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Controversies in cardiac computed tomography

Non-invasive Imaging: Cardiac Computed Tomography


Cardiac computed tomography is a rapidly progressing technology. The appropriate use of this technology remains controversial. Coronary calcium score (CACS) has proven itself to be a strong predictor of coronary events in asymptomatic individuals without known coronary artery disease, and this in the young, old, men, women and all ethnic groups. At present, the appropriate use is in individuals in whom physicians need further refinement of risk factor assessment.

Dr. Alexander Leber from Munich, Germany talked about the value of CACS in symptomatic patients. He presented data that this non-contrast, low radiation (1 mSv) technique shows a lower likelihood of significant coronary stenosis if CACS is low, with an excellent prognostic value (<2% MACE at 42 months). Further, assessing CACS in acute coronary syndrome has shown to have a negative predictive value of 99% (mean age 51 years). He suggested no further testing if CACS is 0, with CT angiography (CTA) with CACS < 400 and stress-imaging with CACS > 400.

Dr. Pim De Feyter from Rotterdam, Netherlands discussed the very controversial issue of management of non-obstructive plaque on CTA in symptomatic patients or asymptomatic high risk patients. The prevalence of non-obstructive plaque in asymptomatic individuals ranges from 30 -50%. Assessing the extent, severity and distribution of the coronary plaque, and association with myocardial flow limitation has a definite prognostic value and can be used for guiding treatment.

Invasive management of obstructive lesions in asymptomatic high risk individuals has excellent prognosis, with optimal medical therapy in case of low to intermediate likelihood of significant CAD. Regarding the predictive value of CTA in symptomatic patients, the 1 year event rate from a meta-analysis was 1.5% for non-obstructive CAD and 11.1% for those with obstructive CAD. He stressed that CTA is not recommended for screening asymptomatic patients.

Dr Chow from Ottawa, Canada told us that non-cardiac incidental findings are fairly common (up to 30%).The objective in reporting these incidental findings is to optimize patient care, therefore only clinically significant findings such as aortic dissection, pneumonia, pulmonary embolism and hiatal hernia should be reported. A full field of view reconstruction should be made without additional scanning. The pros and cons of incidental findings with cost-benefit analysis of follow-up requirements need to be analyzed.

Finally, Dr. Van Velzen from Leiden, Netherlands highlighted the role of CTA in patients with acute chest pain with negative serial ECGs and cardiac enzymes. There is promising data regarding faster workup and definite cost savings. A negative CTA meant a good chance of event free survival up to a period of 1 year. Further work in this field in ongoing.

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Controversies in cardiac computed tomography
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.