Diagnostic Accuracy of 256-row Computed Tomographic Angiography for Detection of Obstructive Coronary Artery Disease Using Invasive Quantitative Coronary Angiography as Reference Standard

doi:10.1016/j.amjcard.2012.10.036

The American Journal of Cardiology

Volume 111, Issue 4, 15 February 2013, Pages 510-515

https://doi.org/10.1016/j.amjcard.2012.10.036 Get rights and content

We assessed the performance of a new-generation, 256-row computed tomography (CT) scanner for detection of obstructive coronary artery disease (CAD) compared to invasive quantitative coronary angiography. A total 121 consecutive symptomatic patients without known CAD referred for invasive coronary angiography (age 59 ± 12 years, 37% women) underwent clinically driven 256-row coronary computed tomographic angiography (CCTA) before the invasive procedure. Obstructive CAD (>50% diameter stenosis) was assessed visually on CCTA by 2 independent observers using the 18-segment society of cardiovascular CT model and on invasive angiograms using quantitative coronary angiography (the reference standard). Observers were unaware of the findings from the alternate modality. Nonassessable coronary computed tomographic angiographic segments were considered obstructive for the purpose of analysis. Quantitative coronary angiography demonstrated obstructive CAD in 145 segments in 82 of 121 patients (68%). Overall, 1,677 coronary segments were available for comparative analysis, of which 39 (2.3%) were nonassessable by CCTA, mostly because of heavy calcification. Patient-based and segment-based analysis showed a sensitivity of 100% and 97% (95% confidence interval 95% to 100%) and specificity of 69% (95% confidence interval 55% to 84%) and 97% (confidence interval 96% to 98%), respectively. Four segments with obstructive CAD in 4 patients were not detected by CCTA. All 4 patients had additional coronary obstructions identified by CCTA. The predictive accuracy was 90% (range 85% to 95%) for patient based and 97% (96% to 98%) for segment based analysis. In conclusion, 256-row CCTA showed high sensitivity and high predictive accuracy for detection of obstructive CAD in patients without previously known disease. Although coronary calcification might still interfere with analysis, the rate of nonassessable segments was low.

Section snippets

Methods

The present retrospective, observational, single-center study was approved by the institutional review board with waiver of informed consent. The cohort included consecutive symptomatic patients without previously diagnosed CAD who underwent 256-row CCTA in our institution within a 2-year period followed by ICA within <2 months after CCTA. Patients presented either as elective outpatients or as emergency department patients with atypical chest pain and without high-risk features (i.e., without

Results

Among 1,477 patients undergoing CCTA during the study period, 931 had no previously known CAD (63%). Of these 931 patients, 121 (37% women, age range 30 to 86 years) met the study inclusion criteria. The patients' baseline characteristics are presented in Table 1.

No scan was excluded because of poor diagnostic quality. The mean heart rate during the scans was 61 ± 8 beats/min (range 42–82). With the advances in scanner software during the study period, the scanning modes changed. In general,

Discussion

The present study has shown that in symptomatic patients with chest pain referred for ICA, 256-row CCTA has high diagnostic accuracy compared to QCA. The sensitivity and negative predictive value from a patient-based analysis were both 100%; thus, the CCTA did not miss any patients with obstructive CAD. Moreover, the rate of nonassessable segments was low (2.3%), allowing a meaningful evaluation of almost all available coronary segments.

Few data describing the diagnostic accuracy of the

Disclosures

Drs. Gaspar and Peled have received research grants from Philips Healthcare (Andover, Massachusetts).

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Citation Excerpt :
Coronary atherosclerotic heart disease is a leading cause of death across the world. Invasive coronary angiography (ICA) has been considered the reference standard for the diagnosis of coronary heart disease1–3; however, it is not always the first choice in clinical practice because of it is invasive, complex, incurs a high dose of irradiation, and is costly. Along with the development of multi-slice spiral computed tomography (CT), coronary CT angiography (CCTA) has attracted increasing attention as a non-invasive imaging method for the evaluation of coronary arteries.
To investigate the superiority of free-breathing coronary computed tomography angiography (CCTA) with 16-cm wide-detector CT for challenging patients who cannot hold their breath.
A total of 76 patients (62% with either heart rate >75 beats/min or arrhythmia) who were unable to breath-hold underwent both free-breathing CCTA and invasive coronary angiography (ICA) were included. Two reviewers evaluated coronary arteries on a per-segment, per-vessel, and per-patient basis for image quality using a four-point scale and stenosis degree. CCTA results were compared with ICA to calculate the diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).
Out of 1,368 segments, 228 (16.7%) were <1.5 mm in diameter and were excluded. Thirty-two (2.3%) with calcification and 26 (1.9%) with motion artefacts were considered positive at CT. One thousand and eighty-two segments (79.1%) were evaluated both on CCTA and ICA, and 128 (11.8%) segments had ≥50% stenosis on ICA. The diagnostic accuracy, sensitivity, specificity, PPV, and NPV of CCTA were 90.8%, 88.3%, 91.1%, 57.1%, and 98.3% on a per-segment basis; 93.4%, 90.6%, 94.2%, 80.5% and 97.4% on a per-vessel basis; and 92.1%, 100%, 85%, 85.7% and 100% on a per-patient basis. For patients with high heart rates or arrhythmia, 81% (versus 79.1%) segments were evaluable, and the accuracy, sensitivity, specificity, PPV, and NPV were statistically the same as the entire study population.
Free-breathing CCTA using 16-cm wide-detector CT has high accuracy compared to ICA for detecting coronary artery stenosis for challenging patients.
Coronary computed tomography angiography and calcium scoring in routine clinical practice for identification of patients who require revascularization
2016, Archives of Cardiovascular Diseases
Citation Excerpt :
But the degree of calcification might affect image quality, and could be the main cause of false-positive findings, resulting in an overestimation of the calcified plaque (Fig. 3). Our results are consistent with those of previous studies, in which the tendency to overestimate CAD severity was reported [18–20]. Although numerous studies have shown good agreement between CCTA and ICA in detecting CAD, a major limitation of CCTA is the discrepancy between angiographic and flow-limiting stenoses [21,22].
The predictive value of CCTA to predict coronary artery disease is high in particular in the absence of coronary calcification. However, the consideration of both CCTA and the calcium score, in addition to the risk factors to determine the indication for coronary revascularization, has not been yet studied.
This study included 2302 patients (mean age: 60 ± 9.8 years, 46% men), without known coronary artery disease (CAD), who underwent 320-row CCTA. Logistic regression, c-statistic and net reclassification improvement (NRI) were used to assess the role of coronary artery calcium score (CACS) in predicting revascularization after CCTA.
The revascularization rates were 0.75% in patients with a CACS of 0, and there were no adverse events during the follow-up period. The revascularization rates were 3.3% in patients with a CACS of 1–99, 15.4% in patients with a CACS of 100–399, 25.6% in patients with a CACS of 400–999, and 42.4% in patients with a CACS ≥ 1000. The crude and adjusted odds ratios (95% confidence interval) for revascularization per CACS group category were 2.89 (2.53–2.3) and 2.71 (2.33–3.15), respectively; the area under the ROC curve (AUC) was 0.85 (0.83–0.88). The addition of CACS to conventional risk factors improved the accuracy of risk prediction model for revascularization (AUC 0.74 vs 0.63, P = 0.001), but it did not reclassify a substantial proportion of patients with positive CACS to risk categories (NRI = −0.023, P = 0.66).
The 320-row CCTA might rule out CAD in low- to intermediate-risk patients. However, its accuracy in identifying patients who require revascularization is limited. The CACS added to the conventional risk factors did not improve the identification of patients who require revascularization.
La valeur prédictive du coronaroscanner pour éliminer une coronaropathie est élevée en particulier en l’absence de calcification coronaire. Cependant, la prise en compte simultanée des résultats du coronaroscanner, et de l’évaluation du score calcique en sus de la prise en compte des facteurs de risque pour déterminer l’indication à une revascularisation, n’a pas été étudiée à ce jour.
Cette étude a inclus 2302 patients, d’âge moyen 60 ± 9,8 ans, 46 % de sexe masculin, sans coronaropathie connue qui ont bénéficié d’une coronaroscanner. La régression logistique, le score C-statistic et l’amélioration nette de la reclassification (NRI) ont été utilisés pour évaluer le rôle du score calcique dans la prédiction de l’indication à une revascularisation au décours d’un coronaroscanner.
Le taux de revascularisation était de 0,75 % chez les patients ayant un score calcique = 0 et il n’y avait pas d’évènement indésirable colligé pendant la période de suivi. Le taux de revascularisation était de 3,3 % chez les patients ayant un score calcique entre 0 et 99, 15,4 % lorsque ce score était entre 100 et 399, 25,6 % lorsque ce score était entre 400 et 999 et 42,4 % chez les patients ayant un score ≥ 1000. Les odds ratios brut et ajusté avec IC 95 % pour l’indication à la revascularisation par catégorie de score calcique étaient de 2,89 (IC 95 % −2,3–2,53) et de 2,71 (IC 95 % 2,33–3,15), respectivement. La surface sous la courbe ROC était à 0,85 (IC 95 % 0,83–0,88). Le fait de prendre en considération les facteurs de risque en sus du score calcique améliore la précision du modèle pour prédire l’indication à une revascularisation puisque la surface sur la courbe ROC passe de 0,63 à 0,74, p = 0,001. En revanche, il n’y a pas d’amélioration de la classification correcte des patients en utilisant le résultat du score calcique par catégorie, puisque le NRI est égal à −0,023, p = 0,66.
Le coronaroscanner peut éliminer une coronaropathie chez les patients à faible risque où à risque intermédiaire. Cependant, sa capacité à identifier les patients ayant une indication à une revascularisation est limitée. Le score calcique améliore la prédiction d’un geste de revascularisation, en sus de la prise en compte des facteurs de risque cardiovasculaire mais n’améliore pas l’identification des patients ayant une indication à revascularisation.
Automated Computer-Assisted Diagnosis of Obstructive Coronary Artery Disease in Emergency Department Patients Undergoing 256-Slice Coronary Computed Tomography Angiography for Acute Chest Pain
2015, American Journal of Cardiology
A 256-slice coronary computed tomography angiography (CCTA) is an accurate method for detection and exclusion of obstructive coronary artery disease (OBS-CAD). However, accurate image interpretation requires expertise and may not be available at all hours. The purpose of this study was to evaluate the usefulness of a fully automated computer-assisted diagnosis (COMP-DIAG) tool for exclusion of OBS-CAD in patients in the emergency department (ED) presenting with chest pain. Three hundred sixty-nine patients in ED without known coronary disease underwent 256-slice CCTA as part of the assessment of chest pain of uncertain origin. COMP-DIAG (CorAnalyzer II) automatically reported presence or exclusion of OBS-CAD (>50% stenosis, ≥1 vessel). Performance characteristics of COMP-DIAG for exclusion and detection of OBS-CAD were determined using expert reading as the reference standard. Seventeen (5%) studies were unassessable by COMP-DIAG software, and 352 patients (1,056 vessels) were therefore available for analysis. COMP-DIAG identified 33% of assessable studies as having OBS-CAD, but the prevalence of OBS-CAD on CCTA was only 18% (66 of 352 patients) by standard expert reading. However, COMP-DIAG correctly identified 61 of the 66 patients (93%) with OBS-CAD with 21 vessels (2%) with OBS-CAD misclassified as negative. In conclusion, compared to expert reading, automated computer-assisted diagnosis using the CorAnalyzer showed high sensitivity but only moderate specificity for detection of obstructive coronary disease in patients in ED who underwent 256-slice CCTA. The high negative predictive value of this computer-assisted algorithm may be useful in the ED setting.
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Coronary artery diseaseDiagnostic Accuracy of 256-row Computed Tomographic Angiography for Detection of Obstructive Coronary Artery Disease Using Invasive Quantitative Coronary Angiography as Reference Standard

Section snippets

Methods

Results

Discussion

Disclosures

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Cardiovac Comput Tomogr

JACC Cardiovasc Imaging

J Am Coll Cardiol

J Cardiovasc Comput Tomogr

J Am Coll Cardiol

Am J Cardiol

J Cardiovasc Comput Tomogr

JACC Cardiovasc Imaging

Advances in cardiac CT imaging: 64-slice scanner

Int J Cardiovasc Imaging

Coronary artery disease
Diagnostic Accuracy of 256-row Computed Tomographic Angiography for Detection of Obstructive Coronary Artery Disease Using Invasive Quantitative Coronary Angiography as Reference Standard