A meta-analysis of 64-section coronary CT angiography findings for predicting 30-day major adverse cardiac events in patients presenting with symptoms suggestive of acute coronary syndrome

Evolving Role of Coronary CT Angiography in Coronary Angiography and Intervention: A State-of-the-Art Review

PURPOSE OF REVIEW

Despite growing evidence supporting the diagnostic utility of coronary computed tomographic angiography (CCTA) for anatomical assessment of coronary artery disease (CAD), its is underutilized in peri-procedural planning especially in the acute setting.

RECENT FINDINGS

Incorporation of flow reserve measurement techniques into CCTA has expanded its sensitivity and specificity for obstructive disease, and continued improvement in CCTA technology permits more accurate cross-sectional plaque characterization. CCTA has the potential to constitute the mainstay of pre-procedural planning for patients with CAD, who are being considered for percutaneous coronary intervention , reducing their ad hoc nature while facilitating equipment selection and improving catheterization lab safety and throughput. Future studies are needed to compare the cost and benefits of more frequent use of routine pre-procedural CCTA prior to coronary angiography and intervention.

Appropriateness criteria for the use of cardiac computed tomography, SIC-SIRM part 2: acute chest pain evaluation; stent and coronary artery bypass graft patency evaluation; planning of coronary revascularization and transcatheter valve procedures; cardiomyopathies, electrophysiological applications, cardiac masses, cardio-oncology and pericardial diseases evaluation

In the past 20 years, cardiac computed tomography (CCT) has become a pivotal technique for the noninvasive diagnostic workup of coronary and cardiac diseases. Continuous technical and methodological improvements, combined with fast growing scientific evidence, have progressively expanded the clinical role of CCT. Randomized clinical trials documented the value of CCT in increasing the cost-effectiveness of the management of patients with acute chest pain presenting in the emergency department, also during the pandemic. Beyond the evaluation of stents and surgical graft patency, the anatomical and functional coronary imaging have the potential to guide treatment decision-making and planning for complex left main and three-vessel coronary disease. Furthermore, there has been an increasing demand to use CCT for preinterventional planning in minimally invasive procedures, such as transcatheter valve implantation and mitral valve repair. Yet, the use of CCT as a roadmap for tailored electrophysiological procedures has gained increasing importance to assure maximum success. In the meantime, innovations and advanced postprocessing tools have generated new potential applications of CCT from the simple coronary anatomy to the complete assessment of structural, functional and pathophysiological biomarkers of cardiac disease. In this complex and revolutionary scenario, it is urgently needed to provide an updated guide for the appropriate use of CCT in different clinical settings. This manuscript, endorsed by the Italian Society of Cardiology (SIC) and the Italian Society of Medical and Interventional Radiology (SIRM), represents the second of two consensus documents collecting the expert opinion of cardiologists and radiologists about current appropriate use of CCT.

When More Is Better: Underused Advanced Imaging Exams That Can Improve Outcomes and Reduce Cost of Care

Appropriate use of resources is a tenet of care transformation efforts, with a national campaign to reduce low-value imaging. The next level of performance improvement is to bolster evidence-based screening, imaging surveillance, and diagnostic innovation, which can avert more costly, higher-risk elements of unnecessary care like emergent interventions. Clinical scenarios in which underused advanced imaging can improve outcomes and reduce total cost of care are reviewed, including abdominal aortic aneurysm surveillance, coronary artery disease diagnosis, and renal mass characterization. Reliable abdominal aortic aneurysm surveillance imaging reduces emergency surgery and can be driven by radiologists incorporating best practice standardized recommendations in imaging interpretations. Coronary computed tomography angiography in patients with stable and unstable chest pain can reduce downstream resource use while improving outcomes. Preoperative ^99mTc-sestamibi single-photon emission computed tomography (SPECT) reliably distinguishes oncocytoma from renal cell carcinoma to obviate unnecessary nephrectomy. As technological advances in diagnostic, molecular, and interventional radiology improve our ability to detect and cure disease, analyses of cost effectiveness will be critical to radiology leadership and sustainability in the transition to a value-based reimbursement model.

The Impact of Implementing 24/7 Cardiac CTA Interpretation in the Emergency Department on Patient Care: Retrospective Analysis of a Single-Center Experience

OBJECTIVE. The objective of our study was to provide insight on the diagnostic validity of cardiac CTA (CCTA) to identify obstructive coronary artery disease (CAD) and patients who require urgent intervention, compared with those who require same-admission coronary catheterization (CC), and to help elucidate the necessity of a 24/7 CCTA service. MATERIALS AND METHODS. We retrospectively reviewed 658 consecutive CCTA examinations performed of emergency department (ED) patients who presented with acute chest pain from October 1, 2013, to February 28, 2018. Patients were categorized by CAD severity on CCTA. Using same-admission CC as the reference standard, we assessed CCTA's validity to identify obstructive disease using PPV, NPV, sensitivity, and specificity and CCTA's validity to identify patients who require urgent intervention. The added value of the CCTA findings of subendocardial hypoattenuation and wall motion abnormality was evaluated. CCTA examinations were categorized on the basis of the time of day when scanning was performed. RESULTS. The PPV, NPV, and sensitivity of CCTA to diagnose obstructive CAD were 0.87, 0.79, and 0.95, respectively. Nine percent of the scanned patients underwent percutaneous coronary intervention (PCI) or were referred for urgent coronary artery bypass grafting (CABG). The presence of obstructive CAD on CCTA has a PPV of 0.73 to identify patients deemed to be at higher acute coronary syndrome (ACS) risk to warrant urgent PCI or CABG. Wall motion abnormality increased the PPV to 1.0; subendocardial attenuation increased the PPV to 0.9. The NPV and sensitivity were 0.89 and 0.97, respectively. Of the CCTA examinations, 54% were performed outside regular working hours. Of the patients who received urgent interventions, 62% underwent CCTA examinations performed outside regular working hours. CONCLUSION. CCTA provides high correlation with CC, helps identify individuals with high ACS risk, and is further strengthened by functional analysis; 24/7 CCTA service is warranted.

Influence of contrast material density and kV setting on detectability of calcified plaques on coronary CT angiography

PURPOSE

To analyze the impact of tube potential and iodine concentration on the visibility of calcified plaques in coronary computed tomography angiography (cCTA).

METHODS & MATERIALS

164 consecutive patients (65.9 % men and a mean age of 57.1 ± 11.3 years) with suspected coronary artery disease underwent calcium scoring (CaSc) scan followed by cCTA with topogram-based automated tube voltage selection (70 kV, 80 kV, 90 kV, 100 kV or 120 kV). In 127 Patients (HC), we injected 50 mL of contrast material (CM) with a concentration of 400 mg iodine per ml and in 37 patients (LC) 50 mL iodine concentration of 280 mg/mL. Sensitivity of cCTA for detecting calcified plaques was calculated with CaSc serving as gold standard. Density of CM enhanced coronary vessels and calcified plaques were quantified by region-of-interest (ROI) measurements in unenhanced and cCTA image series.

RESULTS

Overall sensitivity of cCTA to detect calcified plaques was significantly higher using LC compared to HC (79 % vs. 73 %; p = 0.0035). The impact of LC was impressive at 70 kV with an improved sensitivity of 70 % vs. 57.1 % in HC (p = 0.0082). Furthermore, density values of HC enhanced coronary vessels exceeded those of calcified plaques, especially at low kV levels. In LC, except for the 70 kV setting, higher density values were shown for calculi than enhanced vessels.

CONCLUSION

Low kV cCTA in routine using highly concentrated CM leads to reduced calcified plaque perceptibility and hence potentially underestimation of stenosis. Thus, low kV cCTA using CM with lower iodine concentration is necessary. In addition, a dose reduction up to 77.7 % can also be benefited.

Statement from the North American Society for Cardiovascular Imaging on imaging strategies to reduce the scarcity of healthcare resources during the COVID-19 outbreak

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is an evolving global pandemic that is predicted to strain healthcare resources at multiple locations throughout North America and the World. As of April 6, 2020, the apex of infection rates is predicted to occur within 1 to 5 weeks at various locations. Widespread reports of personal protective equipment (PPE) shortages, and healthcare worker exposure to disease have become commonplace. To mitigate this crisis, we are suggesting imaging strategies that aim to use the least PPE, require the smallest number of potential staff exposures, and streamlines utilization of imaging. They are broadly organized by (1) substituting a noninvasive diagnostic test in place of a semi-invasive or invasive diagnostic tests, and (2) consolidating diagnostic imaging.

ACR Appropriateness Criteria® Chest Pain-Possible Acute Coronary Syndrome

Chest pain is a frequent cause for emergency department visits and inpatient evaluation, with particular concern for acute coronary syndrome as an etiology, since cardiovascular disease is the leading cause of death in the United States. Although history-based, electrocardiographic, and laboratory evaluations have shown promise in identifying coronary artery disease, early accurate diagnosis is paramount and there is an important role for imaging examinations to determine the presence and extent of anatomic coronary abnormality and ischemic physiology, to guide management with regard to optimal medical therapy or revascularization, and ultimately to thereby improve patient outcomes. A summary of the various methods for initial imaging evaluation of suspected acute coronary syndrome is outlined in this document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association

Spontaneous coronary artery dissection (SCAD) has emerged as an important cause of acute coronary syndrome, myocardial infarction, and sudden death, particularly among young women and individuals with few conventional atherosclerotic risk factors. Patient-initiated research has spurred increased awareness of SCAD, and improved diagnostic capabilities and findings from large case series have led to changes in approaches to initial and long-term management and increasing evidence that SCAD not only is more common than previously believed but also must be evaluated and treated differently from atherosclerotic myocardial infarction. High rates of recurrent SCAD; its association with female sex, pregnancy, and physical and emotional stress triggers; and concurrent systemic arteriopathies, particularly fibromuscular dysplasia, highlight the differences in clinical characteristics of SCAD compared with atherosclerotic disease. Recent insights into the causes of, clinical course of, treatment options for, outcomes of, and associated conditions of SCAD and the many persistent knowledge gaps are presented.

State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes

It is well established that clinicians cannot use clinical judgment alone to determine whether an individual patient who presents to the emergency department has an acute coronary syndrome. The history and physical examination do not distinguish sufficiently between the many conditions that can cause acute chest pain syndromes. Cardiac risk factors do not have sufficient discriminatory ability in symptomatic patients presenting to the emergency department. Most patients with non-ST-segment-elevation myocardial infarction do not present with electrocardiographic evidence of active ischemia. The improvement in cardiac troponin assays, especially in conjunction with well-validated clinical decision algorithms, now enables the clinician to rapidly exclude myocardial infarction. In patients in whom unstable angina remains a concern or there is a desire to evaluate for underlying coronary artery disease, coronary computed tomography angiography can be used in the emergency department. Once a process that took ≥24 hours, computed tomography angiography now can rapidly exclude myocardial infarction and coronary artery disease in patients in the emergency department.

Noninvasive cardiac imaging in suspected acute coronary syndrome

Noninvasive cardiac imaging has an important role in the assessment of patients with acute-onset chest pain. In patients with suspected acute coronary syndrome (ACS), cardiac imaging offers incremental value over routine clinical assessment, the electrocardiogram, and blood biomarkers of myocardial injury, to confirm or refute the diagnosis of coronary artery disease and to assess future cardiovascular risk. This Review covers the current guidelines and clinical use of the common noninvasive imaging techniques, including echocardiography and stress echocardiography, computed tomography coronary angiography, myocardial perfusion scintigraphy, positron emission tomography, and cardiovascular magnetic resonance imaging, in patients with suspected ACS, and provides an update on the developments in noninvasive imaging techniques in the past 5 years.

The Essentials of Cardiac Computerized Tomography

Cardiac computerized tomography (CT) has evolved from a research tool to an important diagnostic investigation in cardiology, and is now recommended in European, US, and UK guidelines. This review is designed to give the reader an overview of the current state of cardiac CT. The role of cardiac CT is multifaceted, and includes risk stratification, disease detection, coronary plaque quantification, defining congenital heart disease, planning for structural intervention, and, more recently, assessment of ischemia. This paper addresses basic principles as well as newer evidence.

Age-related risk of major adverse cardiac event risk and coronary artery disease extent and severity by coronary CT angiography: results from 15 187 patients from the International Multisite CONFIRM Study

AIMS

Prior studies evaluating the prognostic utility of cardiac CT angiography (CCTA) have been largely constrained to an all-cause mortality endpoint, with other cardiac endpoints generally not reported. To this end, we sought to determine the relationship of extent and severity of coronary artery disease (CAD) by CCTA to risk of incident major adverse cardiac events (MACEs) (defined as death, myocardial infarction, and late revascularization).

METHODS AND RESULTS

We identified subjects without prior known CAD who underwent CCTA and were followed for MACE. CAD by CCTA was defined as none (0% luminal stenosis), mild (1-49% luminal stenosis), moderate (50-69% luminal stenosis), or severe (≥70% luminal stenosis), and ≥50% luminal stenosis was considered as obstructive. CAD severity was judged on per-patient, per-vessel, and per-segment basis. Time to MACE was estimated using univariable and multivariable Cox proportional hazards models. Among 15 187 patients (57 ± 12 years, 55% male), 595 MACE events (3.9%) occurred at a 2.4 ± 1.2 year follow-up. In multivariable analyses, an increased risk of MACE was observed for both non-obstructive [hazard ratio (HR) 2.43, P < 0.001] and obstructive CAD (HR: 11.21, P < 0.001) when compared with patients with normal CCTA. Risk-adjusted MACE increased in a dose-response relationship based on the number of vessels with obstructive CAD ≥50%, with increasing hazards observed for non-obstructive (HR: 2.54, P < 0.001), obstructive one-vessel (HR: 9.15, P < 0.001), two-vessel (HR: 15.00, P < 0.001), or three-vessel or left main (HR: 24.53, P < 0.001) CAD. Among patients stratified by age <65 vs. ≥65 years, older individuals experienced higher risk-adjusted hazards for MACE for non-obstructive, one-, and two-vessel, with similar event rates for three-vessel or left main (P < 0.001 for all) compared with normal individuals age <65. Finally, there was a dose relationship of CAD findings by CCTA and MACE event rates with each advancing decade of life.

CONCLUSION

Among individuals without known CAD, non-obstructive, and obstructive CAD are associated with higher MACE rates, with different risk profiles based on age.

Cardiac CT: atherosclerosis to acute coronary syndrome

Coronary computed tomographic angiography (CCTA) is a robust non-invasive method to assess coronary artery disease (CAD). Qualitative and quantitative assessment of atherosclerotic coronary stenosis with CCTA has been favourably compared with invasive coronary angiography (ICA) and intravascular ultrasound (IVUS). Importantly, it allows the study of preclinical stages of atherosclerotic disease, may help improve risk stratification and monitor the progressive course of the disease. The diagnostic accuracy of CCTA in the assessment of coronary artery bypass grafts (CABG) is excellent and the constantly improving technology is making the evaluation of stents feasible. Novel techniques are being developed to assess the functional significance of coronary stenosis. The excellent negative predictive value of CCTA in ruling out disease enables early and safe discharge of patients with suspected acute coronary syndromes (ACS) in the Emergency Department (ED). In addition, CCTA is useful in predicting clinical outcomes based on the extent of coronary atherosclerosis and also based on individual plaque characteristics such as low attenuation plaque (LAP), positive remodelling and spotty calcification. In this article, we review the role of CCTA in the detection of coronary atherosclerosis in native vessels, stented vessels, calcified arteries and grafts; the assessment of plaque progression, evaluation of chest pain in the ED, assessment of functional significance of stenosis and the prognostic significance of CCTA.

Investigation of publication bias in meta-analyses of diagnostic test accuracy: a meta-epidemiological study

Background

The validity of a meta-analysis can be understood better in light of the possible impact of publication bias. The majority of the methods to investigate publication bias in terms of small study-effects are developed for meta-analyses of intervention studies, leaving authors of diagnostic test accuracy (DTA) systematic reviews with limited guidance. The aim of this study was to evaluate if and how publication bias was assessed in meta-analyses of DTA, and to compare the results of various statistical methods used to assess publication bias.

Methods

A systematic search was initiated to identify DTA reviews with a meta-analysis published between September 2011 and January 2012. We extracted all information about publication bias from the reviews and the two-by-two tables. Existing statistical methods for the detection of publication bias were applied on data from the included studies.

Results

Out of 1,335 references, 114 reviews could be included. Publication bias was explicitly mentioned in 75 reviews (65.8%) and 47 of these had performed statistical methods to investigate publication bias in terms of small study-effects: 6 by drawing funnel plots, 16 by statistical testing and 25 by applying both methods. The applied tests were Egger’s test (n = 18), Deeks’ test (n = 12), Begg’s test (n = 5), both the Egger and Begg tests (n = 4), and other tests (n = 2). Our own comparison of the results of Begg’s, Egger’s and Deeks’ test for 92 meta-analyses indicated that up to 34% of the results did not correspond with one another.

Conclusions

The majority of DTA review authors mention or investigate publication bias. They mainly use suboptimal methods like the Begg and Egger tests that are not developed for DTA meta-analyses. Our comparison of the Begg, Egger and Deeks tests indicated that these tests do give different results and thus are not interchangeable. Deeks’ test is recommended for DTA meta-analyses and should be preferred.

Role of CT angiography for detection of coronary atherosclerosis

As laparoscopic surgery is replacing open surgery, similarly computed tomography angiography is replacing invasive conventional cardiac angiography. In the last century, marvelous efforts in research have improved strategies for cure, diagnosis and prevention of fatal human diseases; however, coronary artery disease, as the most prevalent cause of mortality and morbidity in the world, has remained a great challenge. Due to advancements in technology and research, it has become more simple and robust to diagnose and treat coronary artery disease (CAD) with minimal or no intervention, promising to not only diagnosis at an early stage but potential prevention altogether. While most with obvious CAD can be diagnosed easily and quickly with ECG, those identified as 'low risk' require more extensive testing to diagnose or rule out CAD. For example in emergency departments, low-risk patients with chest pain are diagnosed solely depending on history, ECG and blood testing for biomarkers. This approach has resulted in either delayed or miss-diagnosis of Acute coronary syndrome. To prevent this, many emergency departments now use protocols for low-risk heart patients that include cardiac stress tests and/or CT heart imaging. This review provides an overview of the current literature on the value of Computed tomography angiography and discusses how prognostic information obtained with Computed tomography angiography can be used to further integrate the technique into clinical practice.

Is it prime time for "rapid comprehensive cardiopulmonary imaging" in the emergency department?

Reducing hospital admissions through improved risk stratification of patients with potential acute coronary syndrome represents a critical focus for reducing health care expenditure. Coronary computed tomographic angiography (CTA) has been used with increasing frequency as part of the evaluation of chest pain in the Emergency Department. In the appropriate group of patients at low to intermediate risk CTA appears to be an excellent evaluation strategy, safely and efficiently allowing for the rapid discharge of patients home.