REVIEW
Responsible Use of Computed Tomography in the Evaluation of Coronary Artery Disease and Chest Pain

https://doi.org/10.4065/mcp.2009.0652Get rights and content

Many options are available to clinicians for the noninvasive evaluation of the cardiovascular system and patient concerns about chest discomfort. Cardiac computed tomography (CT) is a rapidly advancing field of noninvasive imaging. Computed tomography incorporates coronary artery calcium scoring, coronary angiography, ventricular functional analysis, and information about noncardiac thoracic anatomy. We searched the PubMed database and Google from inception to September 2009 for resources on the accuracy, risk, and predictive capacity of coronary artery calcium scoring and CT coronary angiography and have reviewed them herein. Cardiac CT provides diagnostic information comparable to echocardiography, nuclear myocardial perfusion imaging, positron emission tomography, and magnetic resonance imaging. A cardiac CT study can be completed in minutes. In patients with a nondiagnostic stress test result, cardiac CT can preclude the need for invasive angiography. Prognostic information portends excellent outcomes in patients with normal study results. Use of cardiac CT can reduce health care costs and length of emergency department stays for patients with chest pain. Cardiac CT examination provides clinically relevant information at a radiation dose similar to well-established technologies, such as nuclear myocardial perfusion imaging. Advances in technique can reduce radiation dose by 90%. With appropriate patient selection, cardiac CT can accurately diagnose heart disease, markedly decrease health care costs, and reliably predict clinical outcomes.

Section snippets

CT TECHNOLOGY

Two types of CT scanners are available for imaging the heart. The first is electron beam CT (EBCT), which is an older technology infrequently used today. The second is multidetector helical CT (MDCT), which represents most CT use. Electron beam CT does not use a mechanical rotating gantry. Instead, an electron gun generates electrons, which are then electromagnetically steered across a stationary tungsten anode.1 Although EBCT has excellent temporal resolution,2 its spatial resolution is

CLINICAL USES OF CARDIAC CT

Cardiac CT is a term encompassing several tests, including CAC scoring, CTA, ventricular function analysis, and structural analysis of masses, congenital defects, bypass grafts, and reconstructive procedures. Our review focuses on the assessment of CAD with CAC and CTA.

RADIATION RISK ASSOCIATED WITH CARDIAC CT

Perhaps the most often discussed drawback of cardiac CT imaging modalities is concern about radiation exposure. Discussion of this topic is difficult because of confusing terms, imprecise measures of radiation dose, and limited evidence to accurately estimate future risk from exposure. The most commonly used term in the medical imaging literature to reflect the biological risk associated with exposure to ionizing radiation is the effective dose, which is expressed in units of millisieverts

SELECTING THE APPROPRIATE PATIENT FOR CTA

The American College of Cardiology, American College of Radiology, and several other subspecialty societies have outlined criteria for appropriate use of cardiac CT.56 Physicians from the participating groups reviewed potential indications for cardiac CT and rated the indications based on a balance between evidence of and experience with cardiac CT; these indications were based on the Delphi method from the RAND corporation.57 The 2006 appropriateness criteria did not recommend routine use of

ILLUSTRATIVE CASES

To illustrate how CTA might be used for patients encountered in a general medical setting, we describe 3 patients who may warrant evaluation for cardiovascular disease. Key to deciding whether CTA is appropriate is to know whether the patient has already been diagnosed as having CAD anddetermining the pretest probability of making the diagnosis of CAD. The authors of the appropriateness criteria used the quality of patients' symptoms, their age, and their sex to determine their pretest

CONCLUSION

Cardiac CT, and particularly CTA, is a rapidly improving noninvasive imaging modality for assessment of many types of cardiac disease, especially CAD. The technology has limitations, particularly in patients with arrhythmias or prior CAD and stenting.

Coronary artery calcium scoring has excellent NPV, which is additive beyond traditional risk factor assessment, such as Framingham risk. Extensive data have demonstrated the prognostic value of CAC scoring. These data suggest that aggressive

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