Computerized tomography: coronary angiography and cardiac imaging

Patients presenting with acute chest pain constitute a common and important diagnostic challenge. This has increased interest in using computed tomography for non-invasive visualization of coronary artery disease in patients presenting with acute chest pain to the emergency department; particularly the subset of patients who are suspected of having an acute coronary syndrome, but without typical electrocardiographic changes and with normal troponin levels at presentation. As a result of rapid developments in coronary computed tomography angiography technology, high diagnostic accuracies for excluding coronary artery disease can be obtained. It has been shown that these patients can be discharged safely. The accuracy for detecting a significant coronary artery stenosis is also high, but the presence of coronary artery atherosclerosis or stenosis does not imply necessarily that the cause of the chest pain is related to coronary artery disease. Moreover, the non-invasive detection of coronary artery disease by computed tomography has been shown to be related with an increased use of subsequent invasive coronary angiography and revascularization, and further studies are needed to define which patients benefit from invasive evaluation following coronary computed tomography angiography. Conversely, the implementation of coronary computed tomography angiography can significantly reduce the length of hospital stay, with a significant cost reduction. Additionally, computed tomography is an excellent modality in patients whose symptoms suggest other causes of acute chest pain such as aortic aneurysm, aortic dissection, or pulmonary embolism. Furthermore, the acquisition of the coronary arteries, thoracic aorta, and pulmonary arteries in a single computed tomography examination is feasible, allowing ‘triple rule-out’ (exclusion of aortic dissection, pulmonary embolism, and coronary artery disease). Finally, other applications, such as the evaluation of coronary artery plaque composition, myocardial function and perfusion, or fractional flow reserve, are currently being developed and may also become valuable in the setting of acute chest pain in the future.

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Computed tomography angiography and other applications of computed tomography

10.1093/med/9780199687039.003.0022 ◽

2015 ◽

Author(s):

Michiel A de Graaf ◽

Arthur JHA Scholte ◽

Lucia Kroft ◽

Jeroen J Bax

Keyword(s):

Computed Tomography ◽

Coronary Artery Disease ◽

Chest Pain ◽

Coronary Artery ◽

Computed Tomography Angiography ◽

Coronary Computed Tomography Angiography ◽

Acute Chest Pain ◽

Coronary Computed Tomography ◽

Non Invasive ◽

Artery Disease

Patients presenting with acute chest pain constitute a common and important diagnostic challenge. This has increased interest in using computed tomography for non-invasive visualization of coronary artery disease in patients presenting with acute chest pain to the emergency department; particularly the subset of patients who are suspected of having an acute coronary syndrome, but without typical electrocardiographic changes and with normal troponin levels at presentation. As a result of rapid developments in coronary computed tomography angiography technology, high diagnostic accuracies for excluding coronary artery disease can be obtained. It has been shown that these patients can be discharged safely. The accuracy for detecting a significant coronary artery stenosis is also high, but the presence of coronary artery atherosclerosis or stenosis does not imply necessarily that the cause of the chest pain is related to coronary artery disease. Moreover, the non-invasive detection of coronary artery disease by computed tomography has been shown to be related with an increased use of subsequent invasive coronary angiography and revascularization, and further studies are needed to define which patients benefit from invasive evaluation following coronary computed tomography angiography. Conversely, the implementation of coronary computed tomography angiography can significantly reduce the length of hospital stay, with a significant cost reduction. Additionally, computed tomography is an excellent modality in patients whose symptoms suggest other causes of acute chest pain such as aortic aneurysm, aortic dissection, or pulmonary embolism. Furthermore, the acquisition of the coronary arteries, thoracic aorta, and pulmonary arteries in a single computed tomography examination is feasible, allowing ‘triple rule-out’ (exclusion of aortic dissection, pulmonary embolism, and coronary artery disease). Finally, other applications, such as the evaluation of coronary artery plaque composition, myocardial function and perfusion, or fractional flow reserve, are currently being developed and may also become valuable in the setting of acute chest pain in the future.

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Non-Invasive Magnetocardiography for the Early Diagnosis of Coronary Artery Disease in Patients Presenting With Acute Chest Pain

Circulation Journal ◽

10.1253/circj.cj-09-0975 ◽

2010 ◽

Vol 74 (7) ◽

pp. 1424-1430 ◽

Cited By ~ 20

Author(s):

Hyukchan Kwon ◽

Kiwoong Kim ◽

Yong-Ho Lee ◽

Jin-Mok Kim ◽

Kwon Kyu Yu ◽

...

Keyword(s):

Coronary Artery Disease ◽

Chest Pain ◽

Coronary Artery ◽

Early Diagnosis ◽

Acute Chest Pain ◽

Non Invasive ◽

Artery Disease

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Is the validity of non-invasive computerized tomography coronary angiography equivalent to invasive coronary angiography for the evaluation of coronary artery disease

10.5353/th_b3972457 ◽

2007 ◽

Author(s):

Wing-hung, Edward Sitt

Keyword(s):

Coronary Artery Disease ◽

Coronary Artery ◽

Coronary Angiography ◽

Computerized Tomography ◽

Invasive Coronary Angiography ◽

Non Invasive ◽

Artery Disease

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Computed tomography angiography and other applications of computed tomography

10.1093/med/9780199687039.003.0022_update_003 ◽

2018 ◽

Author(s):

Michiel A de Graaf ◽

Arthur JHA Scholte ◽

Lucia Kroft ◽

Jeroen J Bax

Keyword(s):

Computed Tomography ◽

Coronary Artery Disease ◽

Chest Pain ◽

Coronary Artery ◽

Computed Tomography Angiography ◽

Coronary Computed Tomography Angiography ◽

Acute Chest Pain ◽

Coronary Computed Tomography ◽

Non Invasive ◽

Artery Disease

Patients presenting with acute chest pain constitute a common and important diagnostic challenge. This has increased interest in using computed tomography for non-invasive visualization of coronary artery disease in patients presenting with acute chest pain to the emergency department; particularly the subset of patients who are suspected of having an acute coronary syndrome, but without typical electrocardiographic changes and with normal troponin levels at presentation. As a result of rapid developments in coronary computed tomography angiography technology, high diagnostic accuracies for excluding coronary artery disease can be obtained. It has been shown that these patients can be discharged safely. The accuracy for detecting a significant coronary artery stenosis is also high, but the presence of coronary artery atherosclerosis or stenosis does not imply necessarily that the cause of the chest pain is related to coronary artery disease. Moreover, the non-invasive detection of coronary artery disease by computed tomography has been shown to be related with an increased use of subsequent invasive coronary angiography and revascularization, and further studies are needed to define which patients benefit from invasive evaluation following coronary computed tomography angiography. Conversely, the implementation of coronary computed tomography angiography can significantly reduce the length of hospital stay, with a significant cost reduction. Additionally, computed tomography is an excellent modality in patients whose symptoms suggest other causes of acute chest pain such as aortic aneurysm, aortic dissection, or pulmonary embolism. Furthermore, the acquisition of the coronary arteries, thoracic aorta, and pulmonary arteries in a single computed tomography examination is feasible, allowing ‘triple rule-out’ (exclusion of aortic dissection, pulmonary embolism, and coronary artery disease). Finally, other applications, such as the evaluation of coronary artery plaque composition, myocardial function and perfusion, or fractional flow reserve, are currently being developed and may also become valuable in the setting of acute chest pain in the future.

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Computed tomography angiography and other applications of computed tomography

10.1093/med/9780199687039.003.0022_update_002 ◽

2017 ◽

Author(s):

Michiel A de Graaf ◽

Arthur JHA Scholte ◽

Lucia Kroft ◽

Jeroen J Bax

Keyword(s):

Computed Tomography ◽

Coronary Artery Disease ◽

Chest Pain ◽

Coronary Artery ◽

Computed Tomography Angiography ◽

Coronary Computed Tomography Angiography ◽

Acute Chest Pain ◽

Coronary Computed Tomography ◽

Non Invasive ◽

Artery Disease

Patients presenting with acute chest pain constitute a common and important diagnostic challenge. This has increased interest in using computed tomography for non-invasive visualization of coronary artery disease in patients presenting with acute chest pain to the emergency department; particularly the subset of patients who are suspected of having an acute coronary syndrome, but without typical electrocardiographic changes and with normal troponin levels at presentation. As a result of rapid developments in coronary computed tomography angiography technology, high diagnostic accuracies for excluding coronary artery disease can be obtained. It has been shown that these patients can be discharged safely. The accuracy for detecting a significant coronary artery stenosis is also high, but the presence of coronary artery atherosclerosis or stenosis does not imply necessarily that the cause of the chest pain is related to coronary artery disease. Moreover, the non-invasive detection of coronary artery disease by computed tomography has been shown to be related with an increased use of subsequent invasive coronary angiography and revascularization, and further studies are needed to define which patients benefit from invasive evaluation following coronary computed tomography angiography. Conversely, the implementation of coronary computed tomography angiography can significantly reduce the length of hospital stay, with a significant cost reduction. Additionally, computed tomography is an excellent modality in patients whose symptoms suggest other causes of acute chest pain such as aortic aneurysm, aortic dissection, or pulmonary embolism. Furthermore, the acquisition of the coronary arteries, thoracic aorta, and pulmonary arteries in a single computed tomography examination is feasible, allowing ‘triple rule-out’ (exclusion of aortic dissection, pulmonary embolism, and coronary artery disease). Finally, other applications, such as the evaluation of coronary artery plaque composition, myocardial function and perfusion, or fractional flow reserve, are currently being developed and may also become valuable in the setting of acute chest pain in the future.

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Diagnostic and prognostic value of coronary artery calcium score of zero: is it time for guidelines to change?

European Heart Journal ◽

10.1093/ehjci/ehaa946.1383 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

E Arbas Redondo ◽

D Tebar Marquez ◽

I.D Poveda Pinedo ◽

R Dalmau Gonzalez-Gallarza ◽

S.C Valbuena Lopez ◽

...

Keyword(s):

Coronary Artery Disease ◽

Coronary Artery ◽

Coronary Angiography ◽

Coronary Artery Calcium ◽

Cardiac Ct ◽

Invasive Coronary Angiography ◽

Agatston Score ◽

Non Invasive ◽

Artery Disease

Abstract Introduction Cardiac computed tomography (CT) use has progressively increased as the preferred initial test to rule out coronary artery disease (CAD) when clinical likelihood is low. Coronary artery calcium (CAC) detected by CT is a well-established marker for cardiovascular risk. However, it is not recommended for diagnosis of obstructive CAD. Absence of CAC, defined as an Agatston score of zero, has been associated to good prognosis despite underestimation of non-calcified plaques. Purpose To evaluate whether zero CAC score could help ruling out obstructive CAD in a safely manner. Methods Observational study based on a prospective database of patients (pts) referred to cardiac CT between 2017 and 2019. Pts with an Agatston score of zero were selected. Results We included 176 pts with zero CAC score and non-invasive coronary angiography performed. The median duration of follow-up was 23.9 months. Baseline characteristics of the population are shown in Table 1. In 117 pts (66.5%), cardiac CT was indicated as part of their chest pain evaluation. Mean age was 57.2 years old, 68.2% were women and only and 9.4% were active smokers. Normal coronary arteries were found in 173 pts (98.3%). Obstructive CAD, defined as ≥50% luminal diameter stenosis of a major vessel, was present in 1/176 (0.6%); while non-obstructive atherosclerotic plaques were found in 2 pts (1.1%). During follow-up, one patient died of out-of-hospital cardiac arrest. None either suffered from myocardial infarction or needed coronary revascularization. Conclusions In our cohort, a zero CAC score detected by cardiac CT rules out obstructive coronary artery disease in 98.3%, with only 1.7% of non-calcified atherosclerosis plaques and 0.6% of major adverse events. Although further research on this topic is needed, these results support the fact that non-invasive coronary angiography could be avoided in patients with low clinical likelihood of CAD and zero CAC score, facilitating the management of the increasing demand for coronary CT and reduction of radiation dose. Funding Acknowledgement Type of funding source: None

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Downstream testing after CT coronary angiography: time for a rethink?

Open Heart ◽

10.1136/openhrt-2021-001597 ◽

2021 ◽

Vol 8 (1) ◽

pp. e001597

Author(s):

Gareth Morgan-Hughes ◽

Michelle Claire Williams ◽

Margaret Loudon ◽

Carl A Roobottom ◽

Alice Veitch ◽

...

Keyword(s):

Coronary Artery Disease ◽

Chest Pain ◽

Coronary Artery ◽

Coronary Angiography ◽

Communication Systems ◽

Ct Coronary Angiography ◽

Second Line ◽

Recent Onset ◽

Line Test ◽

Artery Disease

ObjectiveWe surveyed UK practice and compliance with the National Institute for Health and Care Excellence (NICE) ‘recent-onset chest pain’ guidance (Clinical Guideline 95, 2016) as a service quality initiative. We aimed to evaluate the diagnostic utility and efficacy of CT coronary angiography (CTCA), NICE-guided investigation compliance, invasive coronary angiography (ICA) use and revascularisation.MethodsA prospective analysis was conducted in nine UK centres between January 2018 and March 2020. The reporter decided whether the CTCA was diagnostic. Coronary artery disease was recorded with the Coronary Artery Disease–Reporting and Data System (CAD-RADS). Local electronic records and picture archiving/communication systems were used to collect data regarding functional testing, ICA and revascularisation. Duplication of coronary angiography without revascularisation was taken as a surrogate for ICA overuse.Results5293 patients (mean age, 57±12 years; body mass index, 29±6 kg/m²; 50% men) underwent CTCA, with a 96% diagnostic scan rate. 618 (12%) underwent ICA, of which 48% (298/618) did not receive revascularisation. 3886 (73%) had CAD-RADS 0–2, with 1% (35/3886) undergoing ICA, of which 94% (33/35) received ICA as a second-line test. 547 (10%) had CAD-RADS 3, with 23% (125/547) undergoing ICA, of which 88% (110/125) chose ICA as a second-line test, with 26% (33/125) leading to revascularisation. For 552 (10%) CAD-RADS 4 and 91 (2%) CAD-RADS 5 patients, ICA revascularisation rates were 64% (221/345) and 74% (46/62), respectively.ConclusionsWhile CTCA for recent-onset chest pain assessment has been shown to be a robust test, which negates the need for further investigation in three-quarters of patients, subsequent ICA overuse remains with almost half of these procedures not leading to revascularisation.

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