In a healthcare environment relying on evidence-based medicine and cost-effectiveness, patient outcome and prognosis should be the final and main step in the evaluation process of any newly installed diagnostic technique. In this sense, an increasing number of ongoing studies are being developed to determine the prognostic value of CCTA in symptomatic patients with chest pain and suspected or known CAD. After a mean follow-up of 78 months of a cohort of 2538 consecutive patients who underwent CCTA by electron beam CT, Ostrom et al68 observed that the burden of angiographic disease detected by CCTA provided both independent and incremental value in predicting all-cause mortality in symptomatic patients independent of age, sex, conventional risk factors, and coronary artery calcification. Min et al69 analyzed the association between extent and severity of CAD defined by CCTA and all-cause death in a consecutive cohort of 1127 symptomatic patients 45 years of age or older with similar results. These investigators concluded that CCTA could identify increased risk for all-cause death, whereas a negative CCTA study showed an extremely low risk for death. Hence, in symptomatic individuals with an intermediate likelihood of CAD referred for CCTA, normal coronary arteries or nonobstructive CAD carries an excellent prognosis, whereas the finding of obstructive CAD identifies patients at a higher risk of subsequent myocardial infarction.70–72 In line with this, diverse follow-up studies also reveal that CCTA safely rules out CAD in patients with suspected disease,73,74 effectively triaging symptomatic patients for conventional coronary angiography. From a slightly different point of view, Hadamitzky et al75 compared the observed rate of all cardiac events with the event rate predicted by the Framingham risk score in 1256 consecutive patients with suspected CAD who underwent 64-row CCTA during the 18-month follow-up period. Interestingly, these investigators observed that in their patient population, the rate of all cardiac events in patients without obstructive CAD was significantly lower than predicted by the Framingham risk score. Thus, all these studies agree that there is evidence that the extent and severity of CAD defined at CCTA predicts all-cause mortality, whereas patients with a normal CCTA have an excellent prognosis (Fig. 7).
After almost 2 decades of feasibility testing, cost-effectiveness results of CCTA with respect to clinically established diagnostic modalities are now becoming available. Initial reports suggested that CCTA is the most cost-effective approach for individuals with low and intermediate pretest likelihood of CAD, whereas for patients with a pretest probability of CAD greater than 60%, conventional coronary angiography remains more cost-effective.76 In a recent systematic review, Mowatt et al77 analyzed the clinical effectiveness and cost-effectiveness of 64-row or higher CCTA as an alternative to conventional catheterization in the CAD scenario and concluded that in this clinical setting, 64-row CCTA seems to be superior to myocardial perfusion scintigraphy. In terms of cost, these investigators described CCTA to be a short-term and probably a long-term cost-effective replacement for myocardial perfusion scintigraphy in diagnosing CAD.77 A negative CCTA for CAD should avoid the costs of unnecessary catheterizations, thus resulting in overall cost savings in the diagnostic process of CAD.
As discussed, particularly when performed with the newest technology, CCTA provides accurate and reliable information regarding CAD. This technique allows noninvasive assessment of the extent of CAD. The cornerstone of CCTA is based, however, on its high negative predictive value, which allows for significant coronary artery stenosis to be ruled out in the majority of individuals. Limitations regarding insufficient spatial and temporal resolution of the MDCT scanners may cause false-positive findings, directly influencing patient management. Thus, CCTA should be used in the appropriate clinical scenario and should be prevented from indiscriminate use to invigorate its adequate role in the diagnostic workup of patients with suspicion of CAD. Because CCTA has so far been an anatomic modality, it hardly provides information about the functional significance of stenosis severity. The presence of significant coronary artery stenosis does not necessarily translate into myocardial ischemia,78 a fact that supports the need for diagnostic tools that combine morphologic and functional information. Furthermore, because CCTA provides a significant amount of information that was not readily available before the development of CCTA, such as coronary artery plaque composition or detection of significant coronary artery stenosis in individuals with noncardiac origin atypical chest pain, determination of the prognostic significance of these findings requires further research. Finally, CCTA may serve as guidance for percutaneous interventional procedures, as this noninvasive technique may influence the decision-making of individuals who may benefit from percutaneous therapy or rather undergo elective bypass surgery.79,80
The availability, ease of use, and accuracy of CCTA has substantially improved in the last decade. This technique has shown its usefulness in a number of clinical scenarios in individuals with known or suspected CAD. Particularly, its ability to confidently rule out significant coronary artery stenosis has been consistently recognized. The clinical use of CCTA in the context of surgical revascularization is indubitable, whereas its role in addressing coronary artery stent patency requires further technical refinement. Ongoing research points toward the comprehensive assessment of CAD, including integrative morphologic and functional evaluation of the myocardium and coronary vessels. Most recent reports emphasize the prognostic value and cost-effectiveness of CCTA. Hence, CCTA may emerge as one of the most important clinical tools in the assessment of CAD, but further research is warranted.
1. Lloyd-Jones D, Adams R, Carnethon M, et al. Heart disease and stroke statistics—2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2009;119:480–486.
2. Hendel RC, Patel MR, Kramer CM, et al. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology. J Am Coll Cardiol. 2006;48:1475–1497.
3. Schroeder S, Achenbach S, Bengel F, et al. Cardiac computed tomography: indications, applications, limitations, and training requirements: report of a Writing Group deployed by the Working Group Nuclear Cardiology and Cardiac CT of the European Society of Cardiology and the European Council of Nuclear Cardiology. Eur Heart J. 2008;29:531–556.
4. Bluemke DA, Achenbach S, Budoff M, et al. Noninvasive coronary artery imaging: magnetic resonance angiography and multidetector computed tomography angiography: a scientific statement from the American Heart Association Committee on cardiovascular imaging and intervention of the council on cardiovascular radiology and intervention, and the councils on clinical cardiology and cardiovascular disease in the young. Circulation. 2008;118:586–606.
5. Ghostine S, Caussin C, Habis M, et al. Non-invasive diagnosis of ischaemic heart failure using 64-slice computed tomography. Eur Heart J. 2008Apr 1. [Epub ahead of print].
6. Meijboom WB, Mollet NR, Van Mieghem CA, et al. Pre-operative computed tomography coronary angiography to detect significant coronary artery disease in patients referred for cardiac valve surgery. J Am Coll Cardiol. 2006;48:1658–1665.
7. Mastrobuoni S, Bastarrika G, Ubilla M, et al. Dual-source CT coronary angiogram in heart transplant recipients in comparison with dobutamine stress echocardiography for detection of cardiac allograft vasculopathy. Transplantation. 2009;87:587–590.
8. Komatsu S, Sato Y, Ichikawa M, et al. Anomalous coronary arteries in adults detected by multislice computed tomography: presentation of cases from multicenter registry and review of the literature. Heart Vessels. 2008;23:26–34.
9. Budoff MJ, Dowe D, Jollis JG, et al. Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial. J Am Coll Cardiol. 2008;52:1724–1732.
10. Ehara M, Surmely JF, Kawai M, et al. Diagnostic accuracy of 64-slice computed tomography for detecting angiographically significant coronary artery stenosis in an unselected consecutive patient population: comparison with conventional invasive angiography. Circ J. 2006;70:564–571.
11. Meijboom WB, Meijs MF, Schuijf JD, et al. Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study. J Am Coll Cardiol. 2008;52:2135–2144.
12. Miller JM, Rochitte CE, Dewey M, et al. Diagnostic performance of coronary angiography by 64-row CT. N Engl J Med. 2008;359:2324–2336.
13. Mollet NR, Cademartiri F, van Mieghem CA, et al. High-resolution spiral computed tomography coronary angiography in patients referred for diagnostic conventional coronary angiography. Circulation. 2005;112:2318–2323.
14. Oncel D, Oncel G, Tastan A, et al. Detection of significant coronary artery stenosis with 64-section MDCT angiography. Eur J Radiol. 2007;62:394–405.
15. Raff GL, Gallagher MJ, O'Neill WW, et al. Diagnostic accuracy of noninvasive coronary angiography using 64-slice spiral computed tomography. J Am Coll Cardiol. 2005;46:552–557.
16. Ropers D, Rixe J, Anders K, et al. Usefulness of multidetector row spiral computed tomography with 64×0.6-mm collimation and 330-ms rotation for the noninvasive detection of significant coronary artery stenoses. Am J Cardiol. 2006;97:343–348.
17. Stein PD, Yaekoub AY, Matta F, et al. 64-slice CT for diagnosis of coronary artery disease: a systematic review. Am J Med. 2008;121:715–725.
18. Mowatt G, Cook JA, Hillis GS, et al. 64-Slice computed tomography angiography in the diagnosis and assessment of coronary artery disease: systematic review and meta-analysis. Heart. 2008;94:1386–1393.
19. Brodoefel H, Burgstahler C, Tsiflikas I, et al. Dual-source CT: effect of heart rate, heart rate variability, and calcification on image quality and diagnostic accuracy. Radiology. 2008;247:346–355.
20. Johnson TR, Nikolaou K, Busch S, et al. Diagnostic accuracy of dual-source computed tomography in the diagnosis of coronary artery disease. Invest Radiol. 2007;42:684–691.
21. Leber AW, Johnson T, Becker A, et al. Diagnostic accuracy of dual-source multi-slice CT-coronary angiography in patients with an intermediate pretest likelihood for coronary artery disease. Eur Heart J. 2007;28:2354–2360.
22. Rixe J, Rolf A, Conradi G, et al. Detection of relevant coronary artery disease using dual-source computed tomography in a high probability patient series: comparison with invasive angiography. Circ J. 2009;73:316–322.
23. Ropers U, Ropers D, Pflederer T, et al. Influence of heart rate on the diagnostic accuracy of dual-source computed tomography coronary angiography. J Am Coll Cardiol. 2007;50:2393–2398.
24. Tsiflikas I, Brodoefel H, Reimann AJ, et al. Coronary CT angiography with dual source computed tomography in 170 patients. Eur J Radiol. 2010;74:161–165.
25. Weustink AC, Meijboom WB, Mollet NR, et al. Reliable high-speed coronary computed tomography in symptomatic patients. J Am Coll Cardiol. 2007;50:786–794.
26. Achenbach S, Ropers U, Kuettner A, et al. Randomized comparison of 64-slice single- and dual-source computed tomography coronary angiography for the detection of coronary artery disease. JACC Cardiovasc Imaging. 2008;1:177–186.
27. Baumuller S, Leschka S, Desbiolles L, et al. Dual-source versus 64-section CT coronary angiography at lower heart rates: comparison of accuracy and radiation dose. Radiology. 2009;253:56–64.
28. Ong TK, Chin SP, Liew CK, et al. Accuracy of 64-row multidetector computed tomography in detecting coronary artery disease in 134 symptomatic patients: influence of calcification. Am Heart J. 2006;151:1323 e1321–e1326.
29. Dewey M, Zimmermann E, Deissenrieder F, et al. Noninvasive coronary angiography by 320-row computed tomography with lower radiation exposure and maintained diagnostic accuracy: comparison of results with cardiac catheterization in a head-to-head pilot investigation. Circulation. 2009;120:867–875.
30. Lell M, Marwan M, Schepis T, et al. Prospectively ECG-triggered high-pitch spiral acquisition for coronary CT angiography using dual source CT: technique and initial experience. Eur Radiol. 2009;19:2576–2583.
31. Leschka S, Stolzmann P, Desbiolles L, et al. Diagnostic accuracy of high-pitch dual-source CT for the assessment of coronary stenoses: first experience. Eur Radiol. 2009;19:2896–2903.
32. Earls JP, Berman EL, Urban BA, et al. Prospectively gated transverse coronary CT angiography versus retrospectively gated helical technique: improved image quality and reduced radiation dose. Radiology. 2008;246:742–753.
33. Hirai N, Horiguchi J, Fujioka C, et al. Prospective versus retrospective ECG-gated 64-detector coronary CT angiography: assessment of image quality, stenosis, and radiation dose. Radiology. 2008;248:424–430.
34. Hoffmann U, Bamberg F, Chae CU, et al. Coronary computed tomography angiography for early triage of patients with acute chest pain: the ROMICAT (Rule Out Myocardial Infarction using Computer Assisted Tomography) trial. J Am Coll Cardiol. 2009;53:1642–1650.
35. Eagle KA, Berger PB, Calkins H, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery—executive summary a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation. 2002;105:1257–1267.
36. Engelmann MG, von Smekal A, Knez A, et al. Accuracy of spiral computed tomography for identifying arterial and venous coronary graft patency. Am J Cardiol. 1997;80:569–574.
37. Ropers D, Ulzheimer S, Wenkel E, et al. Investigation of aortocoronary artery bypass grafts by multislice spiral computed tomography with electrocardiographic-gated image reconstruction. Am J Cardiol. 2001;88:792–795.
38. Martuscelli E, Romagnoli A, D'Eliseo A, et al. Evaluation of venous and arterial conduit patency by 16-slice spiral computed tomography. Circulation. 2004;110:3234–3238.
39. Feuchtner GM, Schachner T, Bonatti J, et al. Diagnostic performance of 64-slice computed tomography in evaluation of coronary artery bypass grafts. AJR Am J Roentgenol. 2007;189:574–580.
40. Jabara R, Chronos N, Klein L, et al. Comparison of multidetector 64-slice computed tomographic angiography to coronary angiography to assess the patency of coronary artery bypass grafts. Am J Cardiol. 2007;99:1529–1534.
41. Malagutti P, Nieman K, Meijboom WB, et al. Use of 64-slice CT in symptomatic patients after coronary bypass surgery: evaluation of grafts and coronary arteries. Eur Heart J. 2007;28:1879–1885.
42. Meyer TS, Martinoff S, Hadamitzky M, et al. Improved noninvasive assessment of coronary artery bypass grafts with 64-slice computed tomographic angiography in an unselected patient population. J Am Coll Cardiol. 2007;49:946–950.
43. Nazeri I, Shahabi P, Tehrai M, et al. Assessment of patients after coronary artery bypass grafting using 64-slice computed tomography. Am J Cardiol. 2009;103:667–673.
44. Onuma Y, Tanabe K, Chihara R, et al. Evaluation of coronary artery bypass grafts and native coronary arteries using 64-slice multidetector computed tomography. Am Heart J. 2007;154:519–526.
45. Pache G, Saueressig U, Frydrychowicz A, et al. Initial experience with 64-slice cardiac CT: non-invasive visualization of coronary artery bypass grafts. Eur Heart J. 2006;27:976–980.
46. Ropers D, Pohle FK, Kuettner A, et al. Diagnostic accuracy of noninvasive coronary angiography in patients after bypass surgery using 64-slice spiral computed tomography with 330-ms gantry rotation. Circulation. 2006;114:2334–2341; quiz 2334.
47. Hamon M, Lepage O, Malagutti P, et al. Diagnostic performance of 16- and 64-section spiral CT for coronary artery bypass graft assessment: meta-analysis. Radiology. 2008;247:679–686.
48. Weustink AC, Nieman K, Pugliese F, et al. Diagnostic accuracy of computed tomography angiography in patients after bypass grafting: comparison with invasive coronary angiography. JACC Cardiovasc Imaging. 2009;2:816–824.
49. Kamdar AR, Meadows TA, Roselli EE, et al. Multidetector computed tomographic angiography in planning of reoperative cardiothoracic surgery. Ann Thorac Surg. 2008;85:1239–1245.
50. Pump H, Mohlenkamp S, Sehnert CA, et al. Coronary arterial stent patency: assessment with electron-beam CT. Radiology. 2000;214:447–452.
51. Hamon M, Champ-Rigot L, Morello R, et al. Diagnostic accuracy of in-stent coronary restenosis detection with multislice spiral computed tomography: a meta-analysis. Eur Radiol. 2008;18:217–225.
52. Kumbhani DJ, Ingelmo CP, Schoenhagen P, et al. Meta-analysis of diagnostic efficacy of 64-slice computed tomography in the evaluation of coronary in-stent restenosis. Am J Cardiol. 2009;103:1675–1681.
53. Halon DA, Gaspar T, Adawi S, et al. Coronary stent assessment on multidetector computed tomography: source and predictors of image distortion. Int J Cardiol. 2008;128:62–68.
54. Pugliese F, Weustink AC, Van Mieghem C, et al. Dual source coronary computed tomography angiography for detecting in-stent restenosis. Heart. 2008;94:848–854.
55. Andreini D, Pontone G, Bartorelli AL, et al. Comparison of feasibility and diagnostic accuracy of 64-slice multidetector computed tomographic coronary angiography versus invasive coronary angiography versus intravascular ultrasound for evaluation of in-stent restenosis. Am J Cardiol. 2009;103:1349–1358.
56. Cademartiri F, Schuijf JD, Pugliese F, et al. Usefulness of 64-slice multislice computed tomography coronary angiography to assess in-stent restenosis. J Am Coll Cardiol. 2007;49:2204–2210.
57. Carbone I, Francone M, Algeri E, et al. Non-invasive evaluation of coronary artery stent patency with retrospectively ECG-gated 64-slice CT angiography. Eur Radiol. 2008;18:234–243.
58. Carrabba N, Bamoshmoosh M, Carusi LM, et al. Usefulness of 64-slice multidetector computed tomography for detecting drug eluting in-stent restenosis. Am J Cardiol. 2007;100:1754–1758.
59. Das KM, El-Menyar AA, Salam AM, et al. Contrast-enhanced 64-section coronary multidetector CT angiography versus conventional coronary angiography for stent assessment. Radiology. 2007;245:424–432.
60. Ehara M, Kawai M, Surmely JF, et al. Diagnostic accuracy of coronary in-stent restenosis using 64-slice computed tomography: comparison with invasive coronary angiography. J Am Coll Cardiol. 2007;49:951–959.
61. Hecht HS, Zaric M, Jelnin V, et al. Usefulness of 64-detector computed tomographic angiography for diagnosing in-stent restenosis in native coronary arteries. Am J Cardiol. 2008;101:820–824.
62. Manghat N, Van Lingen R, Hewson P, et al. Usefulness of 64-detector row computed tomography for evaluation of intracoronary stents in symptomatic patients with suspected in-stent restenosis. Am J Cardiol. 2008;101:1567–1573.
63. Oncel D, Oncel G, Karaca M. Coronary stent patency and in-stent restenosis: determination with 64-section multidetector CT coronary angiography—initial experience. Radiology. 2007;242:403–409.
64. Rist C, von Ziegler F, Nikolaou K, et al. Assessment of coronary artery stent patency and restenosis using 64-slice computed tomography. Acad Radiol. 2006;13:1465–1473.
65. Rixe J, Achenbach S, Ropers D, et al. Assessment of coronary artery stent restenosis by 64-slice multi-detector computed tomography. Eur Heart J. 2006;27:2567–2572.
66. Oncel D, Oncel G, Tastan A, et al. Evaluation of coronary stent patency and in-stent restenosis with dual-source CT coronary angiography without heart rate control. AJR Am J Roentgenol. 2008;191:56–63.
67. Pflederer T, Marwan M, Renz A, et al. Noninvasive assessment of coronary in-stent restenosis by dual-source computed tomography. Am J Cardiol. 2009;103:812–817.
68. Ostrom MP, Gopal A, Ahmadi N, et al. Mortality incidence and the severity of coronary atherosclerosis assessed by computed tomography angiography. J Am Coll Cardiol. 2008;52:1335–1343.
69. Min JK, Shaw LJ, Devereux RB, et al. Prognostic value of multidetector coronary computed tomographic angiography for prediction of all-cause mortality. J Am Coll Cardiol. 2007;50:1161–1170.
70. Gopal A, Nasir K, Ahmadi N, et al. Cardiac computed tomographic angiography in an outpatient setting: an analysis of clinical outcomes over a 40-month period. J Cardiovasc Comput Tomogr. 2009;3:90–95.
71. Carrigan TP, Nair D, Schoenhagen P, et al. Prognostic utility of 64-slice computed tomography in patients with suspected but no documented coronary artery disease. Eur Heart J. 2009;30:362–371.
72. Pundziute G, Schuijf JD, Jukema JW, et al. Prognostic value of multislice computed tomography coronary angiography in patients with known or suspected coronary artery disease. J Am Coll Cardiol. 2007;49:62–70.
73. Gilard M, Le Gal G, Cornily JC, et al. Midterm prognosis of patients with suspected coronary artery disease and normal multislice computed tomographic findings: a prospective management outcome study. Arch Intern Med. 2007;167:1686–1689.
74. Aldrovandi A, Maffei E, Palumbo A, et al. Prognostic value of computed tomography coronary angiography in patients with suspected coronary artery disease: a 24-month follow-up study. Eur Radiol. 2009;19:1653–1660.
75. Hadamitzky M, Freissmuth B, Meyer T, et al. Prognostic value of coronary computed tomographic angiography for prediction of cardiac events in patients with suspected coronary artery disease. JACC Cardiovasc Imaging. 2009;2:404–411.
76. Dewey M, Hamm B. Cost effectiveness of coronary angiography and calcium scoring using CT and stress MRI for diagnosis of coronary artery disease. Eur Radiol. 2007;17:1301–1309.
77. Mowatt G, Cummins E, Waugh N, et al. Systematic review of the clinical effectiveness and cost-effectiveness of 64-slice or higher computed tomography angiography as an alternative to invasive coronary angiography in the investigation of coronary artery disease. Health Technol Assess. 2008;12:iii–iv, ix-143.
78. Gaemperli O, Schepis T, Koepfli P, et al. Accuracy of 64-slice CT angiography for the detection of functionally relevant coronary stenoses as assessed with myocardial perfusion SPECT. Eur J Nucl Med Mol Imaging. 2007;34:1162–1171.
79. Bedi HS, Gill JA, Bakshi SS. Can we perform coronary artery bypass grafting on the basis of computed tomographic angiography alone? A comparison with conventional coronary angiography. Eur J Cardiothorac Surg. 2008;33:633–638.
80. Otsuka M, Sugahara S, Umeda K, et al. Utility of multislice computed tomography as a strategic tool for complex percutaneous coronary intervention. Int J Cardiovasc Imaging. 2008;24:201–210.