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Identifying Coronary Artery Calcification on Non-gated Computed Tomography Scans
Published on: August 28, 2018
CT myocardial perfusion and coronary CT angiography: Influence of coronary calcium on a stress-rest protocol
Ricardo Ladeiras-Lopes1, Nuno Bettencourt1, Nuno Ferreira1
1Department of Cardiology, Gaia Hospital Centre, Vila Nova de Gaia, Portugal; Cardiovascular Research and Development Centre, Faculty of Medicine of the University of Porto, Porto, Portugal.
Insights
CT myocardial perfusion imaging improves coronary artery disease assessment in patients with high calcium scores. This technique enhances diagnostic accuracy when traditional CT angiography is limited by calcification.
Area of Science:
- Cardiovascular Imaging
- Radiology
- Medical Diagnostics
Background:
- High coronary artery calcium (CAC) burden degrades multidetector computed tomography angiography (MDCT CTA) image quality, hindering obstructive coronary artery disease (CAD) assessment.
- CT myocardial perfusion imaging offers a potential solution to overcome CAC-related limitations in MDCT CTA.
Purpose of the Study:
- To evaluate the additive diagnostic value of CT myocardial perfusion imaging to MDCT CTA.
- To assess this additive value in relation to patient's CAC score.
- To compare CT findings against the reference standard of invasive coronary angiography with fractional flow reserve (FFR) measurement.
Main Methods:
- Prospective recruitment of symptomatic patients with intermediate pretest CAD probability.
- Performance of cardiac MDCT (64-slice, stress-rest protocol) and invasive coronary angiography with FFR.
- Definition of hemodynamically significant CAD as occlusive/subocclusive stenosis, left main stenosis >50%, or FFR ≤0.80.
- Addition of stress CT myocardial perfusion imaging to CTA for all patients.
Main Results:
- Analysis included 95 patients; 42 had hemodynamically significant CAD.
- CTA alone achieved 100% sensitivity, 59% specificity, and 0.79 AUC (77% correct classification).
- Adding CT myocardial perfusion in patients with CAC >100 improved AUC to 0.81 (88% sensitivity, 74% specificity).
- In patients with CAC >400, CT perfusion yielded 91% sensitivity, 70% specificity, and 0.80 AUC (82% correct classification).
Conclusions:
- CT myocardial perfusion imaging significantly enhances diagnostic accuracy for obstructive CAD in patients with high CAC scores.
- Limiting CT perfusion to patients with CAC >400 appears a feasible strategy to optimize diagnostic performance.
- This approach addresses limitations of MDCT CTA in heavily calcified arteries.
Background:
High amounts of coronary artery calcium limit image quality and diagnostic accuracy of multidetector computed tomography (MDCT) angiography (CTA) regarding the assessment of obstructive coronary artery disease (CAD). CT myocardial perfusion imaging may represent an opportunity to overcome this limitation.
Objective:
To explore the additive value of CT myocardial perfusion to CTA depending on the patient's calcium score and in comparison to the reference standard of invasive coronary angiography plus fractional flow reserve (FFR) measurement.
Methods:
Symptomatic patients with intermediate pretest probability of CAD were prospectively recruited and underwent both cardiac MDCT (64-slice scanner, retrospectively-gated stress-rest protocol) and invasive coronary angiography including FFR assessment. We defined hemodynamically significant CAD by the presence of occlusive or subocclusive (99%) stenosis, >50% stenosis in left main or FFR≤0.80. Stress CT myocardial perfusion imaging was performed in all patients in addition to CTA. The additive value of CT myocardial perfusion to rule in or rule out the presence of hemodynamically relevant stenosis on a per-patient basis was assessed and analyzed relative to the patient's calcium score.
Results:
95 patients were included in the analysis (62 ± 8.2 years, 68%males). Hemodynamically significant CAD was present in 42 patients. Sixty-four patients had a fully evaluable CTA examination. Per-patient, CTA alone had a sensitivity, specificity and AUC of 100%, 59% and 0.79 respectively (77% patients correctly classified). Adding CT myocardial perfusion to evaluate uninterpretable vessel territories in CTA in 66 patients with a calcium score>100 yielded a sensitivity of 88%, a specificity of 74% and an AUC of 0.81 (81% patients correctly classified), and in 52 patients with a calcium score>400 sensitivity was 91%, specificity 70%, and AUC 0.80 (82% patients correctly classified, p = 0.733 versus using perfusion imaging in all patients).
Conclusions:
From a pragmatic standpoint, limiting the use of CT perfusion to individuals with a calcium score above 400 might be a feasible strategy to optimize the diagnostic accuracy of CT imaging for diagnosis of obstructive CAD.
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