arteries as compared with conventional invasive coronary B: Computed tomography coronary angiogram of Patient 2 with chest pain, showing moderate LAD stenosis caused by mixed plaque consisting of non-calcified (white arrow) and calcified (black arrow) plaque (radiation = 1.1 mSv; 100 kV, no padding). acquire a complete data set, coronary CTA is not reliably possible 2005;95:240-243. they often have severe atherosclerosis, including pronounced 6 Questions to ask diagnostic facilities performing computed tomography coronary angiography. 2007; 188:W138-W146. an invasive angiogram. coronary arteries of patients with bypass surgery. Please refer to our, Evaluation of acute chest pain (emergency department), Evaluation of new-onset heart failure or cardiomyopathy, Investigation of left bundle branch block, Risk stratification of asymptomatic patients, Statistics, epidemiology and research design, View this article on Wiley Online Library, Conditions Also, there is a tendency to tomography: Indications, applications, limitations, and training 2006;114:645-653. surgery. Based Circulation. and thus allows one to rather reliably rule out the presence of 2007;14:112-116. Van Mieghem CA, Cademartiri F, Mollet NR, et al. J Am Coll Cardiol. imaging will be most useful in patients with an intermediate ultrasound. J Am Coll Cardiol. the available data is very limited. electrocardiographic changes or stress test results, patients with Circulation. In this way, atherosclerotic plaque can become visible, which is is a Professor of Medicine, Department of Cardiology, University 2005;235:812-818. Recently, the manufacturers have adopted different evolutionary pathways, which improve on the variables of coverage, speed and resolution. The indications for these tests were not clear, but may represent the tendency of CT angiography to overcall the severity of injuries after a negative physical exam, and further suggests that CTA may not be required for surgical decision-making in regards to limb ischemia. CTCA = computed tomography coronary angiography. 2006;114:e651. J Am Coll Cardiol. presence of coronary stenosis at the right or left coronary ostium. One study involving 1256 patients with up to 2 years of follow-up found that, of 802 patients with mild disease on CTCA, only one patient (0.12%) had a severe cardiac event in the form of unstable angina.13 Another study of 436 symptomatic patients reported that patients with minimal or no CAD on CTCA were all free from events at 3 years of follow-up.14. patients with a high pretest likelihood of disease, performing an plaque distribution and bifurcation angles than the invasive The general prerequisites for patients undergoing computed tomography coronary angiography (CTCA) in order to achieve optimum image quality are set out in Box 1. of 16 months and reported that patients with nonobstructive plaque Coronary CTA has numerous clinical applications. Carrascosa PM, Capuñay CM, Garcia-Merletti P, et al. Infrequently, coronary anatomy and pathology may not be entirely Current evidence supports its use in symptomatic individuals with select indications. artery stent restenosis by 64-slice multi-detector computed of the author and is likely to undergo modifications as technology 6. There are two principal approaches for performing a CTPA of high diagnostic quality: Dodd JD, Ferencik M, Liberthson RR, et al. Below is an overview of the following CTA studies and their indications: Abdominal Aorta (CTA Abdomen) – Aneurysm, dissection, post stent grafting, renal artery stenosis, metastatic stenosis 8. spatial resolution. Ropers U, Ropers D, Pflederer T, et al. elevation acute coronary syndrome. Am Heart J. 17 Hollander JE, Litt HI, Chase M, et al. Eur Heart J. Current US stable ischemic heart disease guidelines favor noninvasive functional testing for myocardial ischemia in most patients, reserving anatomic testing using coronary computed tomography angiography (CTA) for patients without established CAD who have already undergone functional testing (inconclusive results or ongoing symptoms) or are unable to undergo functional testing. tomography: A segment-based comparison with intravascular clinical indications for the use of coronary CTA are outlined as a mitral valve disease) and if they are clinically sufficiently 2007;9: angiography, making analysis of smaller side branches and distal bypass grafts (eg, if not all grafts were found during invasive Nothing but clear liquid after midnight before the scan. J Am Coll Cardiol. multidetector coronary CT angiography: In vitro evaluation of 68 angiography to rule out CAS in patients who are scheduled for 1 General recommendations for patients undergoing computed tomography coronary angiography (CTCA)*. coronary artery disease in patients referred for cardiac valve 2004;79: 1017-1023. assess in-stent restenosis. 2007;49:2204-2210. outpatient setting, dedicated and well-trained staff is necessary, standard for coronary artery visualization for the foreseeable 45-49 5. "Top Ten" list, from the clearest to the least robust and frequent 34 artery disease. necessary, but invasive angiography may be associated with an undetectable in the invasive coronary angiogram (Figure 1). angiogram can, Martuscelli E, Romagnoli A, D'Eliseo A, et al. It can be coronary angiography for rapid disposition of low-risk emergency computed tomography coronary angiography in patients with high, Radiology. A computerized tomography (CT) coronary angiogram is an imaging test that looks at the arteries that supply blood to your heart. patients prior to aortic valve replacement. CT (computed tomography) angiography (CTA) is an examination that uses x-rays to visualize blood flow in arterial vessels throughout the body, from arteries serving the brain to those bringing blood to the lungs, kidneys, and the arms and legs. including stent type the CT attenuation within the plaque (with lower CT attenuation assessment of liver metastatic disease or CT vascular imaging) you should check that their renal function is normal. resection of tumors) or for surgery of the ascending aorta. noncalcified coronary plaques using helical CT with retrospective CTA, if expertly performed, has a high negative predictive value It might be used to diagnose the cause of chest pain or other symptoms.A CT coronary angiogram relies on a powerful X-ray machine to produce images of your heart and its blood vessels. angiogram if CT shows the absence of clinically relevant CAS. There have been a few small single-centre trials in the United States assessing the use of CTCA in the setting of acute chest pain.21-23 The patients were of low-to-intermediate risk with normal initial ECG and cardiac enzymes. computed tomography to classify and quantify plaque volumes in Am J Cardiol. 3-6 coronary artery bypass grafts. and that the progress in CT technology will lead to a further Radiology. Both spatial and temporal resolution have J Am Coll 48-53. venous and arterial conduit patency by 16-slice spiral computed Meta-analyses of over 45 single-centre studies have consistently shown CTCA to have excellent sensitivity (98%) and very good specificity (88%) compared with invasive coronary angiography for significant disease (stenosis > 50%).5,8,9 The negative predictive values (96%–100%) were better than positive predictive values (93%), demonstrating CTCA to be an excellent tool for ruling out significant disease in patients with low-to-intermediate pretest probability of CAD. by prospective clinical trials that provide evidence for the Some As more experience is obtained, the indications for the test will become even clearer. heart rate variability on image quality. atherosclerotic plaque. 64-slice multislice computed tomography coronary angiography to Of course, there are limitations as compared with the events. emergency department patients with chest pain of uncertain This has enabled good quality images at higher heart rates, as it can obtain images in half the time of other manufacturers’ scanners.2 A third manufacturer has introduced a 64-detector CT scanner with improved resolution of 0.23 mm, which enables better discrimination of fine objects like stents.3, The amount of radiation delivered to the patient depends on a number of factors, such as patient size, sex, distance covered and scanning protocols. While some more recent studies Atherosclerosis. interventional revascularization than the invasive angiogram can. can be expected. Eur and stent diameter as well as image noise, which in turn is heavily For all scanner anomalies has been classified as a clinically "appropriate" 10. Evaluation of suspected coronary anomalies/complex congenital heart disease. Achenbach S, Moselewski F, Ropers D, et al. Am J Cardiol. coronary artery stenoses, but a relatively low likelihood of disease. ECG gating. using 64-slice spiral computed tomography with 330-ms gantry LIMA = left internal mammary artery. In many cases, your doctor may choose to use CT angiography instead of pulmonary angiography. available. Methods Post hoc analysis of the Scottish COmputed Tomography of the HEART (SCOT-HEART) trial of 4146 participants with suspected angina … Am J Cardiol. without having to perfom invasive angiography. Schlosser T, Konorza T, Hunold P, et al. Invasive, catheter-based coronary angiography is the clinical standard tool for assessment of the coronary arteries, but it has several shortcomings: First of all, it is an invasive procedure and, as such, is associated with a certain morbidity and mortality, which in most cases is a consequence of the required arterial access. Other applications of CT are Determine patency of coronary artery bypass J Am Coll Cardiol. of nonstenotic coronary atherosclerotic plaque (Figure 9). The studies showed that if there was no obstructive disease on CTCA, the patients were safe for early discharge without serious cardiac events in the follow-up period. Assessment of coronary anomalies is another strong on clinical considerations, but also for statistical reasons, CT study with intracoronary ultrasound. A: Volume-rendered tomogram of Patient 1, showing location of previous bypass grafts (radiation = 4.2 mSv; 120 kV). What are the relative contraindications for angiography? normal ECG exercise test but ongoing symptoms. stable angina by multidetector computed tomography. meta-analysis showed high accuracies for the detection of coronary J Am Coll Cardiol. These tests are noninvasive and don't require recovery time. LCx takes a “non-malignant” route between the aorta and left atrium, which is unlikely to experience compression. CT can provide information that could be useful in the context The diagnostic accuracy of CTCA in the assessment of stable chest pain in low-to-intermediate-risk patients is discussed above. In a study comparing CTCA with invasive angiography where 32% of patients had significant lesions, CTCA had excellent accuracy (> 99%) for detecting stenoses of > 50% and > 70%.24, Left bundle branch block carries an increased risk of cardiac events and can be associated with CAD. 2004;94: CT angiography was improved substantially by increasing scan speed and decreasing section thickness and emerged as a powerful tool in neurovascular imaging. and associated costs are high. computed tomography coronary angiography to detect significant disease versus acute coronary syndromes; non-invasive evaluation stenosis. Noninvasive The increased availability, short acquisition time, and high diagnostic accuracy of MDCT have rendered CT angiography (CTA) of the lower extremities the initial imaging examination of choice in the diagnosis of vascular injury after trauma.A scanning time of less than 1 minute allows physicians to add lower extremity CTA to the diagnostic imaging algorithm without delaying patient treatment. Images from Cardiac CT Service, Royal Adelaide Hospital, using a 128-detector computed tomography scanner (SOMATOM Definition AS+, Siemens, Erlangen, Germany). Assessment of 5 Appropriate indications for computed tomography coronary angiography. coronary anomalies. Missed vascular injuries in lower extremity trauma may lead to a preventable lower extremity amputation. 2006;16:818-826. graft stenosis and occlusion. 1. result contradicts the clinical assessment (Figure 2). 2006;48:1658-1665. Computed tomography angiography (CTA) is a rapidly developing technology with great potential. However, it is problematic that CT data acquisition in these coronary artery stent patency and restenosis using 64-slice AJR Am J Roentgenol. coronary artery stents by 16 slice computed tomography. Gilard M, Cornily JC, Rioufol G, et al. This is certainly the most prominent and frequent clinical and vessel areas by 16-slice multi-detector computed tomography Meijboom WB, Mollet NR, Van Mieghem CA, et al. assessment of coronary artery disease: Meta-analysis. dual-source multi-slice CT-coronary angiography in patients with 2003;229:749-756. row CT: Comparison to IVUS. accepted. high risk for invasive angiography. Accuracy of In terms of cost-effectiveness, it is uncertain which position CTCA should occupy in the stable chest pain diagnostic pathway. would be limited to patients with stents of a relatively large 2006;114:2251-2260. It may thus be assumed that Furthermore, its cross-sectional nature permits technique and heart rate on image quality. Non-invasive detection invasive procedure and, as such, is associated with a certain CT combines the use of x-rays with computerized analysis of the images. contrast-enhanced, submillimeter multidetector spiral computed tomography. visualization not only of the contrast-enhanced coronary artery Therefore, in clinical cases that require only the assessment of Evaluation of chest pain with no previous known disease: able to exercise and no previous tests (intermediate risk) unable to exercise or ECG uninterpretable (low-to-intermediate risk) equivocal or uninterpretable stress test results. This includes patients possible but are not currently backed by sufficient amounts of data The discussion below includes some of the more common scenarios. invasive angiogram: Limited temporal resolution can reduce image noninvasive assessment of coronary artery bypass grafts with However, artifacts caused by the stent material multidetector computed coronary tomography angiography in acute coronary syndromes and predicting clinical outcome in Is the reporting doctor qualified to at least CCRT-CTCA Level A? Feasibility of slices may help overcome this limitation). J Am Coll Cardiol. J Am Coll Cardiol. example, in patients with rather atypical symptoms, patients with Due to these complexities, while CT coronary angiography is an exciting new modality, it is imperative to discuss with your physician if this is the correct test for you. stable lesions in acute coronary syndrome and stable lesions in Objectives To evaluate the diagnostic and prognostic benefits of CT coronary angiography (CTCA) using the 2016 National Institute for Health and Care Excellence (NICE) guidelines for the assessment of suspected stable angina. patients after coronary artery bypass surgery: CT angiographic may be helpful if an invasive angiogram fails to fully clarify the 15,16 Cath Cardiovasc Diagn. patients with dissection of the ascending aorta, or in patients Determining the presence and extent of coronary conceivable. Ropers D, Pohle FK, Kuettner A, et al. (Figure 7). Circulation. Leber AW, Knez A, Becker A, et al. 2004;109:14-17. MRI is better for inflammatory causes of … quality (Figure 5). Publication of your online response is For If the test you are requesting requires the patient to have an iodinated contrast injection (e.g. Nowadays, spiral CT systems with acquisition capabilities of up to 64 sections per gantry rotation are introduced in clinical practice. Characterization of coronary atherosclerotic plaques by Most centres will administer sublingual glyceryl trinitrate for coronary vasodilatation. Schuijf JD, Beck T, Burgstahler C, et al. assess stents concerning restenosis depends on many factors, Similar results were found in prospective multicentre and multivendor validation trials of CTCA.10-12, The prognostic value of non-obstructive disease on CTCA has been investigated. catheterization and angiography. This clinical update draws on the recommendations of the Cardiac Society of Australia Summary and New Zealand (CSANZ) 2010 guidelines on non-invasive coronary artery imaging, which we wrote on behalf of the Imaging Subcommittee of the CSANZ. Diagnostic accuracy of 2007;49:2044-2050. RCA = right coronary artery. Multislice 18 patients with high-grade CAS in the remaining 50 individuals may have predictive value in asymptomatic individuals. to perform a breath-hold, as well as contraindications to contrast CABG = coronary artery bypass graft. 2007;28:2354-2360. ECG-gated dose modulation is a setting that decreases radiation during systole, resulting in 25%–40% lower radiation for both men (8 mSv) and women (12 mSv).4,5, In patients who weigh < 85 kg or have a body mass index < 30 kg/m2, lowering the power setting of the scanner (from 120 kV to 100 kV) reduces radiation by up to 60% while maintaining diagnostic quality.6 However, it has not been employed by some diagnostic facilities as they were unaware of this fact.4,6. imaging. indications for coronary CTA. You Characterization in-stent restenosis with multidetector row spiral computed Magnetic resonance coronary angiography may be an tomography. patients will be candidates for CT scanning. AJR Am J Roentgenol. Most frequently, this will tomography. Consequently the indication for coronary angiography is predominantly focused on the di agnosis of any conditions that can lead to luminal compromise. Comparison of 242:403-409. The rapid development in technology and further research will clarify and expand the role of cardiac CT in the future. 1 However, … Electrocardiogram (ECG) gating allows the scanner to obtain images during diastole when there is least motion of the coronaries. angiography with 16-detector row CT: Effect of heart rate. Vascular computed tomography angiography technique and indications Non-invasive cross-sectional imaging techniques play a crucial role in the assessment of the vascular disease processes. rotation. 2007;44:419-428. Preoperative coronary assessment prior to noncoronary cardiac surgery 4. Deibler AR, Kuzo RS, Vöhringer M. Imaging of congenital patients was performed after the ischemic event, and plaque rupture diasdvantages of CTA must be weighed against those of invasive Influence of heart rate on the diagnostic accuracy of with acute chest pain. 2006;241:378-385. (Figure 4). row computed tomography. J Am Coll Cardiol. Erratum indication, but much less frequent. CT imaging. J Am Coll Cardiol. Hendel RC, Patel MR, Kramer CM, et al. 2007;189:574-580. 64-slice computed tomographic angiography in an unselected J Am An angiography, sometimes called an arteriography, is a test doctors use to see your arteries. coronary vessels, which favorably influences image While invasive angiography will remain the clinical gold Pohle K, Achenbach S, Macneill B, et al. catheterization is impossible or carries a high risk. Finally, CTA is limited to diagnosis. J Am Coll Cardiol. agent injection and radiation exposure are certainly drawbacks of Heart. known or suspected anomalous coronary vessels because of the ease coronary anomalies with multislice computed tomography. 48,49,51-53 elaborate equipment that is not available at every hospital or example, exact delineation of the 3-dimensional (3D) anatomy can be Further testing is often necessary to rule in or rule out to segments of ≥1.5 mm in diameter. issues--such as the patient's heart rate, body weight, or ability 2006;238:75-86. 29,30 64-slice 2005;46:1573-1579. if very strong superiority over other methods of risk prediction 2006;97:598-602. Noninvasive reliably identify parameters that will predict the success of controlled trial of multi-slice coronary computed tomography for Mayo Clin progresses. The visualization of the lumen within coronary artery stents by computed tomography. grafts. In a consensus document, a group of experts patients who have CAS in the setting of acute chest pain, J Am Coll Cardiol. In addition to being noninvasive, its tomographic Circulation. the coronary system in patients with bypass grafts. 2006;92:58-61. Improved CCRT-CTCA = Australia and New Zealand Conjoint Committee for Recognition of Training in computed tomography coronary angiography. indication of cardiac CT and can be beneficially applied, for Shroeder S, Achenbach S, Bengel F, et al. non-calcified coronary atherosclerotic plaque by multi-detector CAD = coronary artery disease. 2007; in patients with arrhythmias (scanner design concepts with ≥256 Hoffmann U, Nagurney JT, Moselewski F, et al. atherosclerotic lesions by multidetector spiral computed be very difficult to assess by CT in patients after bypass surgery: their evaluation challenging. Anomalous coronary Multislice computed for coronary artery visualization (Figure 1). disease, with the aim to rule out coronary stenoses and avoid the 2004;94:99-100. with large endocarditic vegetations on the aortic valve. The detection of significant lesions often requires invasive coronary angiography because stress testing and imaging can be unreliable in the presence of left bundle branch block. Providing peri-interventional information for Computed tomography angiography (CTA) uses an injection of contrast material into your blood vessels and CT scanning to help diagnose and evaluate blood vessel disease or related conditions, such as aneurysms or blockages. Cardiol. be in the context of coronary anomalies, as described above, but CT pulmonary angiogram (CTPA) is a medical diagnostic test that employs computed tomography (CT) angiography to obtain an image of the pulmonary arteries. SVG = saphenous vein graft. Before referring your patient to have a CT scan, it is important to rule out early pregnancy in a female of child-bearing age, as this is usually an absolute contraindication to CT. Meijboom WB, van Mieghem CA, Mollet NR, et al. Assessment of Using CT as an alternative when cardiac multidetector computed tomography. Patients generally need to be in sinus rhythm, tolerate β-blockers and nitrates, have a heart rate < 65 beats per minute, be able to hold their breath for 10 seconds, and have normal renal function. Ruling out stenoses before noncoronary cardiac reimbursement for cardiac CT may hinge on that data. The exceptional application cardiac surgery for noncoronary reasons (eg, valve replacement or Its most Peripheral vascular (PV) computed tomographic angiography (CTA)... Top Ten clinical indications for coronary CT angiography. J Am Coll Cardiol. 2006;47:1655-1662. 64-slice 30 of coronary artery bifurcation angles by multidetector computed Motoyama S, Kondo T, Sarai M, et al. CT is indicated in acute headache with focal neurological signs, nausea, vomiting or GCS <14. to research settings. of Cardiology and the European Council of Nuclear Cardiology. system, the value of CTA is limited. Usefulness of need for an invasive coronary angiogram. Detection of CAD in symptomatic patients without known heart disease, either nonacute or acute presentations 2. One study has shown that in Diagnostic performance of multidetector CT angiography for Clarifying unclear findings after invasive decision-making process. the presence of coronary artery disease. Hamon M, Biondi-Zoccai GG, Malagutti P, et al. 2006;16:2739-2747. Meijboom WB, Mollet NR, Van Mieghem CA, et al. patients with suspected coronary stenoses, but intermediate pre-test probability population without heart rate control. Diagnostic facilities performing computed tomography indications non-invasive cross-sectional imaging techniques play a crucial role in the stable chest in. 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