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Identifying Coronary Artery Calcification on Non-gated Computed Tomography Scans
Published on: August 28, 2018
Limited clinical utility of CT coronary angiography in a district hospital setting
S M M Jenkins1, N Johnston, N M Hawkins
1Department of Cardiology, Stobhill Hospital, 133 Balornock Road, Glasgow G21 3UW, UK. shonajenkins@hotmail.com
Insights
Multi-slice CT coronary angiography (MSCT-CA) accurately rules out coronary artery disease (CAD) in low-risk patients at district hospitals. However, its specificity is reduced in patients with high-risk factors, necessitating heart rate control and careful patient selection.
Area of Science:
- Cardiology
- Radiology
- Medical Imaging
Background:
- Multi-slice CT coronary angiography (MSCT-CA) shows high accuracy for coronary artery disease (CAD) detection compared to invasive methods.
- The transferability of MSCT-CA accuracy from tertiary centers to routine practice remains unclear.
Purpose of the Study:
- To assess the diagnostic accuracy of MSCT-CA for detecting CAD in a Scottish district general hospital setting.
- To evaluate the effectiveness of MSCT-CA in a real-world, non-specialized clinical environment.
Main Methods:
- A prospective diagnostic accuracy study involving 100 patients with suspected CAD.
- Patients underwent both MSCT-CA and invasive coronary angiography (I-CA).
- Data were analyzed by independent, blinded radiologists and cardiologists using the AHA 15-segment model.
Main Results:
- MSCT-CA demonstrated a high negative predictive value (NPV) of 90.6% for detecting CAD.
- Sensitivity was 92.1%, but specificity was lower at 47.5%.
- Specificity was compromised in patients with high pre-test probability, coronary calcification, obesity, and suboptimal heart rate control.
Conclusions:
- Forty-slice MSCT-CA is effective for ruling out CAD in low-intermediate pre-test probability patients with minimal calcification in district hospitals.
- Specificity limitations require careful patient selection and optimal heart rate control.
- Adherence to national guidelines for patient selection and reporter training is crucial for quality control.
Background:
Studies have demonstrated considerable accuracy of multi-slice CT coronary angiography (MSCT-CA) in comparison to invasive coronary angiography (I-CA) for evaluating coronary artery disease (CAD). The extent to which published MSCT-CA accuracy parameters are transferable to routine practice beyond high-volume tertiary centres is unknown.
Aim:
To determine the accuracy of MSCT-CA for the detection of CAD in a Scottish district general hospital.
Design:
Prospective study of diagnostic accuracy.
Method:
One hundred patients with suspected CAD recruited from two Glasgow hospitals underwent both MSCT-CA (Philips Brilliance 40 × 0.625 collimation, 50-200 ms temporal resolution) and I-CA. Studies were reported by independent, blinded radiologists and cardiologists and compared using the AHA 15-segment model.
Results:
Of 100 patients [55 male, 45 female, mean (SD) age 58.0 (10.7) years], 59 and 41% had low-intermediate and high pre-test probabilities of significant CAD, respectively. Mean (SD) heart rate during MSCT-CA was 68.8 (9.0) bpm. Fifty-seven per cent of patients had coronary artery calcification and 35% were obese. Patient prevalence of CAD was 38%. Per-patient sensitivity, specificity, positive and negative (NPV) predictive values for MSCT-CA were 92.1, 47.5, 52.2 and 90.6%, respectively. NPV was reduced to 75.0% in the high pre-test probability group. Specificity was compromised in patients with sub-optimally controlled heart rates, calcified arteries and elevated BMI.
Conclusion:
Forty-Slice MSCT-CA has a high NPV for ruling out significant CAD when performed in a district hospital setting in patients with low-intermediate pre-test probability and minimal arterial calcification. Specificity is compromised by clinically appropriate strategies for dealing with unevaluable studies. Effective heart rate control during MSCT-CA is imperative. National guidelines should be utilized to govern patient selection and direct MSCT-CA reporter training to ensure quality control.
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