Coronary heart disease CT

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Clinical practice guidelines address the usage of coronary computed tomographic angiography (CCTA)[1][2].

Coronary calcium scores

The Agatston scores are:

  • 0 No identifiable disease
  • 1 to 99 Mild disease
  • 100 to 399 Moderate disease
  • ≥400 Severe disease

In asymptomatic patients

Clinical practice guidelines

In 2018, the United States Preventive Services Task Force (USPSTF) guideline[3] and evidence report[4] concluded:

  • "the current evidence is insufficient to assess the balance of benefits and harms of using the ABI, hsCRP level, or CAC score in risk assessment for CVD in asymptomatic adults to prevent CVD events"

The 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol concluded[5]:

  • "In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dL to 189 mg/dL (≥1.8–4.9 mmol/L), at a 10-year ASCVD risk of ≥7.5% to 19.9%, if a decision about statin therapy is uncertain, consider measuring CAC."


Yeboah et al[6] found in a cohort study that the reclassification[7] was:

  • Among patients without an event, the ASCVD risk alone with less than 7.5% in 82.3% and >= 7.5% in 17.7%. With the CAC:
    • The predicted risk was < 7.5% in 76.2%. Thus, the true negative rate dropped by 6%.
    • The predicted risk was >= 7.5% in 23.8%. Thus the false positive rate rose by 6%
  • Among patients with an event, the ASCVD risk alone was over 7.5% in 42.8%. With the CAC:
    • The predicted risk was < 7.5% in 60.6%. Thus the true positive rate rose by 18%

Overall, the net classification improvement was 12% (18% - 6%) and the accuracy dropped due to the drop in specificity in a population with low prevalence.

A preliminary randomized controlled trial of CAC suggests benefit on LDL levels[8].

Systematic review

Coronary artery calcium (CAC) scoring adds 4% the C-statistic for predicting ASCVD outcomes[9].

Coronary computed tomographic angiography (CCTA)

The role of coronary computed tomographic angiography (CCTA) versus functional testing is not clear:

  • The SCOT-HEART trial in 2015 did not find clear statistical evidence of benefit although there was a trend towards less cardiac outcomes among patients who received CCTA[10]
  • The PROMISE trial in 2015 did not find benefit[11]
  • A meta-analysis in 2018 that included the SCOT-HEART and PROMISE trials found no benefit[12]
  • Subsequent publication of longer term follow-up of the SCOT-HEART trial found cardiac benefit[13] The benefit may be in part due to "During follow-up, patients assigned to CTA were more likely than patients assigned to standard care alone to have commenced preventive therapies (19.4% [402 patients] vs. 14.7% [305 patients]; odds ratio, 1.40; 95% confidence interval [CI], 1.19 to 1.65)." This is larger than the difference in clinical outcomes, "2.3% [48 patients] in the CTA group vs. 3.9% [81 patients] in the standard-care group; hazard ratio, 0.59; 95% CI, 0.41 to 0.84; P=0.004."

CCTA may best benefit patients with intermediate risk[14][15].

Noninvasive fractional flow reserve

Estimation of fractional flow reserve using coronary computed tomographic angiography (FFRCT) did not reduce cardiac events over one year[16].

Epidural fatpad thickness


  1. Knuuti J, Wijns W, Saraste A, Capodanno D, Barbato E, Funck-Brentano C; et al. (2020). "2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes". Eur Heart J. 41 (3): 407–477. doi:10.1093/eurheartj/ehz425. PMID 31504439.
  2. Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP; et al. (2012). "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 126 (25): 3097–137. doi:10.1161/CIR.0b013e3182776f83. PMID 23166210. Check |pmid= value (help).
  3. US Preventive Services Task Force. Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB; et al. (2018). "Risk Assessment for Cardiovascular Disease With Nontraditional Risk Factors: US Preventive Services Task Force Recommendation Statement". JAMA. 320 (3): 272–280. doi:10.1001/jama.2018.8359. PMID 29998297.
  4. Lin JS, Evans CV, Johnson E, Redmond N, Coppola EL, Smith N (2018). "Nontraditional Risk Factors in Cardiovascular Disease Risk Assessment: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force". JAMA. 320 (3): 281–297. doi:10.1001/jama.2018.4242. PMID 29998301.
  5. Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS; et al. (2019). "2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". Circulation. 139 (25): e1082–e1143. doi:10.1161/CIR.0000000000000625. PMC 7403606 Check |pmc= value (help). PMID 30586774.
  6. Yeboah J, Young R, McClelland RL, Delaney JC, Polonsky TS, Dawood FZ; et al. (2016). "Utility of Nontraditional Risk Markers in Atherosclerotic Cardiovascular Disease Risk Assessment". J Am Coll Cardiol. 67 (2): 139–147. doi:10.1016/j.jacc.2015.10.058. PMC 4724058. PMID 26791059.
  7. Kerr KF, Wang Z, Janes H, McClelland RL, Psaty BM, Pepe MS (2014). "Net reclassification indices for evaluating risk prediction instruments: a critical review". Epidemiology. 25 (1): 114–21. doi:10.1097/EDE.0000000000000018. PMC 3918180. PMID 24240655.
  8. Muhlestein JB, Knowlton KU, Le VT, Lappe DL, May HT, Min DB; et al. (2022). "Coronary Artery Calcium Versus Pooled Cohort Equations Score for Primary Prevention Guidance: Randomized Feasibility Trial". JACC Cardiovasc Imaging. 15 (5): 843–855. doi:10.1016/j.jcmg.2021.11.006. PMID 34922872 Check |pmid= value (help).
  9. Bell, Katy J. L.; White, Sam; Hassan, Omar; Zhu, Lin; Scott, Anna Mae; Clark, Justin; Glasziou, Paul (1 June 2022). "Evaluation of the Incremental Value of a Coronary Artery Calcium Score Beyond Traditional Cardiovascular Risk Assessment". JAMA Internal Medicine. 182 (6): 634. doi:10.1001/jamainternmed.2022.1262. ISSN 2168-6106. PMID 35467692 Check |pmid= value (help).
  10. SCOT-HEART investigators (2015). "CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): an open-label, parallel-group, multicentre trial". Lancet. 385 (9985): 2383–91. doi:10.1016/S0140-6736(15)60291-4. PMID 25788230.
  11. Douglas PS, Hoffmann U, Patel MR, Mark DB, Al-Khalidi HR, Cavanaugh B; et al. (2015). "Outcomes of anatomical versus functional testing for coronary artery disease". N Engl J Med. 372 (14): 1291–300. doi:10.1056/NEJMoa1415516. PMC 4473773. PMID 25773919. Review in: Evid Based Med. 2015 Aug;20(4):145 Review in: Ann Intern Med. 2015 Aug 18;163(4):JC11
  12. Siontis GC, Mavridis D, Greenwood JP, Coles B, Nikolakopoulou A, Jüni P; et al. (2018). "Outcomes of non-invasive diagnostic modalities for the detection of coronary artery disease: network meta-analysis of diagnostic randomised controlled trials". BMJ. 360: k504. doi:10.1136/bmj.k504. PMC 5820645. PMID 29467161.
  13. SCOT-HEART Investigators. Newby DE, Adamson PD, Berry C, Boon NA, Dweck MR; et al. (2018). "Coronary CT Angiography and 5-Year Risk of Myocardial Infarction". N Engl J Med. 379 (10): 924–933. doi:10.1056/NEJMoa1805971. PMID 30145934. Review in: Ann Intern Med. 2018 Dec 18;169(12):JC70
  14. Han D, Beecy A, Anchouche K, Gransar H, Dunham PC, Lee JH; et al. (2019). "Risk Reclassification With Coronary Computed Tomography Angiography-Visualized Nonobstructive Coronary Artery Disease According to 2018 American College of Cardiology/American Heart Association Cholesterol Guidelines (from the Coronary Computed Tomography Angiography Evaluation for Clinical Outcomes : An International Multicenter Registry [CONFIRM])". Am J Cardiol. 124 (9): 1397–1405. doi:10.1016/j.amjcard.2019.07.045. PMID 31547994.
  15. DISCHARGE Trial Group. Maurovich-Horvat P, Bosserdt M, Kofoed KF, Rieckmann N, Benedek T; et al. (2022). "CT or Invasive Coronary Angiography in Stable Chest Pain". N Engl J Med. doi:10.1056/NEJMoa2200963. PMID 35240010 Check |pmid= value (help).
  16. Douglas PS, De Bruyne B, Pontone G, Patel MR, Norgaard BL, Byrne RA; et al. (2016). "1-Year Outcomes of FFRCT-Guided Care in Patients With Suspected Coronary Disease: The PLATFORM Study". J Am Coll Cardiol. 68 (5): 435–445. doi:10.1016/j.jacc.2016.05.057. PMID 27470449.