Objectives This study sought to determine the diagnostic accuracy of 64-slice computed tomographic coronary angiography (CTCA) to detect or rule out significant coronary artery disease (CAD). ...Background CTCA is emerging as a noninvasive technique to detect coronary atherosclerosis. Methods We conducted a prospective, multicenter, multivendor study involving 360 symptomatic patients with acute and stable anginal syndromes who were between 50 and 70 years of age and were referred for diagnostic conventional coronary angiography (CCA) from September 2004 through June 2006. All patients underwent a nonenhanced calcium scan and a CTCA, which was compared with CCA. No patients or segments were excluded because of impaired image quality attributable to either coronary motion or calcifications. Patient-, vessel-, and segment-based sensitivities and specificities were calculated to detect or rule out significant CAD, defined as ≥50% lumen diameter reduction. Results The prevalence among patients of having at least 1 significant stenosis was 68%. In a patient-based analysis, the sensitivity for detecting patients with significant CAD was 99% (95% confidence interval CI: 98% to 100%), specificity was 64% (95% CI: 55% to 73%), positive predictive value was 86% (95% CI: 82% to 90%), and negative predictive value was 97% (95% CI: 94% to 100%). In a segment-based analysis, the sensitivity was 88% (95% CI: 85% to 91%), specificity was 90% (95% CI: 89% to 92%), positive predictive value was 47% (95% CI: 44% to 51%), and negative predictive value was 99% (95% CI: 98% to 99%). Conclusions Among patients in whom a decision had already been made to obtain CCA, 64-slice CTCA was reliable for ruling out significant CAD in patients with stable and unstable anginal syndromes. A positive 64-slice CTCA scan often overestimates the severity of atherosclerotic obstructions and requires further testing to guide patient management.
Abstract Objectives The aim of this study was to investigate the individual and combined accuracy of dynamic computed tomography (CT) myocardial perfusion imaging (MPI) and computed tomography ...angiography (CTA) fractional flow reserve (FFR) for the identification of functionally relevant coronary artery disease (CAD). Background Coronary CTA has become an established diagnostic test for ruling out CAD, but it does not allow interpretation of the hemodynamic severity of stenotic lesions. Two recently introduced functional CT techniques are dynamic MPI and CTA FFR using computational fluid dynamics. Methods From 2 institutions, 74 patients (n = 62 men, mean age 61 years) planned for invasive angiography with invasive FFR measurement in 142 vessels underwent CTA imaging and dynamic CT MPI during adenosine vasodilation. A patient-specific myocardial blood flow index was calculated, normalized to remote myocardial global left ventricular blood flow. CTA FFR was computed using an on-site, clinician-operated application. Using binary regression, a single functional CT variable was created combining both CT MPI and CTA FFR. Finally, stepwise diagnostic work-up of CTA FFR with selective use of CT MPI was simulated. The diagnostic performance of CT MPI, CTA FFR, and CT MPI integrated with CTA FFR was evaluated using C statistics with invasive FFR, with a threshold of 0.80 as a reference. Results Sensitivity, specificity, and accuracy were 73% (95% confidence interval CI: 61% to 86%), 68% (95% CI: 56% to 80%), and 70% (95% CI: 62% to 79%) for CT MPI and 82% (95% CI: 72% to 92%), 60% (95% CI: 48% to 72%), and 70% (63% to 80%) for CTA FFR. For CT MPI integrated with CTA FFR, diagnostic accuracy was 79% (95% CI: 71% to 87%), with improvement of the area under the curve from 0.78 to 0.85 (p < 0.05). Accuracy of the stepwise approach was 77%. Conclusions CT MPI and CTA FFR both identify functionally significant CAD, with comparable accuracy. Diagnostic performance can be improved by combining the techniques. A stepwise approach, reserving CT MPI for intermediate CTA FFR results, also improves diagnostic performance while omitting nearly one-half of the population from CT MPI examinations.
64-Slice Computed Tomography Coronary Angiography in Patients With High, Intermediate, or Low Pretest Probability of Significant Coronary Artery Disease W. Bob Meijboom, Carlos A. G. van Mieghem, ...Nico R. Mollet, Francesca Pugliese, Annick C. Weustink, Niels van Pelt, Filippo Cademartiri, Koen Nieman, Eric Boersma, Peter de Jaegere, Gabriel P. Krestin, Pim J. de Feyter We assessed the usefulness of 64-slice computed tomography (CT) coronary angiography to detect or rule out coronary artery disease (CAD) in patients with various estimated pretest probabilities. The estimated pretest probability of CAD in patients with high, intermediate, or low pretest probability was 87%, 53%, and 13%. The estimated post-test probability of a negative CT scan was 17%, 0%, and 0%, and of a positive CT scan was 96%, 88%, and 68%. Computed tomography coronary angiography is useful in symptomatic patients with low or intermediate estimated pretest probability of having CAD and does not provide additional diagnostic information in patients with a high estimated pretest probability.
Patients with asymptomatic heart failure (HF; stage A and B) are characterized by maladaptive left ventricular (LV) remodeling. Classic 4-group classification of remodeling considers only LV mass ...index and relative wall thickness as variables. Complex remodeling classification (CRC) includes also LV end-diastolic volume index. Main aim was to assess the prognostic impact of CRC in stage A and B HF. A total of 1,750 asymptomatic subjects underwent echocardiographic examination as a screening evaluation in the presence of cardiovascular risk factors. LV dysfunction, both systolic (ejection fraction) and diastolic (transmitral flow velocity pattern), was evaluated, together with LV remodeling. We considered a composite end point: all-cause death, myocardial infarction, coronary revascularizations, cerebrovascular events, and acute pulmonary edema. CRC was suitable for 1,729 patients (men 53.6%; age 58.3 ± 13 years). Two hundred thirty-eight patients presented systolic dysfunction (ejection fraction <50%) and 483 diastolic dysfunction. According to the CRC, 891 patients were normals or presented with physiologic hypertrophy, 273 concentric remodeling, 47 eccentric remodeling, 350 concentric hypertrophy, 29 mixed hypertrophy, 86 dilated hypertrophy, and 53 eccentric hypertrophy. Age and gender distribution was noticed (p <0.001). After a median follow-up of 21 months, Kaplan-Meier analysis showed different survival distribution (p <0.001) of the CRC patterns. In multivariate Cox regression (adjusted for age, gender, history of stable ischemic heart disease, classic remodeling classification, systolic, and diastolic dysfunction), CRC was independent predictor of primary end point (p = 0.044, hazard ratio 1.101, 95% CI 1.003 to 1.21), confirmed in a logistic regression (p <0.03). In conclusion, CRC could help physicians in prognostic stratification of patients in stage A and B HF.
Objectives We sought to investigate whether positron emission tomography/computed tomography (CT) angiography using 11 C-PK11195, a selective ligand for peripheral benzodiazepine receptors expressed ...in activated macrophages, can be used to image vascular inflammation. Background Activated macrophages and T lymphocytes are fundamental elements in the pathogenesis of large-vessel vasculitides. Methods Fifteen patients (age 52 ± 16 years) with systemic inflammatory disorders (6 consecutive symptomatic patients with clinical suspicion of active vasculitis and 9 asymptomatic control patients) underwent positron emission tomography with 11 C-PK11195 and CT angiography. 11 C-PK11195 uptake was measured by calculating target-to-background ratios of activity normalized to venous blood. Results Coregistration of positron emission tomography with contrast-enhanced CT angiography facilitated localization of 11 C-PK11195 arterial wall uptake. Visual analysis revealed focal 11 C-PK11195 uptake in the arterial wall of all 6 symptomatic patients, but in none of the asymptomatic controls. Although serum inflammatory biomarkers (C-reactive protein, erythrocyte sedimentation rate, white cell count) did not differ significantly between the 2 groups, symptomatic patients had increased 11 C-PK11195 vascular uptake (target-to-background ratio 2.41 ± 1.59 vs. 0.98 ± 0.10; p = 0.001). Conclusions By binding to activated macrophages in the vessel wall, 11 C-PK11195 enables noninvasive imaging of vascular inflammation. Alternative longer-lived radioligands for probing peripheral benzodiazepine receptors are being tested for wider clinical applications.
Usefulness of 64-Slice Multislice Computed Tomography Coronary Angiography to Assess In-Stent Restenosis Filippo Cademartiri, Joanne D. Schuijf, Francesca Pugliese, Nico R. Mollet, J. Wouter Jukema, ...Erica Maffei, Lucia J. Kroft, Alessandro Palumbo, Diego Ardissino, Patrick W. Serruys, Gabriel P. Krestin, Ernst E. Van der Wall, Pim J. de Feyter, Jeroen J. Bax The purpose of the present study was to evaluate the diagnostic accuracy of 64-slice multislice computed tomography (MSCT) coronary angiography in the follow-up of patients with previous coronary stent implantation. In 182 patients with 192 previously implanted stents, 64-slice MSCT angiography was performed in addition to quantitative coronary angiography to evaluate the presence of in-stent restenosis (≥50%). In total, 14 (7.3%) stents were uninterpretable. In the interpretable stents, sensitivity, specificity, and positive and negative predictive value to identify in-stent restenosis were 95.0%, 93.0%, 63.3%, and 99.3%, respectively. Accordingly, 64-slice MSCT may be valuable as a noninvasive method of excluding in-stent restenosis.
Abstract Background Concerns have been raised about radiation dose of coronary CT angiography. Although high-pitch acquisition technique yields high potential for radiation dose savings, it is more ...vulnerable to artifacts, which impair diagnostic image quality. Objective The purpose of this study was to compare 2 scan strategies for coronary CT angiography: a high-pitch helical scan first or a conventional scan first strategy. Methods In this prospective, multicenter trial, we randomized 303 consecutive patients with a low and stable heart rate to either of the aforementioned mentioned strategies. Intravenous β-blockers were administered to achieve target heart rates. All scans were performed on a second-generation dual-source CT scanner. In case of nondiagnostic image quality, coronary CT angiography was allowed to be repeated. The primary end point was to demonstrate noninferior image quality in the high-pitch group. Image quality was assessed on a 4-point scale (1: nondiagnostic, 4: excellent). Secondary end point was total radiation dose. Results In the high-pitch helical first group, repeat scanning was necessary in 21 patients compared with 14 patients in the conventional first scan group ( P = .25). Image quality in the high-pitch group was noninferior compared to the conventional scan group (3.81 ± 0.35 vs 3.83 ± 0.37; P for noninferiority <.0001). The total effective radiation dose estimate was 58% lower in the high-pitch group (2.0 ± 2.4 vs 4.7 ± 4.8 mSv; P < .0001). Conclusions In patients with a low and stable heart rate diagnostic image quality can be maintained with a high-pitch helical scan first strategy while 58% of radiation dose can be saved.
Abstract Background In patients with chronic angina-like chest pain, the probability of coronary artery disease (CAD) is estimated by symptoms, age, and sex according to the Genders clinical model. ...We investigated the incremental value of circulating biomarkers over the Genders model to predict functionally significant CAD in patients with chronic chest pain. Methods In 527 patients (60.4 years, standard deviation, 8.9 years; 61.3% male participants) enrolled in the European Ev aluation of In tegrated Cardiac I maging (EVINCI) study, clinical and biohumoral data were collected. Results Functionally significant CAD—ie, obstructive coronary disease seen at invasive angiography causing myocardial ischemia at stress imaging or associated with reduced fractional flow reserve (FFR < 0.8), or both—was present in 15.2% of patients. High-density lipoprotein (HDL) cholesterol, aspartate aminotransferase (AST) levels, and high-sensitivity C-reactive protein (hs-CRP) were the only independent predictors of disease among 31 biomarkers analyzed. The model integrating these biohumoral markers with clinical variables outperformed the Genders model by receiver operating characteristic curve (ROC) (area under the curve AUC, 0.70 standard error (SE), 0.03 vs 0.58 SE, 0.03, respectively, P < 0.001) and reclassification analysis (net reclassification improvement, 0.15 SE, 0.07; P = 0.04). Cross-validation of the ROC analysis confirmed the discrimination ability of the new model (AUC, 0.66). As many as 56% of patients who were assigned to a higher pretest probability by the Genders model were correctly reassigned to a low probability class (< 15%) by the new integrated model. Conclusions The Genders model has a low accuracy for predicting functionally significant CAD. A new model integrating HDL cholesterol, AST, and hs-CRP levels with common clinical variables has a higher predictive accuracy for functionally significant CAD and allows the reclassification of patients from an intermediate/high to a low pretest likelihood of CAD.
We compared the diagnostic accuracy of 64-slice computed tomographic (CT) coronary angiography to detect significant coronary artery disease (CAD) in women and men. The 64-slice CT coronary ...angiography was performed in 402 symptomatic patients, 123 women and 279 men, with CAD prevalence of 51% and 68%, respectively. Significant CAD, defined as ≥50% coronary stenosis on quantitative coronary angiography, was evaluated on a patient, vessel, and segment level. The sensitivity and negative predictive value to detect significant CAD was very good, both for women and men (100% vs 99%, p = NS; 100% vs 98%, p = NS), whereas diagnostic accuracy (88% vs 96%; p <0.01), specificity (75% vs 90%, p <0.05), and positive predictive value (81% vs 95%, p <0.001) were lower in women. The per-segment analysis demonstrated lower sensitivity in women compared with men (82% vs 93%, p <0.001). The sensitivity in women did not show a difference in proximal and midsegments, but was significantly lower in distal segments (56% vs 85%, p <0.05) and side branches (54% vs 89%, p <0.001). In conclusion, CT coronary angiography reliably rules out the presence of obstructive CAD in both men and women. Specificity and positive predictive value of CT coronary angiography were lower in women. The sensitivity to detect stenosis in small coronary branches was lower in women compared with men.
In this paper, we describe a rare case of coronary artery aneurysms occasionally found on a pre interventional Coronary Computed Tomography Angiography performed on a 67-year-old man with a history ...of aneurysm of the ascending aorta previously treated with Bentall surgery, who arrived at our hospital to have a percutaneous valve-in-valve implantation procedure. Even though the patient was considered not eligible for the procedure, due to his many comorbidities, and conservatively managed, at 1-year followup his angiographic condition remained stable.
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