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Coronary Computed Tomography Angiography

Educational Objective
To understand how to interpret the results of diagnostic tests and apply them clinically.
1 Credit CME

A 56-year-old woman presented to her cardiologist with stable atypical chest pain. A 20% pretest probability of coronary artery disease (CAD) was estimated, considering sex, age, and type of chest pain.1 Functional tests performed 3 months earlier were inconclusive: a stress electrocardiogram (ECG) showed ST-segment depressions at 100 W of −0.2 mV in lead I and −0.15 mV in V5, while stress magnetic resonance (MR) perfusion imaging had negative results. The patient had cardiovascular risk factors including arterial hypertension and a family history of CAD. With antihypertensive therapy, her blood pressure was 119/79 mm Hg. Blood lipids were as follows: total cholesterol, 167 mg/dL (abnormal >200 mg/dL); low-density lipoprotein cholesterol, 80 mg/dL (abnormal >100 mg/dL); high-density lipoprotein cholesterol, 55 mg/dL (abnormal <60 mg/dL); and triglycerides, 80 mg/dL (abnormal >150 mg/dL). To evaluate for CAD, she underwent coronary computed tomography (CT) angiography (Figure).

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C. No stenosis or plaque. Because of high negative predictive value, no further testing is necessary.

Invasive coronary angiography (ICA) is the reference procedure for detecting obstructive CAD; however, approximately two-thirds of ICAs performed fail to reveal any CAD, and these patients need no interventional therapy.2 Coronary CT angiography is a noninvasive diagnostic test with high diagnostic accuracy (97% sensitivity, 87% specificity, 95% negative predictive value, and area under the curve of 0.93 [95% CI, 0.91-0.95] even if nonevaluable scans are included),3 and if performed as an initial test, it can improve the diagnostic yield of ICA.2,4 New European Society of Cardiology (ESC) guidelines recommend coronary CT angiography for patients with stable chest pain, especially when they have low to intermediate pretest disease probability.1 With its high sensitivity and resulting high negative predictive value, CT angiography is especially suited as a test to rule out ICA. This is important as ICA is still associated with a low risk of relevant complications such as coronary occlusion, coronary infarction, cerebral infarction, and artery dissection.5 Both ICA and coronary CT angiography require the administration of a contrast agent, and both should be avoided in patients with kidney failure (glomerular filtration rate <30 mL/min). Coronary CT angiography can be performed rapidly (about 5 minutes) and does not require hospitalization. The scan is performed with ECG triggering, which means that in patients with a low and stable heart rate, acquisition is confined to predefined intervals of the cardiac R-R cycle (prospective scan) instead of a retrospective scan of the entire R-R interval. This improves general image quality by reducing motion artifacts while at the same time, lowering radiation exposure. Another option to reduce radiation exposure is dose modulation, which can be used in conjunction with retrospective gating. Patients with contraindications to nitroglycerin (eg, arterial hypotension), β-blockers (eg, bradycardia, asthma, acute heart failure, or bronchospasm), or contrast agent (eg, documented previous severe reaction, kidney failure) should undergo alternative diagnostic testing. To optimize diagnostic accuracy and reduce radiation exposure, careful patient preparation is necessary.6

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Article Information

Corresponding Author: Marc Dewey, MD, Charité–Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany (marc.dewey@charite.de).

Published Online: September 23, 2020. doi:10.1001/jama.2020.10831

Conflict of Interest Disclosures: Dr Dewey reports receipt of grant support from the European Commission, the German Research Foundation (DFG), Berlin University Alliance, and the Berlin Institute of Health; lecture fees from Canon, Guerbet, Cardiac MR Academy of Berlin, and Bayer; personal fees as editor of Cardiac CT; other for courses on CT imaging; voluntary service as research chair for the European Society of Radiology (only travel expenses); institutional master research agreements with Siemens, General Electric, Philips, and Canon (managed by the legal department of Charité–Universitätsmedizin Berlin); and a joint patent on dynamic perfusion analysis using fractal analysis (all outside the submitted work). Dr Feger reports no disclosures.

Disclaimer: The opinions in this article are the authors’ and do not represent the view of ESR.

Additional Contributions: We thank the patient for providing permission to share her information, the radiographic staff, and referring physicians. In addition, we thank Bettina Herwig for copy editing.

References
1.
Knuuti  J , Wijns  W , Saraste  A ,  et al.  2019 ESC guidelines for the diagnosis and management of chronic coronary syndromes.   Eur Heart J. 2020;41(3):407-477. PubMedGoogle ScholarCrossref
2.
Patel  MR , Dai  D , Hernandez  AF ,  et al.  Prevalence and predictors of nonobstructive coronary artery disease identified with coronary angiography in contemporary clinical practice.   Am Heart J. 2014;167(6):846-52.e2.PubMedGoogle ScholarCrossref
3.
Schuetz  GM , Schlattmann  P , Dewey  M .  Use of 3 x 2 tables with an intention to diagnose approach to assess clinical performance of diagnostic tests.   BMJ. 2012;345:e6717.PubMedGoogle Scholar
4.
Dewey  M , Rief  M , Martus  P ,  et al.  Evaluation of computed tomography in patients with atypical angina or chest pain clinically referred for invasive coronary angiography.   BMJ. 2016;355:i5441.PubMedGoogle ScholarCrossref
5.
Levenson  B , Albrecht  A , Göhring  S ,  et al.  6th Report of the German Association of Cardiologists in private practice (BNK) on quality assurance in cardiac catheterization and coronary intervention 2006–2009.   Herz. 2011;36(1):41-49.PubMedGoogle ScholarCrossref
6.
Dewey  M .  Cardiac CT. 2nd ed. Springer Verlag; 2014:chap 6.
7.
Foy  AJ , Dhruva  SS , Peterson  B , Mandrola  JM , Morgan  DJ , Redberg  RF .  Coronary computed tomography angiography vs functional stress testing for patients with suspected coronary artery disease.   JAMA Intern Med. 2017;177(11):1623-1631.PubMedGoogle ScholarCrossref
8.
Takx  RA , Blomberg  BA , El Aidi  H ,  et al.  Diagnostic accuracy of stress myocardial perfusion imaging compared to invasive coronary angiography with fractional flow reserve meta-analysis.   Circ Cardiovasc Imaging. 2015;8(1):e002666.PubMedGoogle Scholar
9.
Smulders  MW , Jaarsma  C , Nelemans  PJ ,  et al.  Comparison of the prognostic value of negative non-invasive cardiac investigations in patients with suspected or known coronary artery disease-a meta-analysis.   Eur Heart J Cardiovasc Imaging. 2017;18(9):980-987.PubMedGoogle ScholarCrossref
10.
National Institute for Health and Care Excellence.  Chest pain overview. Accessed September 21, 2020. https://pathways.nice.org.uk/pathways/chest-pain7
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