiography (CT angiography)

References

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