Coronary computed tomography
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
In meta-analyses CTA has demonstrated a high diagnostic accuracy to identify patients with ≥50% stenoses by QCA, with a pooled AUC of 0.99. (1,2) Multicenter studies yielded AUCs of 0.93 and 0.96 for 64-slice detector technology. (3-6) However, assessment of stenosis severity in individual coronary arterial lesions is more limited. In the study by Meijboom et al. (5) sensitivity for detecting ≥50% stenoses by QCA decreased from 99% on a patient level to 88% on a segment-based analysis and positive predictive value fell from 86% to 47%.
Using the presence or absence of obstructive and nonobstructive coronary artery disease, extensive data has accumulated demonstrating the prognostic information of CTA. Several studies examined the positive predictive value of CTA. (7,8)Bamberg et al report on the predictive value of the presence and the extent of CAD by CTA in their meta-analysis of 11 studies enrolling 7,335 patients. In patients with ≥1 significant coronary stenosis, annualized event rate (including revascularization) and hazard ratio were 11.9% and 10.74, respectively. (8)
More importantly, several studies demonstrate a low incidence of myocardial infarction or CAD-related death in patients after a normal CTA over a period of at least 2 years and possibly >5 years. (10-13)
In a meta-analysis of 9,592 patients from 17 studies, Hulten et al reported a sensitivity of 99% (95% CI 0.93-1.00, P < .001) to exclude adverse cardiovascular events at follow up. During the median follow-up period of 20 months, myocardial infarction or death occurred in 0.15% per year, which is comparable to healthy low-risk populations adjusted for age. (7) The CONFIRM international registry reported an annualized death rate of 0.28% after a normal CTA in 24,775 patients. (14)
Because of the high negative predictive value, CTA is suitable for clinical situations in which the exclusion of significant proximal disease is required.
- Several studies describe the negative predictive value of CT in patient presenting to the ED with chest pain. (15-18)
- This could include preoperative coronary evaluation before non-cardiac surgery.
References
Further Reading
1. von Ballmoos MW, Haring B, Juillerat P, Alkadhi H. Meta-analysis: Diagnostic performance of low-radiation-dose coronary computed tomography angiography. Ann Intern Med 2011;154(6):413-20.
2. Mowatt G, Cook JA, Hillis GS, Walker S, Fraser C, Jia X, et al. 64-Slice computed tomography angiography in the diagnosis and assessment of coronary artery disease: Systematic review and meta-analysis. Heart 2008;94(11):1386-93.
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3. Budoff MJ, Dowe D, Jollis JG, Gitter M, Sutherland J, Halamert E, et al. Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: Results from the prospective multicenter ACCURACY. J Am Coll Cardiol 2008;52(21):1724-32.
4. Arbab-Zadeh A, Miller JM, Rochitte CE, Dewey M, Niinuma H, Gottlieb I, et al. Diagnostic accuracy of CT coronary angiography according to pretest probability of coronary artery disease and severity of coronary arterial calcification: The CorE-64 international, multicenter study. J Am Coll Cardiol 2012;59:379-87.
5. Meijboom WB, Meijs MF, Schuijf JD, Cramer MJ, Mollet NR, van Mieghem CA, et al. Diagnostic accuracy of 64-slice computed tomography coronary angiography: A prospective, multicenter, multivendor study. J Am Coll Cardiol 2008;52:2135-44.
6. Miller JM, Rochitte CE, Dewey M, Arbab-Zadeh A, Niinuma H, Gottlieb I, Paul N, Clouse ME, Shapiro EP, Hoe J, Lardo AC, Bush DE, de Roos A, Cox C, Brinker J, Lima JA. Diagnostic performance of coronary angiography by 64-row CT. N Engl J Med. 2008 Nov 27;359(22):2324-36.
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7. Hulten EA, Carbonaro S, Petrillo SP, Mitchell JD, Villines TC. Prognostic value of cardiac computed tomography angiography: a systematic review and meta-analysis. J Am Coll Cardiol. 2011;57:1237-47.
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9. Bamberg F, Sommer WH, Hoffmann V, Achenbach S, Nikolaou K, Conen D, et al. Meta-analysis and systematic review of the long-term predictive value of assessment of coronary atherosclerosis by contrast-enhanced coronary computed tomography angiography. J Am Coll Cardiol 2011;57(24):2426-36.
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10. Chow BJ, Wells GA, Chen L, Yam Y, Galiwango P, Abraham A, et al. Prognostic value of 64-slice cardiac computed tomography severity of coronary artery disease, coronary atherosclerosis, and left ventricular ejection fraction. J Am Coll Cardiol 2010;55(10):1017-28.
11.Ostrom MP, Gopal A, Ahmadi N, Nasir K, Yang E, Kakadiaris I, et al. Mortality incidence and the severity of coronary atherosclerosis assessed by computed tomography angiography. J Am Coll Cardiol 2008;52(16):1335-43.
12. Lin F, Shaw LJ, Berman DS, Callister TQ, Weinsaft JW, Wong FJ, et al. Multidetector computed tomography coronary artery plaque predictors of stress-induced myocardial ischemia by SPECT. Atherosclerosis 2008;197:700-9.
13. Gilard M, Le Gal G, Cornily JC, Vinsonneau U, Joret C, Pennec PY, et al. Midterm prognosis of patients with suspected coronary artery disease and normal multislice computed tomographic findings: A prospective management outcome study. Arch Intern Med 2007;167:1686-9.
14. Min JK, Dunning A, Lin FY, Achenbach S, Al-Mallah M, Budoff MJ, et al. Age- and sex-related differences in all-cause mortality risk based on coronary computed tomography angiography findings results from the international multicenter CONFIRM (coronary CT angiography evaluation for clinical outcomes: An international multicenter registry) of 23,854 patients without known coronary artery disease. J Am Coll Cardiol 2011;58(8):849-60.
15. Rubinshtein R, Halon DA, Gaspar T, Jaffe R, Goldstein J, Karkabi B, et al. Impact of 64 slice cardiac computed tomographic angiography on clinical decision making in emergency department patients with chest pain of possible myocardial ischemic origin. Am J Cardiol 2007;100:1522-6.
16. Schlett CL, Banerji D, Siegel E, Bamberg F, Lehman SJ, Ferencik M, et al. Prognostic value of CT angiography for major adverse cardiac events in patients with acute chest pain from the emergency department: 2-year outcomes of the ROMICAT trial. JACC Cardiovasc Imaging 2011;4(5):481-91.
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17. Goldstein JA, Chinnaiyan KM, Abidov A, Achenbach S, Berman DS, Hayes SW, et al. The CT-STAT (coronary computed tomographic angiography for systematic triage of acute chest pain patients to treatment) trial. J Am Coll Cardiol 2011;58(14):1414-22.
18. Litt HI, Gatsonis C, Snyder B, Singh H, Miller CD, Entrikin DW, et al. CT angiography for safe discharge of patients with possible acute coronary syndromes. N Engl J Med 26 March 2012. [Epub ahead of print]