Dr. Joao AC Lima,
Prof. Gerald Maurer,
See the press release:Munich, Germany – August 28 2012: A non-invasive imaging strategy which integrates non-invasive CT angiography (CTA) and CT myocardial perfusion imaging (CTP) has robust diagnostic accuracy for identifying patients with flow-limiting coronary artery disease in need of myocardial revascularisation, according to results of the CORE320 study presented here today by Dr Joao AC Lima from Johns Hopkins Hospital, Baltimore, USA...Read more
Presenter: Joao Ac Lima | see Discussant report
Discussant: Gerald Maurer
Background and rationaleCT angiography (CTA) provides morphologic information of coronary anatomy and is capable of detecting the presence of atherosclerotic lesions. Morphologic information alone is, however, limited in its ability to predict physiological significance of coronary luminal stenosis. There is ample evidence that the benefit of revascularization is highest when stenoses are hemodynamically significant, as assessed by SPECT or by invasive measurement of fractional flow reserve. The aim of the present study was to evaluate the diagnostic performance of combined CTA and CT perfusion (CTP) study using a 320-row detector CT scanner to identify patients with flow limiting CAD, as compared to invasive angiography and SPECT.
Study DesignThis was a multicenter (16), multinational (8), prospective study which included 391 patients with suspected coronary artery disease who had been referred for clinically indicated coronary angiography. Noninvasive CT evaluation of coronary lesion severity (by CTA) + hemodynamic significance (by CTP) was compared to invasive angiography + SPECT and analyzed on a per patient and per vessel basis.
Main FindingsCombined CTA and CTP was capable of detecting hemodynamically significant stenoses (50% or 70%), as defined by invasive angiography with an associated SPECT perfusion defect. Furthermore, combined CTA and CTP was found to be superior to CTA alone for correctly identifying flow limiting and functionally relevant obstructive coronary artery disease and predicted revascularization with accuracy similar to invasive coronary angiography+SPECT.
Strengths of the studyThis is a carefully designed, well conducted, relatively large multicenter study. It convincingly shows the ability of combined CTA and CTP study using a 320-row detector CT scanner to provide both anatomic and functional information in coronary artery diease.
Open issues and potential limitations:This procedure is not applicable to the entire CAD patient population, as there are a number of contraindications. Further experience is needed to better understand the future role of this test in clinical practice. In many patients (particularly those with high pre-test likelihood of disease) proceeding directly to invasive angiography based on clinical information (±non-imaging stress test) will likely continue to be the most appropriate option.The role of invasive FFR measurement at time of angiography versus earlier CTP needs to be addressed. Also, while done in the same imaging session, stress CTP (using adenosine) is an additional study after CTA+rest CTP and requires additional radiation and additional contrast administration.320-row detector CT scanner are currently not widely available and CTP using conventional scanners may yield different results.Overall, issues such as exposure to radiation and contrast, as well as cost effectiveness need additional careful deliberation.
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