cardiac computed tomography angiography; coronary computed tomography angiography; CT angiography (CCTA)
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Introduction
Multislice computed tomography using a scanner with 16 detector rows compared well with conventional coronary angiography.
Indications
- 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]
- aortic disease
- cardiac masses
- 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
- high-resolution tomographic images
- enables 3-D reconstructions of aortic & cardiac anatomy
- 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]
- 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
- contrast injection
- radiation exposure
- requires high-resolution (64-slice) CT instruments
- does not provide detailed images of distal vessel anatomy
- catheterization is still needed for intervention (PCI) if coronary artery disease is present
Problems include:
- motion artifacts
- irregular or rapid heart rates
- difficulty visualizing segments with stents or graft anastomoses
- coronary artery calcification in the elderly (may be interpreted as obstructive plaque)[16]
- accuracy varies widely by center
Adverse effects
- radiation exposure:
- exposure may be diminished without loss of quality[1]
- radition exposure[9]
- radiation dose from a single scan varies from 0.8-10.5 mSv depending on the protocol
- excess lifetime risk of cancer from radiation exposure (assuming scans every 5 years) 0.4-0.6/1000 patients[9]
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]
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]
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]
More general terms
Additional terms
- coronary artery
- coronary artery calcification
- coronary artery calcium (CAC testing)
- coronary artery disease; coronary atherosclerosis (CAD)
References
- ↑ 1.0 1.1 Raff GL et al. for the Advanced Cardiovascular Imaging Consortium Co-Investigators. Radiation dose from cardiac computed tomography before and after implementation of radiation dose-reduction techniques. JAMA 2009 Jun 10; 301:2340. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19509381
- ↑ 2.0 2.1 Blaha M et al Absence of coronary artery calcification and all-cause mortality. JACC Cardiovasc Imaging. 2009 Jun;2(6):692-700. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19520338
- ↑ Journal Watch 25(13):107, 2005 Hoffmann MH, Shi H, Schmitz BL, Schmid FT, Lieberknecht M, Schulze R, Ludwig B, Kroschel U, Jahnke N, Haerer W, Brambs HJ, Aschoff AJ. Noninvasive coronary angiography with multislice computed tomography. JAMA. 2005 May 25;293(20):2471-8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15914747
- ↑ Raff GL, Gallagher MJ, O'Neill WW, Goldstein JA. Diagnostic accuracy of noninvasive coronary angiography using 64-slice spiral computed tomography. J Am Coll Cardiol. 2005 Aug 2;46(3):552-7. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16053973
Haberl R, Tittus J, Bohme E, Czernik A, Richartz BM, Buck J, Steinbigler P. Multislice spiral computed tomographic angiography of coronary arteries in patients with suspected coronary artery disease: an effective filter before catheter angiography? Am Heart J. 2005 Jun;149(6):1112-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15976796 - ↑ 5.0 5.1 Garcia MJ et al, Accuracy of 16-row multidetector computed tomography for the assessment of coronary artery stenosis. JAMA 2006, 296:403 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16868298
- ↑ Dewey M et al, Noninvasive detection of coronary artery stenoses with multislice computed tomography of magnetic resonance imaging Ann Intern Med 2006, 145:407 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16983128
Greenland P, Who is a candidate for noninvasive coronary angiography? Ann Intern Med 2006, 145:466 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16983136 - ↑ Greenland P, et al; American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCF/AHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography); Society of Atherosclerosis Imaging and Prevention; Society of Cardiovascular Computed Tomography. ACCF/AHA 2007 clinical expert consensus document on coronary artery calcium scoring by computed tomography in global cardiovascular risk assessment and in evaluation of patients with chest pain: a report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCF/AHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) developed in collaboration with the Society of Atherosclerosis Imaging and Prevention and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol. 2007 Jan 23;49(3):378-402. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/17239724 <Internet> http://content.onlinejacc.org/cgi/content/full/j.jacc.2006.10.001v1
Greenland P et al, American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCF/AHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography); Society of Atherosclerosis Imaging and Prevention; Society of Cardiovascular Computed Tomography. ACCF/AHA 2007 clinical expert consensus document on coronary artery calcium scoring by computed tomography in global cardiovascular risk assessment and in evaluation of patients with chest pain: a report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCF/AHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography). Circulation. 2007 Jan 23;115(3):402-26. Epub 2007 Jan 12. No abstract available. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17220398 - ↑ 8.0 8.1 Rubenstein R et al, Usefulness of a 64-slice cardiac computed tomographic angiography for diagnosing acute coronary syndromes and predicting clinical outcome in emergency department patients with chest pain of uncertain origin. Circulation 2007, 115:1762 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17372178
- ↑ 9.0 9.1 9.2 Kim KP et al Coronary artery calcification screening: Estimated radiation dose and cancer risk. Arch Intern Med 2009 Jul 13; 169:1188. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19597067
- ↑ 10.0 10.1 Chow BJW et al. Ontario multidetector computed tomographic coronary angiography study: Field evaluation of diagnostic accuracy. Arch Intern Med 2011 Mar 14 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21403014
- ↑ 11.0 11.1 Shreibati JB et al. Association of coronary CT angiography or stress testing with subsequent utilization and spending among Medicare beneficiaries. JAMA 2011 Nov 16; 306:2128 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22089720
- ↑ 12.0 12.1 12.2 Litt HI et al. CT angiography for safe discharge of patients with possible acute coronary syndromes. N Engl J Med 2012 Mar 26 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22449295 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1201163
- ↑ Mark DB, Berman DS, Budoff MJ et al ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT 2010 expert consensus document on coronary computed tomographic angiography: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. J Am Coll Cardiol. 2010 Jun 8;55(23):2663-99. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20513611
- ↑ 14.0 14.1 14.2 Douglas PS et al Outcomes of Anatomical versus Functional Testing for Coronary Artery Disease. N Engl J Med. March 14, 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25773919 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1415516
Kramer CM Cardiovascular Imaging and Outcomes - PROMISEs to Keep. N Engl J Med. March 14, 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25773508 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMe1501924 - ↑ 15.0 15.1 SCOT-HEART Investigators. CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): An open-label, parallel-group, multicentre trial. Lancet 2015 Mar 15; <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25788230 <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2815%2960291-4/abstract
- ↑ 16.0 16.1 Medical Knowledge Self Assessment Program (MKSAP) 17, 18, 19. American College of Physicians, Philadelphia 2015, 2018, 2022.
- ↑ 17.0 17.1 Stehli J et al. Accuracy of coronary CT angiography using a submillisievert fraction of radiation exposure: Comparison with invasive coronary angiography. J Am Coll Cardiol 2014 Aug 26; 64:772. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25145520 <Internet> http://www.sciencedirect.com/science/article/pii/S073510971404368X
Wijns W et al. Minimizing CT angiography radiation burden while maintaining accuracy through noise reduction: Is lower always better? J Am Coll Cardiol 2014 Aug 26; 64:781. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25145521 <Internet> http://www.sciencedirect.com/science/article/pii/S0735109714043678 - ↑ 18.0 18.1 18.2 Levsky JM et al Coronary Computed Tomography Angiography Versus Radionuclide Myocardial Perfusion Imaging in Patients With Chest Pain Admitted to Telemetry: A Randomized, Controlled Trial. Ann Intern Med. Published online 9 June 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26052677 <Internet> http://annals.org/article.aspx?articleid=2301406
- ↑ 19.0 19.1 Pagidipati NJ, Hemal K, Coles A et al. Sex differences in functional stress test versus CT angiography in symptomatic patients with suspected CAD: Insights from PROMISE. J Am Coll Cardiol 2016 Apr 4 PMID: https://www.ncbi.nlm.nih.gov/pubmed/27058908
- ↑ 20.0 20.1 Dewey M et al. Evaluation of computed tomography in patients with atypical angina or chest pain clinically referred for invasive coronary angiography: Randomised controlled trial. BMJ 2016;355:i5441 http://www.bmj.com/content/355/bmj.i5441
- ↑ 21.0 21.1 21.2 Wnorowski AM, Halpern EJ. Diagnostic Yield of Triple-Rule-Out CT in an Emergency Setting. AJR Am J Roentgenol. 2016 Aug;207(2):295-301. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27186867
- ↑ 22.0 22.1 22.2 Foy Aj, Dhruva SS, Peterson B et al Coronary Computed Tomography Angiography vs Functional Stress Testing for Patients With Suspected Coronary Artery Disease. A Systematic Review and Meta-analysis. JAMA Intern Med. Published online October 2, 2017. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28973101 <Internet> http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2655243
Villines TC, Shaw LJ Coronary Computed Tomographic Angiography - The First Test for Evaluating Patients With Chest Pain? JAMA Intern Med. Published online October 2, 2017. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28973117 <Internet> http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2655240 - ↑ 23.0 23.1 The SCOT-HEART Investigators Coronary CT Angiography and 5-Year Risk of Myocardial Infarction. N Engl J Med. Aug 25, 2018 PMID: https://www.ncbi.nlm.nih.gov/pubmed/30145934 https://www.nejm.org/doi/full/10.1056/NEJMoa1805971
Hoffmann U, Udelson JE. Imaging coronary anatomy and reducing myocardial infarction. N Engl J Med 2018 Aug 25 PMID: https://www.ncbi.nlm.nih.gov/pubmed/30145924 https://www.nejm.org/doi/10.1056/NEJMe1809203 - ↑ 24.0 24.1 Sharma A et al. Stress testing versus CT angiography in patients with diabetes and suspected coronary artery disease. J Am Coll Cardiol 2019 Mar 5; 73:893. PMID: https://www.ncbi.nlm.nih.gov/pubmed/30819356 https://www.sciencedirect.com/science/article/pii/S0735109719300968
Blaha MJ, Cainzos-Achirica M. Coronary CT angiography in new-onset stable chest pain: Time for U.S. guidelines to be NICEr. J Am Coll Cardiol 2019 Mar 5; 73:903 PMID: https://www.ncbi.nlm.nih.gov/pubmed/30819357 https://www.sciencedirect.com/science/article/pii/S073510971930097X - ↑ Han D, Berman DS, Miller RJH et al. Association of cardiovascular disease risk factor burden with progression of coronary atherosclerosis assessed by serial coronary computed tomographic angiography. JAMA Netw Open 2020 Jul 24; 3:e2011444. PMID: https://www.ncbi.nlm.nih.gov/pubmed/32706382 Free PMC article. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2768616
- ↑ 26.0 26.1 26.2 Han D, Lin A, Kuronuma K et al Association of Plaque Location and Vessel Geometry Determined by Coronary Computed Tomographic Angiography With Future Acute Coronary Syndrome- Causing Culprit Lesions. JAMA Cardiol. Published online January 26, 2022 PMID: https://www.ncbi.nlm.nih.gov/pubmed/35080587 https://jamanetwork.com/journals/jamacardiology/fullarticle/2788006