Journal of Cardiovascular Computed Tomography
Volume 3 , Pages S99-S108 , November 2009

Efficacy of coronary CT angiography: Where we are, where we are going, and where we want to be

  • Jeffrey M. Levsky, MD, PhD

      Affiliations

    • Department of Radiology, Montefiore Medical Center and Albert Einstein College of Medicine, 111 East 210th Street Bronx, NY 10467-2490, USA
    • Corresponding Author InformationCorresponding author.
  • ,
  • Choo-Won Kim, MS

      Affiliations

    • Department of Radiology, Montefiore Medical Center and Albert Einstein College of Medicine, 111 East 210th Street Bronx, NY 10467-2490, USA
  • ,
  • Daniel M. Spevack, MD, MS

      Affiliations

    • Department of Internal Medicine, Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, 111 East 210th Street Bronx, NY 10467-2490, USA
  • ,
  • Mark I. Travin, MD

      Affiliations

    • Department of Nuclear Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, 111 East 210th Street Bronx, NY 10467-2490, USA
  • ,
  • Jonathan N. Tobin, PhD

      Affiliations

    • Department of Epidemiology and Population Health, Montefiore Medical Center and Albert Einstein College of Medicine, 111 East 210th Street Bronx, NY 10467-2490, USA
    • Clinical Directors Network (CDN), New York, NY, USA
  • ,
  • Linda B. Haramati, MD, MS

      Affiliations

    • Department of Radiology, Montefiore Medical Center and Albert Einstein College of Medicine, 111 East 210th Street Bronx, NY 10467-2490, USA

Received 7 July 2009 ,Accepted 23 October 2009.

References 

  1. Lloyd-Jones D, Adams R, Carnethon M, De Simone G, Ferguson TB, Flegal K, et al. Subcommittee: Heart disease and stroke statistics–2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2009;119:480–486
  2. Hollingworth W, Jarvik JG. Technology assessment in radiology: putting the evidence in evidence-based radiology. Radiology. 2007;244:31–38
  3. Thrall JH. Utilization of imaging: challenges and opportunities. J Am Coll Radiol. 2009;6:287–288
  4. Bonow RO. Sixth Annual Mario S. Verani, MD, Memorial Lecture: cardiovascular imaging–added value or added cost?. J Nucl Cardiol. 2008;15:170–177
  5. Hendel RC, Patel MR, Kramer CM, Poon M, Hendel RC, Carr JC, et al. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology. J Am Coll Cardiol. 2006;48:1475–1497
  6. Gibbons RJ, Gardner TJ, Anderson JL, Goldstein LB, Meltzer N, Weintraub WS, et al. on behalf of the American Heart Association Advocacy Coordinating Committee: The American Heart Association's Principles for Comparative Effectiveness Research. A Policy Statement from the American Heart Association. Circulation. 2009;119:2955–2962
  7. Lauer MS. Comparative effectiveness research: the view from the NHLBI. J Am Coll Cardiol. 2009;53:1084–1086
  8. Lord SJ, Irwig L, Simes RJ. When is measuring sensitivity and specificity sufficient to evaluate a diagnostic test, and when do we need randomized trials?. Ann Intern Med. 2006;144:850–855
  9. van Werkhoven JM, Schuijf JD, Gaemperli O, Jukema JW, Boersma E, Wijns W, et al. Prognostic value of multislice computed tomography and gated single-photon emission computed tomography in patients with suspected coronary artery disease. J Am Coll Cardiol. 2009;53:623–632
  10. Fryback DG, Thornbury JR. The efficacy of diagnostic imaging. Med Decis Making. 1991;11:88–94
  11. Choi EK, Choi SI, Rivera JJ, Nasir K, Chang SA, Chun EJ, et al. Coronary computed tomography angiography as a screening tool for the detection of occult coronary artery disease in asymptomatic individuals. J Am Coll Cardiol. 2008;52:357–365
  12. Einstein AJ. Medical imaging: the radiation issue. Nat Rev Cardiol. 2009;6:436–438
  13. Bachar GN, Atar E, Fuchs S, Dror D, Kornowski R. Prevalence and clinical predictors of atherosclerotic coronary artery disease in asymptomatic patients undergoing coronary multidetector computed tomography. Coron Artery Dis. 2007;18:353–360
  14. Zeina AR, Odeh M, Rosenschein U, Zaid G, Barmeir E. Coronary artery disease among asymptomatic diabetic and nondiabetic patients undergoing coronary computed tomography angiography. Coron Artery Dis. 2008;19:37–41
  15. Kornowski R, Bachar GN, Dvir D, Fuchs S, Atar E. Angiographic findings and clinical outcomes in asymptomatic patients with severe obstructive atherosclerosis on computed tomography angiography. Isr Med Assoc J. 2008;10:627–633
  16. Zeina AR, Barmeir E, Zaid G, Odeh M. Coronary artery disease among hypertensive patients undergoing coronary computed tomography angiography. J Cardiovasc Med (Hagerstown). 2009;10:252–256
  17. Scholte AJ, Schuijf JD, Kharagjitsingh AV, Jukema JW, Pundziute G, van der Wall EE, et al. Prevalence of coronary artery disease and plaque morphology assessed by multi-slice computed tomography coronary angiography and calcium scoring in asymptomatic patients with type 2 diabetes. Heart. 2008;94:290–295
  18. Rivera JJ, Nasir K, Choi EK, Yoon YE, Chun EJ, Choi SI, et al. Detection of occult coronary artery disease in asymptomatic individuals with diabetes mellitus using non-invasive cardiac angiography. Atherosclerosis. 2009;203:442–448
  19. Eroğlu E, Bayrak F, Gemici G, Güneysu T, Mutlu B, Kalkan AK, et al. Prevalence of coronary artery disease in low to moderate-risk asymptomatic women: a multislice computed tomography study. Turk Kardiyol Dern Ars. 2008;36:439–445
  20. Bluemke DA, Achenbach S, Budoff M, Gerber TC, Gersh B, Hillis LD, et al. Noninvasive coronary artery imaging: magnetic resonance angiography and multidetector computed tomography angiography: a scientific statement from the American Heart Association Committee on Cardiovascular Imaging and Intervention of the Council on Cardiovascular Radiology and Intervention, and the Councils on Clinical Cardiology and Cardiovascular Disease in the Young. Circulation. 2008;118:586–606
  21. Detection of subclinical coronary atherosclerosis in diabetes using coronary CT angiography (DESCARTES) trial description. http://clinicaltrials.gov/ct2/show/NCT00431977. Accessed August 25, 2009.
  22. Young LH, Wackers FJ, Chyun DA, Davey JA, Barrett EJ, Taillefer R, et al. DIAD Investigators: Cardiac outcomes after screening for asymptomatic coronary artery disease in patients with type 2 diabetes: the DIAD study: a randomized controlled trial. JAMA. 2009;301:1547–1555
  23. Comparing Proportions for Two Independent Samples online tool. http://www.stat.ubc.ca/∼rollin/stats/ssize/b2.html. Accessed June 12, 2009.
  24. de Vos AM, Rutten A, van de Zaag-Loonen HJ, Bots ML, Dikkers R, Buiskool RA, et al. Non-invasive cardiac assessment in high risk patients (The GROUND study): rationale, objectives and design of a multi-center randomized controlled clinical trial. Trials. 2008;9:49
  25. Haramati LB. Ethical trials to determine the risks and benefits of radiation exposure from coronary CT angiography. J Am Coll Radiol. 2008;5:1073–1076
  26. de Feyter PJ, Schultz CJ. Computed tomography coronary angiography for screening asymptomatic subjects: a bridge too far?. J Am Coll Cardiol. 2008;52:366–368
  27. Black WC, Czum JM. Screening coronary CT angiography: no time soon. J Am Coll Radiol. 2007;4:295–299
  28. Jacobs PC, Mali WP, Grobbee DE, van der Graaf Y. Prevalence of incidental findings in computed tomographic screening of the chest: a systematic review. J Comput Assist Tomogr. 2008;32:214–221
  29. Onuma Y, Tanabe K, Nakazawa G, Aoki J, Nakajima H, Ibukuro K, et al. Noncardiac findings in cardiac imaging with multidetector computed tomography. J Am Coll Cardiol. 2006;48:402–406
  30. Koonce J, Schoepf JU, Nguyen SA, Northam MC, Ravenel JG. Extra-cardiac findings at cardiac CT: experience with 1,764 patients. Eur Radiol. 2009;19:570–576
  31. Aglan I, Jodocy D, Hiehs S, Soegner P, Frank R, Haberfellner B, Klauser A, Jaschke W, Feuchtner GM: Clinical relevance and scope of accidental extracoronary findings in coronary computed tomography angiography: a cardiac versus thoracic FOV study. Eur J Radiol. Published ahead of print on March 4, 2009, as DOI: 10.1016/j.ejrad.2009.01.038.
  32. Gallagher MJ, Ross MA, Raff GL, Goldstein JA, O'Neill WW, O'Neil B. The diagnostic accuracy of 64-slice computed tomography coronary angiography compared with stress nuclear imaging in emergency department low-risk chest pain patients. Ann Emerg Med. 2007;49:125–136
  33. White CS, Kuo D, Kelemen M, Jain V, Musk A, Zaidi E, et al. Chest pain evaluation in the emergency department: can MDCT provide a comprehensive evaluation?. AJR Am J Roentgenol. 2005;185:533–540
  34. Levsky JM, Travin MI, Spevack DM, Menegus MA, Huang PW, Goldberg Y, et al. Rationale and design of a randomized controlled trial comparing stress myocardial perfusion imaging and coronary CT angiography as the initial imaging test for intermediate risk patients admitted with chest pain. J Cardiovasc Comput Tomogr. 2009;3:264–271
  35. Hoffmann U, Nagurney JT, Moselewski F, Pena A, Ferencik M, Chae CU, et al. Coronary multidetector computed tomography in the assessment of patients with acute chest pain. Circulation. 2006;114:2251–2260
  36. Rubinshtein R, Halon DA, Gaspar T, Jaffe R, Karkabi B, Flugelman MY, et al. Usefulness of 64-slice cardiac computed tomographic angiography for diagnosing acute coronary syndromes and predicting clinical outcome in emergency department patients with chest pain of uncertain origin. Circulation. 2007;115:1762–1768
  37. Hollander JE, Chang AM, Shofer FS, McCusker CM, Baxt WG, Litt HI. Coronary computed tomographic angiography for rapid discharge of low-risk patients with potential acute coronary syndromes. Ann Emerg Med. 2009;53:295–304
  38. Hoffmann U, Bamberg F, Chae CU, Nichols JH, Rogers IS, Seneviratne SK, et al. Coronary computed tomography angiography for early triage of patients with acute chest pain: the ROMICAT (Rule Out Myocardial Infarction using Computer Assisted Tomography) trial. J Am Coll Cardiol. 2009;53:1642–1650
  39. Goldstein JA, Gallagher MJ, O'Neill WW, Ross MA, O'Neil BJ, Raff GL. A randomized controlled trial of multi-slice coronary computed tomography for evaluation of acute chest pain. J Am Coll Cardiol. 2007;49:863–871
  40. Chang SA, Choi SI, Choi EK, Kim HK, Jung JW, Chun EJ, et al. Usefulness of 64-slice multidetector computed tomography as an initial diagnostic approach in patients with acute chest pain. Am Heart J. 2008;156:375–383
  41. Coronary Computed Tomography for Systematic Triage of Acute Chest Pain Patients to Treatment (CT-STAT) trial description. http://www.clinicaltrials.gov/ct2/show/NCT00468325. Accessed June 9, 2009.
  42. Randomized Controlled Study of a Rapid “Rule Out” Strategy Using CT Coronary Angiogram Versus Traditional Care for Low- to Intermediate-Risk ED Patients with Potential Acute Coronary Syndromes trial description. http://www.clinicaltrials.gov/ct2/show/NCT00933400. Accessed September 3, 2009.
  43. ROMICAT II: Rule Out Myocardial Ischemia/Infarction Using Computer Assisted Tomography trial on the protocol summary table of the American College of Radiology Imaging Network. http://www.acrin.org/ PROTOCOLSUMMARYTABLE/tabid/76/Default.aspx. Accessed June 15, 2009.
  44. Lehman SJ, Abbara S, Cury RC, Nagurney JT, Hsu J, Goela A, et al. Significance of cardiac computed tomography incidental findings in acute chest pain. Am J Med. 2009;122:543–549
  45. Hendel RC, Berman DS, Di Carli MF, Heidenreich PA, Henkin RE, Pellikka PA, et al. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine: endorsed by the American College of Emergency Physicians. Circulation. 2009;119:e561–e587
  46. Douglas PS, Khandheria B, Stainback RF, Weissman NJ, Peterson ED, Hendel RC, et al. American College of Cardiology Foundation Appropriateness Criteria Task Force; American Society of Echocardiography; American College of Emergency Physicians; American Heart Association; American Society of Nuclear Cardiology; Society for Cardiovascular Angiography and Interventions; Society of Cardiovascular Computed Tomography; Society for Cardiovascular Magnetic Resonance: ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/ SCMR 2008 appropriateness criteria for stress echocardiography: a report of the American College of Cardiology Foundation Appropriateness Criteria Task Force, American Society of Echocardiography, American College of Emergency Physicians, American Heart Association, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance: endorsed by the Heart Rhythm Society and the Society of Critical Care Medicine. Circulation. 2008;117:1478–1497
  47. Nixdorff U, Küfner C, Achenbach S, Stilianakis N, Voigt JU, Flachskampf FA, et al. Head-to-head comparison of dobutamine stress echocardiography and cardiac computed tomography for the detection of significant coronary artery disease. Cardiology. 2008;110:81–86
  48. Schuijf JD, Wijns W, Jukema JW, Atsma DE, de Roos A, Lamb HJ, et al. Relationship between noninvasive coronary angiography with multi-slice computed tomography and myocardial perfusion imaging. J Am Coll Cardiol. 2006;48:2508–2514
  49. Spevack DM, Levsky JM. Relationship between noninvasive coronary angiography with multislice computerized tomography and myocardial perfusion imaging. J Am Coll Cardiol. 2007;50:288;author reply 288–9
  50. Budoff MJ, Rasouli ML, Shavelle DM, Gopal A, Gul KM, Mao SS, et al. Cardiac CT angiography (CTA) and nuclear myocardial perfusion imaging (MPI)-a comparison in detecting significant coronary artery disease. Acad Radiol. 2007;14:252–257
  51. Pundziute G, Schuijf JD, Jukema JW, Boersma E, de Roos A, van der Wall EE, et al. Prognostic value of multislice computed tomography coronary angiography in patients with known or suspected coronary artery disease. J Am Coll Cardiol. 2007;49:62–70
  52. Min JK, Shaw LJ, Devereux RB, Okin PM, Weinsaft JW, Russo DJ, et al. Prognostic value of multidetector coronary computed tomographic angiography for prediction of all-cause mortality. J Am Coll Cardiol. 2007;50:1161–1170
  53. Shaw LJ, Berman DS, Hendel RC, Borges Neto S, Min JK, Callister TQ. Prognosis by coronary computed tomographic angiography: matched comparison with myocardial perfusion single-photon emission computed tomography. J Cardiovasc Comput Tomogr. 2008;2:93–101
  54. 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;52:1335–1343
  55. Van Lingen R, Kakani N, Veitch A, Manghat NE, Roobottom CA, Morgan-Hughes GJ. Prognostic and accuracy data of multidetector CT coronary angiography in an established clinical service. Clin Radiol. 2009;64:601–607
  56. Shaw LJ, Iskandrian AE. Prognostic value of gated myocardial perfusion SPECT. J Nucl Cardiol. 2004;11:171–185
  57. Metz LD, Beattie M, Hom R, Redberg RF, Grady D, Fleischmann KE. The prognostic value of normal exercise myocardial perfusion imaging and exercise echocardiography: a meta-analysis. J Am Coll Cardiol. 2007;49:227–237
  58. Nicol ED, Stirrup J, Leatham E, Roughton M, Underwood SR, Padley SP, Rubens MB: Clinical management and short-term cost - 64-slice MDCT vs. myocardial perfusion scintigraphy. Int J Cardiol. Published ahead of print on January 29, 2009, as DOI: 10.1016/j.ijcard.2009.01.007.
  59. Chow BJW, Abraham A, Wells GA, Chen L, Ruddy TD, Yeung Y, et al. Diagnostic accuracy and impact of computed tomographic coronary angiography on utilization of invasive coronary angiography. Circ Cardiovasc Imaging. 2009;2:16–23
  60. Min JK, Shaw LJ, Berman DS, Gilmore A, Kang N. Costs and clinical outcomes in individuals without known coronary artery disease undergoing coronary computed tomographic angiography from an analysis of Medicare category III transaction codes. Am J Cardiol. 2008;102:672–678
  61. Min JK, Kang N, Shaw LJ, Devereux RB, Robinson M, Lin F, et al. Costs and clinical outcomes after coronary multidetector CT angiography in patients without known coronary artery disease: comparison to myocardial perfusion SPECT. Radiology. 2008;249:62–70
  62. Min JK, Robinson M, Shaw LJ, Lin F, Legorreta AP, Gilmore A. Differences in episode-based care costs for multidetector computed tomographic coronary angiography versus myocardial perfusion imaging for the diagnosis of coronary artery disease. J Med Econ. 2008;11:327–340
  63. Bashore TM, Bates ER, Berger PB, Clark DA, Cusma JT, Dehmer GJ, et al. American College of Cardiology: Task Force on Clinical Expert Consensus Documents: American College of Cardiology/Society for Cardiac Angiography and Interventions Clinical Expert Consensus Document on cardiac catheterization laboratory standards. A report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol. 2001;37:2170–2214
  64. 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;94:1386–1393
  65. Hausleiter J, Meyer T, Hadamitzky M, Zankl M, Gerein P, Dörrler K, et al. Non-invasive coronary computed tomographic angiography for patients with suspected coronary artery disease: the Coronary Angiography by Computed Tomography with the Use of a Submillimeter resolution (CACTUS) trial. Eur Heart J. 2007;28:3034–3041
  66. 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 (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial. J Am Coll Cardiol. 2008;52:1724–1732
  67. 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;52:2135–2144
  68. Miller JM, Rochitte CE, Dewey M, Arbab-Zadeh A, Niinuma H, Gottlieb I, et al. Diagnostic performance of coronary angiography by 64-row CT. N Engl J Med. 2008;359:2324–2336
  69. Meijboom WB, Mollet NR, Van Mieghem CA, Weustink AC, Pugliese F, van Pelt N, et al. 64-Slice CT coronary angiography in patients with non-ST elevation acute coronary syndrome. Heart. 2007;93:1386–1392
  70. Cole JH, Chunn VM, Morrow JA, Buckley RS, Phillips GM. Cost implications of initial computed tomography angiography as opposed to catheterization in patients with mildly abnormal or equivocal myocardial perfusion scans. J Cardiovasc Comput Tomogr. 2007;1:21–26
  71. Hines JL, Danciu SC, Shah M, Borg MJ, Biga C. Use of multidetector computed tomography after mildly abnormal myocardial perfusion stress testing in a large single-specialty cardiology practice. J Cardiovasc Comput Tomogr. 2008;2:372–378
  72. Menon M, Lesser JR, Hara H, Birkett R, Knickelbine T, Longe T, et al. Multidetector CT coronary angiography for patient triage to invasive coronary angiography: performance and cost in ambulatory patients with equivocal or suspected inaccurate noninvasive stress tests. Catheter Cardiovasc Interv. 2009;73:497–502

 Conflict of interest: The authors report no conflicts of interest.

 The research presented here was funded in part by a grant from the American Heart Association Founders Affiliate Clinical Research Program to J.M.L.

PII: S1934-5925(09)00514-0

doi: 10.1016/j.jcct.2009.10.008

Journal of Cardiovascular Computed Tomography
Volume 3 , Pages S99-S108 , November 2009