Coronary CT angiography has become a robust imaging technique for visualization of the coronary arteries. The most common application is to use this noninvasive technique to reliably rule out coronary artery stenoses in patients in whom the clinical work-up suggests an intermediate likelihood of coronary artery stenoses. This article describes the top ten clinical indications of coronary CT angiography.
is a Professor of Medicine, Department of Cardiology, University
of Erlangen, Erlangen, Germany.
Imaging of the coronary arteries requires high temporal and
spatial resolution. Invasive, catheter-based coronary angiography
is the clinical standard tool for assessment of the coronary
arteries, but it has several shortcomings: First of all, it is an
invasive procedure and, as such, is associated with a certain
morbidity and mortality, which in most cases is a consequence of
the required arterial access.
Secondly, some limitations are due to its projectional nature. For
example, exact delineation of the 3-dimensional (3D) anatomy can be
problematic, which may cause difficulties, eg, in the context of
coronary anomalies. Finally, cardiac catheterization requires
elaborate equipment that is not available at every hospital or
outpatient setting, dedicated and well-trained staff is necessary,
and associated costs are high.
Computed tomographic (CT) technology has progressed rapidly over
the past several years. Both spatial and temporal resolution have
steadly been improved, and the introduction of 64-slice CT has made
coronary CT angiography (CTA) a relatively robust and stable tool
for coronary artery visualization (Figure 1). A recent
meta-analysis showed high accuracies for the detection of coronary
artery stenoses (CAS) by 64slice CT
(Table 1). Of course, there are limitations as compared with the
invasive angiogram: Limited temporal resolution can reduce image
quality, especially if heart rates are above 60 beats per minute
This limitation may not be as pronounced for the newer dual-source
Since data acquired over several heartbeats are necessary to
acquire a complete data set, coronary CTA is not reliably possible
in patients with arrhythmias (scanner design concepts with ≥256
slices may help overcome this limitation). For all scanner
generations, the spatial resolution is lower than that of invasive
angiography, making analysis of smaller side branches and distal
vessel segments impossible--in most studies, analysis was limited
to segments of ≥1.5 mm in diameter. Also, there is a tendency to
overestimate the degree of stenosis in CT as compared with the
invasive angiogram, and extensive calcifications can render image
interpretation impossible. Finally, CTA is limited to diagnosis. In
patients with a high pretest likelihood of disease, performing an
invasive, catheter-based coronary angiogram will often be much more
appropriate because it offers the option of immediate
While invasive angiography will remain the clinical gold
standard for coronary artery visualization for the foreseeable
future, CT imaging has some potential advantages over invasive
angiography. In addition to being noninvasive, its tomographic
nature allows for easier and unambiguous identification of the 3D
anatomy of the coronary vessels, which can be useful in cases of
coronary anomalies. Furthermore, its cross-sectional nature permits
visualization not only of the contrast-enhanced coronary artery
lumen, but also of the vessel wall (if image quality is adequate).
In this way, atherosclerotic plaque can become visible, which is
undetectable in the invasive coronary angiogram (Figure 1).
For potential clinical applications, the advantages and
diasdvantages of CTA must be weighed against those of invasive
coronary angiography. In a consensus document, a group of experts
from various professional societies have listed "appropriate"
clinical indications for coronary CTA, based mostly on the
considerations outlined above (Table 2).
Several additional, more infrequently used indications are
conceivable. Ultimately, the individual clinical situation will
help make the decision for or against coronary CTA; and many
issues--such as the patient's heart rate, body weight, or ability
to perform a breath-hold, as well as contraindications to contrast
or problems with vascular access (which may make invasive
angiography more prone to complication)--will play a role in the
decision-making process. In the following section, potential
clinical indications for the use of coronary CTA are outlined as a
"Top Ten" list, from the clearest to the least robust and frequent
indications. By necessity, this list is a subjective interpretation
of the author and is likely to undergo modifications as technology
1. Ruling out significant luminal stenoses in stable
patients with suspected coronary stenoses, but intermediate
pretest likelihood of disease
The available literature convincingly demonstrates that coronary
CTA, if expertly performed, has a high negative predictive value
and thus allows one to rather reliably rule out the presence of
The aim is to avoid an otherwise necessary invasive coronary
angiogram if CT shows the absence of clinically relevant CAS. Based
on clinical considerations, but also for statistical reasons, CT
imaging will be most useful in patients with an intermediate
likelihood of CAS. In patients with a very low pretest likelihood,
the false-positive rate may be too high, and in patients with a
very high pretest likelihood, sensitivity may not be sufficiently
high. Meijboom et al
have recently presented a careful analysis of the diagnostic value
of coronary CTA, stratified according to the pretest likelihood of
disease. They also found that the technique is most useful in
patients with a low-to-intermediate likelihood of CAS.
This is certainly the most prominent and frequent clinical
indication of cardiac CT and can be beneficially applied, for
example, in patients with rather atypical symptoms, patients with
unclear stress test results, or patients in whom the stress test
result contradicts the clinical assessment (Figure 2). Similarly,
coronary CTA has been shown to rule out CAS in patients with left
bundle branch block of unknown etiology
or in patients with new onset heart failure.
The goal of performing CTA in this context is always to avoid
invasive angiography if the CT scan shows good evaluability and an
absence of CAS.
2. Ruling out coronary artery disease in acute chest
Especially if the electrocardiogram and myocardial enzymes are
normal, many patients who present to the emergency room with acute
chest pain have a relatively low likelihood of coronary artery
disease. Further testing is often necessary to rule in or rule out
the presence of coronary artery disease. In these patients,
coronary CTA can be a useful tool to rapidly assess the coronary
arteries for the presence of coronary lesions (Figure 3). Some
initial studies have shown the high accuracy of CT to identify
patients who have CAS in the setting of acute chest pain,
as well as cost-effectiveness in comparison with standard
and a favorable long-term outcome of patients who were discharged
based on a coronary CT examination that showed the absence of
It can be expected that the use of CT in patients presenting with
acute or unstable chest pain will be one of the most frequent
indications for coronary CTA.
3. Coronary anomalies
Multidetector CT (MDCT) can classify both the origin and also
the often complex course of anomalous coronary vessels
(Figure 4). Magnetic resonance coronary angiography may be an
alternative in experienced hands, and the necessity for contrast
agent injection and radiation exposure are certainly drawbacks of
CT imaging. Coronary CTA is the method of choice for the work-up of
known or suspected anomalous coronary vessels because of the ease
of data acquisition and the predictability with which a
high-resolution data set with optimal image quality for evaluation
can be expected. The use of CTA in the setting of coronary
anomalies has been classified as a clinically "appropriate"
4. Ruling out stenoses before noncoronary cardiac
Cardiothoracic surgeons often require invasive coronary
angiography to rule out CAS in patients who are scheduled for
cardiac surgery for noncoronary reasons (eg, valve replacement or
resection of tumors) or for surgery of the ascending aorta. Stress
testing is not reliable enough, and symptoms may be masked by the
underlying disease. If these patients do not have arrhythmias
(atrial fibrillation may, in fact, be quite common in patients with
mitral valve disease) and if they are clinically sufficiently
stable, CTA may be a useful tool to clear them for cardiac surgery
without having to perfom invasive angiography. One study has
specifically addressed the use of 64-slice CT to detect CAS in
patients prior to aortic valve replacement.
While 35 of 105 patients could not be studied by CT because of
atrial fibrillation or renal failure, CT successfully detected all
18 patients with high-grade CAS in the remaining 50 individuals
(sensitivity 100%, specificity 82%). It may thus be assumed that
coronary CTA will be useful in certain subgroups of patients before
valvular or other noncoronary cardiac surgery, although not all
patients will be candidates for CT scanning.
5. Determine patency of coronary artery bypass
CT angiography has a high accuracy for the detection of bypass
graft stenosis and occlusion.
Bypass grafts have a larger caliber than native coronary arteries,
and they are subjected to motion to a lesser extent than native
coronary vessels, which favorably inﬂuences image
quality (Figure 5). However, the coronary arteries themselves can
be very difficult to assess by CT in patients after bypass surgery:
they often have severe atherosclerosis, including pronounced
calcification, and frequently are of small caliber, which makes
their evaluation challenging.
The most recent scanner generations have higher temporal and
spatial resolution and may thus allow more reliable assessment of
the coronary system in patients with bypass grafts. A recent study
performed by 64-slice CT found a sensitivity and specificity of
only 86% and 76% for the detection of stenoses in the native
coronary arteries of patients with bypass surgery.
Therefore, in clinical cases that require only the assessment of
bypass grafts (eg, if not all grafts were found during invasive
angiography or in the early postoperative situation), the use of
CTA may be beneficial. If, however, the clinical situation requires
assessment of both the bypass grafts and native coronary artery
system, the value of CTA is limited.
6. Using CT as an alternative when cardiac
catheterization is impossible or carries a high risk
In some patients, assessment of the coronary arteries may be
necessary, but invasive angiography may be associated with an
increased risk- eg, in patients with bleeding disorders, in
patients with dissection of the ascending aorta, or in patients
with large endocarditic vegetations on the aortic valve. Even
though this does not constitute a frequent clinical situation,
coronary CTA may be useful and beneficial in these instances. The
use of CTA may be extended beyond low-to-intermediate-risk patients
if such factors are present that would constitute a particularly
high risk for invasive angiography.
7. Clarifying unclear findings after invasive
Infrequently, coronary anatomy and pathology may not be entirely
clear even after an invasive angiogram. Most frequently, this will
be in the context of coronary anomalies, as described above, but
some other situations exist in which CTA may be useful even after
an invasive angiogram. Very infrequently, for example, a CT scan
may be helpful if an invasive angiogram fails to fully clarify the
presence of coronary stenosis at the right or left coronary ostium.
Another potential situation is when a completely obstructed side
branch is suspected, but not clearly visualized in the invasive
angiogram. In such cases and in some other situations, CT can often
clarify the clinical question (Figure 6).
8. Providing peri-interventional information for
percutaneous coronary intervention
CT can provide information that could be useful in the context
of percutaneous coronary intervention. One study has shown that in
cases of chronic total coronary artery occlusion, CT can more
reliably identify parameters that will predict the success of
interventional revascularization than the invasive angiogram can.
The most important parameters are the length and the extent of
calcification of the occluded segment
(Figure 7). Similarly, CT can provide more exact information about
plaque distribution and bifurcation angles than the invasive
which may be helpful in choosing the best strategy for stenting of
9. Assessing coronary artery stents
The visualization of the lumen within coronary artery stents by
MDCT is possible. However, artifacts caused by the stent material
may create problems in a substantial number of patients, especially
in combination with calcium or motion (Figure 8). The ability to
assess stents concerning restenosis depends on many factors,
including stent type
and stent diameter as well as image noise, which in turn is heavily
inﬂuenced by body weight. While some more recent studies
suggest that the analysis of large stents (with a diameter of ≥3.5
mm) may be possible by CT,
the available data is very limited. Because of the relatively high
number of unevaluable studies and the somewhat limited positive
predictive value, stent imaging should currently not be considered
a routine application for coronary CTA. The exceptional application
would be limited to patients with stents of a relatively large
diameter in proximal vessel segments, in whom invasive angiography
cannot be performed without an increased risk of complications.
10. Determining the presence and extent of coronary
Besides detecting CAS, CTA is also able to reveal the presence
of nonstenotic coronary atherosclerotic plaque (Figure 9).
In addition, CT may potentially determine parameters that are
connected to plaque "vulnerability," such as the extent of
the CT attenuation within the plaque (with lower CT attenuation
assumed to be corresponding to higher plaque "vulnerability"),
the degree of stenosis, and plaque dimensions.
This has led to the concept of using contrast-enhanced CT for risk
stratification in order to identify asymptomatic individuals with
an elevated risk for future myocardial infarction. However, there
currently is very little clinical data to support such applications
of cardiac CT. Several smaller studies have retrospectively
analyzed plaque characteristics by CT in patients after acute
coronary syndromes compared with patients with stable angina and
have found a higher percentage of noncalcified plaque and more
positive remodeling in patients and lesions responsible for cardiac
However, it is problematic that CT data acquisition in these
patients was performed after the ischemic event, and plaque rupture
may have contributed to morphologic changes of the atherosclerotic
lesion as seen in CT. Only one prospective trial is currently
available. Pundziute et al
followed 100 patients who underwent coronary CTA for a mean period
of 16 months and reported that patients with nonobstructive plaque
detected by MDCT had a higher cardiovascular event rate than
individuals without any plaque (most of these events, however, may
have been revascularizations).The available data provide some
indication that assessment of noncalcified plaque by coronary CTA
may have predictive value in asymptomatic individuals. However,
plaque imaging by CT requires the injection of a contrast agent and
also involves significant radiation exposure; both these factors
should be considered, and CT should be used as a clinical tool only
if very strong superiority over other methods of risk prediction
has clearly been shown. This is currently not the case, and
contrast-enhanced CT for plaque visualization should be restricted
to research settings.
Coronary CTA has numerous clinical applications. Its most
prominent role is in the assessment of patients with possible
coronary artery stenoses, but a relatively low likelihood of
disease, with the aim to rule out coronary stenoses and avoid the
need for an invasive coronary angiogram. This includes patients
with various clinical scenarios, such as atypical symptoms, unclear
electrocardiographic changes or stress test results, patients with
new onset of heart failure, and patients before noncoronary cardiac
surgery. Assessment of coronary anomalies is another strong
indication, but much less frequent. Other applications of CT are
possible but are not currently backed by sufficient amounts of data
such as to provide peri-interventional information, to detect
in-stent restenosis, or to provide risk stratification. Eventually,
all large-scale applications of coronary CTA will need to be backed
by prospective clinical trials that provide evidence for the
clincal benefit of using CT in the respective situation. In fact,
reimbursement for cardiac CT may hinge on that data. It can be
expected that suitable trials will be performed in the coming years
and that the progress in CT technology will lead to a further
expansion of the range of possible clinical applications.
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