Clinical recommendations on Cardiac-CT in 2015

Management of acute chest pain in the Emergency Department: benefits of coronary computed tomography angiography

Acute chest pain (ACP) is a frequent cause of Emergency Department (ED) admissions, with millions of cases reported globally each year. Timely and accurate diagnosis is crucial due to the wide range of underlying causes, such as acute coronary syndrome (ACS), pulmonary embolism (PE), aortic dissection, and others. Misdiagnosis can lead to missed life-saving interventions or, alternatively, unnecessary hospitalizations, escalating healthcare costs. While risk stratification tools like the HEART, GRACE, and TIMI scores are useful, additional imaging is often required to achieve diagnostic precision. Coronary computed tomography angiography (CCTA) has shown significant potential in enhancing diagnostic accuracy and improving patient outcomes. In this review, we explore the challenges physicians encounter when evaluating ACP in the ED, emphasizing the utility of CCTA as a key diagnostic tool. Additionally, we present a clinical case that illustrates how CT scan effectively aids in diagnosing patients with ambiguous symptoms, with CT imaging playing a pivotal role in identifying the underlying pathology.

Photon-Counting Computed Tomography (PCCT): Technical Background and Cardio-Vascular Applications

Photon-counting computed tomography (PCCT) is a new advanced imaging technique that is going to transform the standard clinical use of computed tomography (CT) imaging. Photon-counting detectors resolve the number of photons and the incident X-ray energy spectrum into multiple energy bins. Compared with conventional CT technology, PCCT offers the advantages of improved spatial and contrast resolution, reduction of image noise and artifacts, reduced radiation exposure, and multi-energy/multi-parametric imaging based on the atomic properties of tissues, with the consequent possibility to use different contrast agents and improve quantitative imaging. This narrative review first briefly describes the technical principles and the benefits of photon-counting CT and then provides a synthetic outline of the current literature on its use for vascular imaging.

Pre-procedural planning of coronary revascularization by cardiac computed tomography: An expert consensus document of the Society of Cardiovascular Computed Tomography

Coronary CT angiography (CCTA) demonstrated high diagnostic accuracy for detecting coronary artery disease (CAD) and a key role in the management of patients with low-to-intermediate pretest likelihood of CAD. However, the clinical information provided by this noninvasive method is still regarded insufficient in patients with diffuse and complex CAD and for planning percutaneous coronary intervention (PCI) and surgical revascularization procedures. On the other hand, technology advancements have recently shown to improve CCTA diagnostic accuracy in patients with diffuse and calcific stenoses. Moreover, stress CT myocardial perfusion imaging (CT-MPI) and fractional flow reserve derived from CCTA (CT-FFR) have been introduced in clinical practice as new tools for evaluating the functional relevance of coronary stenoses, with the possibility to overcome the main CCTA drawback, i.e. anatomical assessment only. The potential value of CCTA to plan and guide interventional procedures lies in the wide range of information it can provide: a) detailed evaluation of plaque extension, volume and composition; b) prediction of procedural success of CTO PCI using scores derived from CCTA; c) identification of coronary lesions requiring additional techniques (e.g., atherectomy and lithotripsy) to improve stent implantation success by assessing calcium score and calcific plaque distribution; d) assessment of CCTA-derived Syntax Score and Syntax Score II, which allows to select the mode of revascularization (PCI or CABG) in patients with complex and multivessel CAD. The aim of this Consensus Document is to review and discuss the available data supporting the role of CCTA, CT-FFR and stress CT-MPI in the preprocedural and possibly intraprocedural planning and guidance of myocardial revascularization interventions.

Pre-procedural planning of coronary revascularization by cardiac computed tomography: An expert consensus document of the Society of Cardiovascular Computed Tomography

Coronary CT angiography (CCTA) demonstrated high diagnostic accuracy for detecting coronary artery disease (CAD) and a key role in the management of patients with low-to-intermediate pretest likelihood of CAD. However, the clinical information provided by this noninvasive method is still regarded insufficient in patients with diffuse and complex CAD and for planning percutaneous coronary intervention (PCI) and surgical revascularization procedures. On the other hand, technology advancements have recently shown to improve CCTA diagnostic accuracy in patients with diffuse and calcific stenoses. Moreover, stress CT myocardial perfusion imaging (CT-MPI) and fractional flow reserve derived from CCTA (CT-FFR) have been introduced in clinical practice as new tools for evaluating the functional relevance of coronary stenoses, with the possibility to overcome the main CCTA drawback, i.e. anatomical assessment only. The potential value of CCTA to plan and guide interventional procedures lies in the wide range of information it can provide: a) detailed evaluation of plaque extension, volume and composition; b) prediction of procedural success of CTO PCI using scores derived from CCTA; c) identification of coronary lesions requiring additional techniques (e.g., atherectomy and lithotripsy) to improve stent implantation success by assessing calcium score and calcific plaque distribution; d) assessment of CCTA-derived Syntax Score and Syntax Score II, which allows to select the mode of revascularization (PCI or CABG) in patients with complex and multivessel CAD. The aim of this Consensus Document is to review and discuss the available data supporting the role of CCTA, CT-FFR and stress CT-MPI in the preprocedural and possibly intraprocedural planning and guidance of myocardial revascularization interventions.

Coronary computed tomography angiography as a screening tool for moderate-high risk asymptomatic type 2 diabetes mellitus patients

Background

There are few data on the clinical significance of coronary computed tomography angiography (CCTA) in asymptomatic type 2 diabetes mellitus (T2DM) patients. We performed a retrospective study to evaluate coronary heart disease (CHD) screening in asymptomatic patients with T2DM using CCTA and CHD risk stratification prediction.

Materials and methods

Data from 141 T2DM patients (58 ± 8 years, 57% males) without known symptoms suggestive of CHD who underwent CCTA were retrospectively analyzed. The patients were classified into three subgroups based on United Kingdom prospective diabetes study (UKPDS) CHD risk stratification prediction. Seventy-four patients without diabetes mellitus and CHD who underwent CCTA successively were chosen as the control group. The segment involvement score (SIS), segment stenosis score (SSS), stenosis coefficient (SC), severe proximal plaque (SPP) positive ratio and CCTA-adapted Leaman score (CT-LeSc) based on CCTA data were evaluated and compared among the groups.

Results

Compared with the patients in the control group, patients in the moderate-high risk DM groups had higher scores on the SIS, SSS, SC, CT-LeSc, and a higher SPP positive ratio (all p-values < 0.001), and no difference was observed between the low-risk group and the control group (p = 0.136, p = 0.088, p = 0.0.067, p = 0.225, p = 1.000, respectively). Compared with patients in the control group, the patients in the moderate-high risk DM groups had increased odds of SIS > 3 [odds ratio (OR) = 6.557, p < 0.001; OR = 4.455, p < 0.001, respectively], SSS > 5 (OR = 5.727, p < 0.001; OR = 5.144, p < 0.001, respectively), CT-LeSc > 8.7 (OR = 3.780, p = 0.001; OR = 2.804, p = 0.007, respectively), and obstructive stenosis (OR = 7.233, p < 0.001; OR = 5.787, p < 0.001, respectively).

Conclusion

The moderate-high CHD risk patients had increased odds of obstructive coronary artery stenosis, and the distribution of coronary artery stenosis was more extensive and more severe in that group compared to the patients without diabetes mellitus and CHD. CHD can be effectively screened in moderate-high risk asymptomatic T2DM patients using CCTA.

Perspectives in noninvasive imaging for chronic coronary syndromes

Both the latest European guidelines on chronic coronary syndromes and the American guidelines on chest pain have underlined the importance of noninvasive imaging to select patients to be referred to invasive angiography. Nevertheless, although coronary stenosis has long been considered the main determinant of inducible ischemia and symptoms, growing evidence has demonstrated the importance of other underlying mechanisms (e.g., vasospasm, microvascular disease, energetic inefficiency). The search for a pathophysiology-driven treatment of these patients has therefore emerged as an important objective of multimodality imaging, integrating "anatomical" and "functional" information. We here provide an up-to-date guide for the choice and the interpretation of the currently available noninvasive anatomical and/or functional tests, focusing on emerging techniques (e.g., coronary flow velocity reserve, stress-cardiac magnetic resonance, hybrid imaging, functional-coronary computed tomography angiography, etc.), which could provide deeper pathophysiological insights to refine diagnostic and therapeutic pathways in the next future.

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.

The Potential Role of Cardiac CT in the Evaluation of Patients With Known or Suspected Cardiomyopathy: From Traditional Indications to Novel Clinical Applications

After 15 years from its advent in the clinical field, coronary computed tomography (CCTA) is now widely considered as the best first-step test in patients with low-to-moderate pre-test probability of coronary artery disease. Technological innovation was of pivotal importance for the extensive clinical and scientific interest in CCTA. Recently, the advent of last generation wide-coverage CT scans paved the way for new clinical applications of this technique beyond coronary arteries anatomy evaluation. More precisely, both biventricular volume and systolic function quantification and myocardial fibrosis identification appeared to be feasible with last generation CT. In the present review we would focus on potential applications of cardiac computed tomography (CCT), beyond CCTA, for a comprehensive assessment patients with newly diagnosed cardiomyopathy, from technical requirements to novel clinical applications.

Potential Application of Cardiac Computed Tomography for Early Detection of Coronary Atherosclerosis: From Calcium Score to Advanced Atherosclerosis Analysis

In the present article, an overview of advanced analysis of coronary atherosclerosis by coronary computed tomography angiography (CCTA) is provided, focusing on the potential application of this technique in a primary prevention setting. Coronary artery calcium score (CACS) has a well-demonstrated prognostic value even in a primary prevention setting; however, fibro-fatty, high-risk coronary plaque may be missed by this tool. On the contrary, even if not recommended for primary prevention in the general population, CCTA may enable early high-risk atherosclerosis detection, and specific subgroups of patients may benefit from its application. However, further studies are needed to determine the possible use of CCTA in a primary prevention setting.

Coronary artery disease (CAD) extension-derived risk stratification for asymptomatic diabetic patients: usefulness of low-dose coronary computed tomography angiography (CCTA) in detecting high-risk profile patients

BACKGROUND

As one of the most frequent risk factors for cardiovascular disease, type 2 diabetes mellitus (T2DM) is one of the largest causes of death. However, an acute cardiac presentation is not uncommon in diabetic patients, and the current investigative approach remains often inadequate. The aim of our study was to retrospectively stratify the risk of asymptomatic T2DM patients using low-dose 640-slice coronary computed tomography angiography (CCTA).

MATERIALS AND METHODS

CCTA examinations of 62 patients (mean age, 65 years) with previous diagnosis of type 2 diabetes and without cardiac symptoms were analyzed. Image acquisition was performed using a 640-slice CT. Per-patient, per-vessel and per-plaque analyses were performed. Stratification risk was evaluated according to the ESC guidelines. The patients were followed up after 2.21 ± 0.56 years from CCTA examination.

RESULTS

Coronary artery disease (CAD) was found in 58 patients (93.55%) presenting 290 plaques. Analysis of all samples showed severe-to-occlusive atherosclerosis in 24 patients (38.7% of cases). However, over the degree of stenosis, 23 patients were evaluated at high risk considering the extension of CAD. Good agreement was shown by the correlation of CAD extension/risk estimation and MACE incidence, according to a Kaplan-Meier survival analysis (p value = 0.001), with a 7.25-fold increased risk (HR 7.25 CI 2.13-24.7; p value = 0.002).

CONCLUSION

Our study confirms the high capability of CCTA to properly stratify the CV risk of asymptomatic T2DM patients. Its use could be recommended if we consider how current investigative strategies to correctly assess these patients often seem inadequate.

The usefulness of cardiac CT integrated with FFRCT for planning myocardial revascularization in complex coronary artery disease: a lesson from SYNTAX studies

After two decades of clinical use, during which coronary CT angiography (CCTA) was considered an appropriate method for the non-invasive assessment of patients with suspected stable coronary artery disease (CAD) and low-to-intermediate pretest likelihood of CAD, a growing body of literature is showing that CCTA may have also a clinical role in patients with high pretest likelihood of CAD, known CAD and complex and diffuse CAD. Particularly, the SYNTAX studies demonstrated the usefulness of CCTA in the field of non-invasive assessment of these patients and planning of interventional and surgical coronary procedures, thanks to its ability to combine, in a single method, precise stenosis quantification, accurate plaque characterization, functional assessment and selection of the revascularization modality for any individual patient and of the vessels that need to be revascularized. Of note, the SYNTAX III Revolution trial showed, in patients with three-vessel CAD, that treatment decision-making between PCI and CABG based on CCTA only has an almost perfect agreement with the treatment decision derived from invasive coronary angiography (ICA). Moreover, the SYNTAX Score II demonstrated a high degree of correlation between the two diagnostic strategies, suggesting the potential feasibility of a treatment decision-making based solely on non-invasive imaging and clinical information. New research prospects have opened up for the future to demonstrate the true feasibility and safety of this innovative approach in the clinical arena.

Coronary CT Angiography in Challenging Patients: High Heart Rate and Atrial Fibrillation. A Review

Despite several strategies have been developed by different vendors to improve image quality and diagnostic accuracy of coronary CT angiography performed at high heart rate (HR) and HR variability, as in patients with atrial fibrillation (AF), some concerns and small clinical experience characterize these subsets of challenging patients. However, patients with AF have been reported to have higher risk of cardiovascular events and noninvasive evaluation of suspected coronary artery disease in this setting may be of extreme clinical interest. The goal of this review is to provide to the reader an overview on the use of cardiac CT in patients with AF and high HR and to outline the technological improvements recently introduced in the clinical field that may enable to definitively overcome the limitations of cardiac CT in this challenging scenario.

Prognostic Value and Therapeutic Perspectives of Coronary CT Angiography: A Literature Review

Coronary stenosis severity is both a powerful and a still debated predictor of prognosis in coronary artery disease. Coronary computed tomographic angiography (CCTA) has emerged as a noninvasive technique that enables anatomic visualization of coronary artery disease (CAD). CCTA with newer applications, plaque characterization and physiologic/functional evaluation, allows a comprehensive diagnostic and prognostic assessment of otherwise low-intermediate subjects for primary prevention. CCTA measures the overall plaque burden, differentiates plaque subtypes, and identifies high-risk plaque with good reproducibility. Research in this field may also advance towards an era of personalized risk prediction and individualized medical therapy. It has been demonstrated that statins may delay plaque progression and change some plaque features. The potential effects on plaque modifications induced by other medical therapies have also been investigated. Although it is not currently possible to recommend routinely serial scans to monitor the therapeutic efficacy of medical interventions, the plaque modulation, as a part of risk modification, appears a feasible strategy. In this review we summarize the current evidence regarding vulnerable plaque and effects of lipid lowering therapy on morphological features of CAD. We also discuss the potential ability of CCTA to characterize coronary atherosclerosis, stratify prognosis of asymptomatic subjects, and guide medical therapy.

Additional value of inflammatory biomarkers and carotid artery disease in prediction of significant coronary artery disease as assessed by coronary computed tomography angiography

Aims

To evaluate the relationship between an incremental model including cardiovascular risk factors, carotid disease, and inflammatory biomarkers to predict the presence of obstructive coronary artery disease (CAD).

Methods and results

A total of 134 consecutive and asymptomatic intermediate-risk patients (mean age 61 ± 9 years, 52% men) were enrolled. Each subject underwent circulating levels assessment of interleukin (IL)-2r, IL-6, IL-8, IL-10, high-sensitivity C-reactive protein (hs-CRP) and carotid and coronary artery evaluation using carotid ultrasound and coronary computed tomography angiography (CCTA), respectively. Carotid disease was diagnosed in 71 (53%) patients. Obstructive and multi-vessel CAD were found in 50 (37%) and 18 (14%) patients, respectively. Patients in whom CCTA showed multi-vessel CAD had a higher rate of carotid disease (89 vs. 46%, P = 0.001) and increased values of all interleukins when compared with patients without multi-vessel obstructive CAD. The univariate and multivariate analysis showed that male gender, diabetes, carotid disease, and IL-6 were independently associated with obstructive CAD. At receiver operating characteristic curve analysis, the multivariate model (including male gender, carotid disease, IL-6 > 5.9 pg/mL, and diabetes) showed the highest area under the curve for prediction of obstructive CAD, multi-vessel CAD, and high-risk plaque defined as mixed and/or remodelled plaque when compared with all other models (P < 0.001).

Conclusion

Among asymptomatic intermediate-risk patients, the presence of increased IL6 levels in addition to traditional risk factors (male gender with diabetes) and carotid artery disease predicts higher rates of obstructive CAD and it could be of help to identify which subset of asymptomatic patients could be referred to CCTA for screening.

Coronary computed tomography angiography in the evaluation of intermediate risk asymptomatic individuals

Cardiovascular disease is still one of the main causes of death and an early identification of coronary artery disease (CAD) remains the primary step in clinical management of patients with cardiovascular risk factor. Coronary computed tomography angiography (CCTA) has shown high sensitivity in CAD detection and could be helpful as screening method. The purpose of this study was to assess the prevalence of coronary artery disease detected by CCTA in asymptomatic patients with an intermediate risk of CAD.

MATERIALS AND METHODS

We retrospectively selected 185 asymptomatic patients with an intermediate Framingan Risk Score (mean age was 62.3 ± 12.4 years); all patients underwent CCTA, using 640-slice CT.

RESULTS

Atherosclerotic plaques were present in 112 out of 185 patients (60.5%); 56 subjects (30.2%) had mild stenosis, 49 (26.5%) moderate stenosis, only 3 patients (1.6%) had severe stenosis and in 4 cases (2.2%) the "blooming effect" did not allow for evaluation of the degree of stenosis. Among the positive cases, a high number of patients (44.6%) [50] showed coronary artery disease in one vessel, 33 patients (29.4%) in two vessels, 22 patients (19.6%) in three vessels and 5 patients in four vessels or more (4.5%). Patients with moderate stenosis were older, had hypertension in most cases, higher total cholesterol levels and more often were smokers. The radiation dose (mSv) dispensed to the patients was 3.7 ± 1.6 mSv.

CONCLUSION

High prevalence of coronary stenosis detected by low-dose CCTA in patients not properly classified by the traditional methods of risk stratification commonly used in clinical practice emphasizes the need to extend the risk stratification to other diagnostic tools with higher capability to detect CAD.

Coronary Atherosclerosis Assessment by Coronary CT Angiography in Asymptomatic Diabetic Population: A Critical Systematic Review of the Literature and Future Perspectives

The prognostic impact of diabetes mellitus (DM) on cardiovascular outcomes is well known. As a consequence of previous studies showing the high incidence of coronary artery disease (CAD) in diabetic patients and the relatively poor outcome compared to nondiabetic populations, DM is considered as CAD equivalent which means that diabetic patients are labeled as asymptomatic individuals at high cardiovascular risk. Lessons learned from the analysis of prognostic studies over the past decade have challenged this dogma and now support the idea that diabetic population is not uniformly distributed in the highest risk box. Detecting CAD in asymptomatic high risk individuals is controversial and, what is more, in patients with diabetes is challenging, and that is why the reliability of traditional cardiac stress tests for detecting myocardial ischemia is limited. Cardiac computed tomography angiography (CCTA) represents an emerging noninvasive technique able to explore the atherosclerotic involvement of the coronary arteries and, thus, to distinguish different risk categories tailoring this evaluation on each patient. The aim of the review is to provide a wide overview on the clinical meaning of CCTA in this field and to integrate the anatomical information with a reliable therapeutic approach.

An atypical pseudoaneurysm as complication of prosthetic aortic-valve endocarditis

Endocarditis of a prosthetic heart valve is a life-threatening condition that is associated with high morbidity and mortality. Perivalvular extension in infective endocarditis includes complications such as periannular or intramyocardial abscesses, pseudoaneurysms and fistulae. The incidence of perivalvular extension ranges from 10 to 30% in native valve endocarditis and 30 to 55% in prosthetic aortic-valve endocarditis. Herein, we describe a case of a 66-year-old man who presented endocarditis of a prosthetic aortic valve complicated by infective pseudoaneurysm with localization next to the right coronary sinus of Valsalva. Moreover, we underscore the importance of the diagnostic imaging tools options and surgical timing.

The presence of remodeled and mixed atherosclerotic plaques at coronary ct angiography predicts major cardiac adverse events - The CAFÉ-PIE Study

BACKGROUND

It is still unclear how to exploit information made available by coronary computed tomography angiography (CCTA) on coronary artery disease (CAD) features in order to better predicting major adverse cardiac events (MACEs). Aim of this study was to validate the prognostic role of a comprehensive and simplified CT-derived score in patients evaluated for suspected CAD.

METHODS

A prospective registry included 477 consecutive symptomatic patients without known CAD who underwent clinically-indicated CCTA. All patients were followed-up for MACE occurrence for a period of 49±15-month.

RESULTS

The mean CT Score was 10.5±10.8, with a MACE rate of 11.3%. There was a stepwise relationship between MACE rate during follow-up and CT Score values. MACEs were 1.9% in patients with CT Score<10 (reference group), 16.6% in those with CT Score 10-20 (OR 9.9, 95% C.I. 3.5-27.8 vs. reference group, p<0.001), 24.5% in those with CT Score 21-30 (OR 16.6, 95% C.I. 6.1-45.0 vs. reference group, p<0.001), and 47.4% in those with CT Score>30 (OR 46.1, 95% C.I. 13.0-162.9 vs. reference group, p<0.001) (p for trend <0.001). At ROC curve analysis, CT Score was the best predictor of MACE (AUC: 0.81, CI 95%: 0.78-0.84) as compared to Diamond and Forrester score (p<0.001), segment stenosis score (p<0.05) and segment involved score (p<.0.01).

CONCLUSIONS

The use of an integrated score obtained with CCTA and based on the presence of remodeled and mixed atherosclerotic coronary plaques may improve MACE prediction in symptomatic patients at intermediate risk outweighing that provided by standard clinical and CCTA scores.