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.
Prognostic Value of Multislice Computed Tomography Coronary Angiography in Patients With Known or Suspected Coronary Artery Disease Gabija Pundziute, Joanne D. Schuijf, J. Wouter Jukema, Eric ...Boersma, Albert de Roos, Ernst E. van der Wall, Jeroen J. Bax The goal of the study was to determine the prognostic value of multislice computed tomography (MSCT) in patients with known or suspected coronary artery disease (CAD). A total of 100 patients underwent MSCT and were followed up for the occurrence of cardiac death, nonfatal myocardial infarction, unstable angina requiring hospitalization, and revascularization. During a mean follow-up of 16 months, 33 events occurred in 26 patients. The first-year event rate in patients with no CAD was 0% versus 30% in patients with CAD. Patients with obstructive lesions (particularly in the left main and left anterior descending coronary arteries) were at greatest risk. The MSCT variables reflecting coronary plaque burden were shown to be independent predictors of events over baseline clinical risk factors.
Objectives This study was designed to determine whether multislice computed tomography (MSCT) coronary angiography has incremental prognostic value over single-photon emission computed tomography ...myocardial perfusion imaging (MPI) in patients with suspected coronary artery disease (CAD). Background Although MSCT is used for the detection of CAD in addition to MPI, its incremental prognostic value is unclear. Methods In 541 patients (59% male, age 59 ± 11 years) referred for further cardiac evaluation, both MSCT and MPI were performed. The following events were recorded: all-cause death, nonfatal infarction, and unstable angina requiring revascularization. Results In the 517 (96%) patients with an interpretable MSCT, significant CAD (MSCT ≥50% stenosis) was detected in 158 (31%) patients, and abnormal perfusion (summed stress score SSS: ≥4) was observed in 168 (33%) patients. During follow-up (median 672 days; 25th, 75th percentile: 420, 896), an event occurred in 23 (5.2%) patients. After correction for baseline characteristics in a multivariate model, MSCT emerged as an independent predictor of events with an incremental prognostic value to MPI. The annualized hard event rate (all-cause mortality and nonfatal infarction) in patients with none or mild CAD (MSCT <50% stenosis) was 1.8% versus 4.8% in patients with significant CAD (MSCT ≥50% stenosis). A normal MPI (SSS <4) and abnormal MPI (SSS ≥4) were associated with an annualized hard event rate of 1.1% and 3.8%, respectively. Both MSCT and MPI were synergistic, and combined use resulted in significantly improved prediction (log-rank test p value <0.005). Conclusions MSCT is an independent predictor of events and provides incremental prognostic value to MPI. Combined anatomical and functional assessment may allow improved risk stratification.
Noninvasive Evaluation With Multislice Computed Tomography in Suspected Acute Coronary Syndrome: Plaque Morphology on Multislice Computed Tomography Versus Coronary Calcium Score Maureen M. Henneman, ...Joanne D. Schuijf, Gabija Pundziute, Jacob M. van Werkhoven, J. Wouter Jukema, Jeroen J. Bax In 40 consecutive patients with suspected acute coronary syndrome (ACS), atherosclerotic plaque burden and morphology were evaluated by multislice computed tomography (MSCT) coronary angiography and related to the calcium score. In 38 patients, coronary artery disease was observed. Coronary calcium was detected in 27 patients, of whom 10 had a score >400. In 13 patients, coronary calcium was absent, but 11 of them had atherosclerosis on MSCT. In patients with suspected ACS, the absence of coronary calcium does not reliably exclude the presence of (significant) atherosclerosis. This information may be of value to improve our understanding of the potential role of MSCT in this patient population.
Head-to-Head Comparison of Coronary Plaque Evaluation Between Multislice Computed Tomography and Intravascular Ultrasound Radiofrequency Data Analysis Gabija Pundziute, Joanne D. Schuijf, J. Wouter ...Jukema, Isabel Decramer, Giovanna Sarno, Piet K. Vanhoenacker, Johannes H. C. Reiber, Martin J. Schalij, William Wijns, Jeroen J. Bax The aim of the study was to perform a head-to-head comparison of coronary plaque observations with 64-slice multislice computed tomography (MSCT) (calcium score and coronary angiography) to virtual histology intravascular ultrasound (VH IVUS). In total, 168 plaques in 50 patients were evaluated by both techniques. A moderate correlation was observed between the Agatston score on MSCT and calcium volume on VH IVUS. Noncalcified plaques on MSCT contained more fibrotic and fibro-fatty tissues on VH IVUS as compared with calcified plaques, whereas mixed (noncalcified and calcified components within the same plaque) and calcified plaques contained more dense calcium. Mixed plaques on MSCT were associated with high-risk features on VH IVUS.
A considerable number of patients with an acute coronary syndrome (ACS) who present with a 0 or low calcium score (CS) still demonstrate coronary artery disease (CAD) and significant stenosis. The ...aim of the present study was to evaluate the relation between the CS and the degree and character of atherosclerosis in patients with suspected ACS versus patients with stable CAD obtained by computed tomography angiography and virtual histology intravascular ultrasound (VH IVUS). Overall 112 patients were studied, 53 with ACS and 59 with stable CAD. Calcium scoring and computed tomography angiography were performed and followed by VH IVUS. On computed tomography angiography each segment was evaluated for plaque and classified as noncalcified, mixed, or calcified. Vulnerable plaque characteristics on VH IVUS were defined by percent necrotic core and presence of thin-cap fibroatheroma. If the CS was 0, patients with ACS had a higher mean number of plaques (5.0 ± 2.0 vs 2.0 ± 1.9, p <0.05) and noncalcified plaques (4.6 ± 3.5 vs 1.3 ± 1.9, p <0.05) on computed tomography angiography than those with stable CAD. If the CS was 0, VH IVUS demonstrated that patients with ACS had a larger amount of necrotic core area (0.58 ± 0.73 vs 0.22 ± 0.43 mm2 , p <0.05) and a higher mean number of thin-cap fibroatheromas (0.6 ± 0.7 vs 0.1 ± 0.3, p <0.05) than patients with stable CAD. In conclusion, even in the presence of a 0 CS, patients with ACS have increased plaque burden and increased vulnerability compared to patients with stable CAD. Therefore, absence of coronary calcification does not exclude the presence of clinically relevant and potentially vulnerable atherosclerotic plaque burden in patients with ACS.
Both myocardial perfusion imaging (MPI) and multislice computed tomography (MSCT) are currently used to detect coronary artery disease (CAD). However, MSCT permits early detection of atherosclerosis ...while myocardial perfusion is still normal. In addition, MPI results can be normal despite the presence of high-risk CAD (left main and balanced 3-vessel CAD). In this study, the range of anatomic findings using MSCT in patients with normal MPI results was evaluated. In 180 patients presenting with chest pain, MPI (with gated single-photon emission computed tomography) and 64-slice MSCT were performed. In patients with normal MPI results, prevalences of completely normal coronary arteries, nonobstructive CAD, and obstructive CAD were determined using MSCT. The occurrence of high-risk CAD, including left main and 3-vessel disease, was also evaluated. Normal MPI and adequate MSCT findings were obtained in 97 patients (54%; 50% women; average age 58 ± 12 years; 5% with known CAD). A total of 38 patients (39%) showed normal coronary anatomy, whereas nonsignificant and significant CAD were observed in 37 (38%) and 18 patients (19%), respectively. Importantly, only 4 patients (4%) presented with high-risk CAD using 64-slice MSCT, 2 with left main and 2 with 3-vessel disease. In conclusion, a normal MPI result can be associated with a wide range of anatomic observations and cannot exclude the presence of both nonobstructive and obstructive CAD. However, importantly, the prevalence of high-risk CAD was rare.
Data evaluating gender- and age-specific differences in plaque observations on multislice computed tomography (MSCT) are scarce. Accordingly, the aim of this study was to evaluate coronary plaque ...patterns in men and women in relation to age using MSCT. The findings were compared to observations on grayscale intravascular ultrasound (IVUS) and virtual histology (VH) IVUS. In total, 93 patients (59 men, 34 women) underwent 64-slice MSCT followed by conventional coronary angiography with IVUS. Plaque extent and composition were assessed on MSCT, grayscale IVUS, and VH IVUS. Coronary plaque patterns were compared between men and women in 2 age groups (<65 and ≥65 years old). In patients aged <65 years, more plaques were observed on MSCT in men (6 ± 4 vs 2 ± 2 in women, p <0.001). Also, a larger plaque burden was observed on grayscale IVUS in men (45.7 ± 11.4% vs 36.3 ± 11.6% in women, p <0.001). Similarly, more mixed plaques were observed in men (3 ± 3 vs 1 ± 1 in women, p = 0.003), whereas a larger arc of calcium was detected on grayscale IVUS in men (91.7 ± 93.5° vs 25.7 ± 51.0° in women, p <0.001). On VH IVUS, the prevalence of thin-cap fibroatheroma was higher in men (31% vs 0%) compared to women. In patients aged ≥65 years old, no important differences in plaque patterns were observed between men and women. In conclusion, more extensive atherosclerosis and more calcified lesions were observed in men than in women. These differences were predominantly present in patients aged <65 years and were lost in those aged ≥65 years.
Multislice computed tomographic coronary angiography (MSCT) can accurately detect the presence of atherosclerosis noninvasively. However, a discrepancy has been observed between MSCT and noninvasive ...functional imaging. The purpose of the present study was to evaluate the correlation between MSCT and invasive fractional flow reserve (FFR) in men with known coronary artery disease. Thirty-three patients (mean age 57 ± 11 years) clinically referred for coronary angiography underwent MSCT and FFR analysis. Coronary angiography and MSCT were evaluated for nonsignificant (30% to 50% luminal narrowing) and significant (>50% luminal narrowing) stenosis. Abnormal FFR was defined as ≤0.75. A total of 36 vessels were evaluated for FFR, with 8 (22%) showing reduced FFR. Results on MSCT were normal (completely normal or <30% luminal narrowing in 11 vessesl 31%, nonsignificant lesions in 13 vessels 36%, and significant stenoses in 12 vessels 33%). Abnormal FFR was observed in only 58% of vessels with lesions >50% on MSCT. Nevertheless, the agreement between normal results on MSCT and normal FFR was excellent; FFR was normal in all 11 vessels with normal results on MSCT. In conclusion, significant stenoses on MSCT frequently do not result in reduced FFR. Normal results on MSCT, however, can accurately rule out the presence of hemodynamically significant lesions in men with known coronary artery disease.
Invasive Versus Noninvasive Evaluation of Coronary Artery Disease Joanne D. Schuijf, Jacob M. van Werkhoven, Gabija Pundziute, J. Wouter Jukema, Isabel Decramer, Marcel P. Stokkel, Petra ...Dibbets-Schneider, Martin J. Schalij, Johannes H. C. Reiber, Ernst E. van der Wall, William Wijns, Jeroen J. Bax This study assesses the relationship among myocardial perfusion and multidetector computed tomography (MDCT) imaging of atherosclerotic lesions with the presence of coronary stenoses in invasive angiography and intravascular ultrasound (IVUS) imaging of plaque in 70 patients. A total of 23 of 26 patients with abnormal myocardial perfusion had signifıcant coronary stenoses confırmed on MDCT (88%) and invasive angiography, the mean luminal area of the worst stenosis was 3.3 mm2 in IVUS. However, in patients with a normal perfusion scan, substantial amount of atherosclerosis was documented both in MDCT and IVUS. In comparing MDCT with perfusion imaging, it is important to differentiate between coronary stenoses and the presence of plaque, because pronounced atherosclerosis even in the absence of perfusion abnormalities is frequent.
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