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[Update on coronary CT-more than just anatomical imaging? : Current guidelines and functional CT techniques for the
Martin Soschynski1,2, Jana Taron3,4, Christopher L Schlett3
1Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Freiburg, Freiburg, Deutschland. Martin.Soschynski@uniklinik-freiburg.de.
Insights
Coronary CT angiography (cCTA) is recommended for diagnosing coronary artery disease. Functional CT techniques like CT-perfusion (CT-P) and CT-based fractional flow reserve (CT-FFR) accurately detect myocardial ischemia but are not yet guideline-supported.
Area of Science:
- Cardiovascular imaging
- Diagnostic cardiology
- Medical technology
Background:
- Coronary CT angiography (cCTA) effectively rules out significant coronary stenoses but struggles to determine their hemodynamic significance.
- This limitation impacts the definitive indication for therapeutic interventions.
Purpose of the Study:
- To outline the current guideline-based use of cCTA for diagnosing coronary artery disease.
- To identify available functional CT techniques for assessing the hemodynamic significance of coronary stenoses.
Main Methods:
- Review of European Society of Cardiology (ESC) guidelines for chronic coronary syndromes.
- Description of functional CT techniques: myocardial CT-perfusion (CT-P) and CT-based fractional flow reserve (CT-FFR).
Main Results:
- ESC guidelines recommend cCTA (Class 1) for symptomatic patients with low clinical likelihood of coronary artery disease.
- For high clinical likelihood or moderate stenoses, noninvasive functional imaging is preferred.
- CT-P and CT-FFR demonstrate substantial evidence for assessing functional significance.
Conclusions:
- cCTA is strongly recommended for coronary artery disease diagnosis per current guidelines.
- CT-P and CT-FFR show high accuracy in diagnosing myocardial ischemia from coronary stenoses.
- These functional CT methods are not yet integrated into guidelines, leading to low clinical adoption.
Background:
Coronary CT angiography (cCTA) has a high negative predictive value for ruling out significant coronary stenoses. However, it is limited in determining hemodynamic significance of a stenosis and hence to prove the indication for therapy.
Objectives:
When and how is cCTA used according to current guidelines? Which functional CT techniques are available to test for hemodynamic significance of coronary stenoses?
Materials And Methods:
The value of cCTA is explained on the basis of current guidelines by the European Society of Cardiology (ESC) for the diagnosis of chronic coronary syndromes. Functional CT techniques which test for hemodynamic significance of coronary stenoses are myocardial CT-perfusion (CT‑P) and CT-based fractional flow reserve (CT-FFR).
Results:
The new ESC guidelines classify cCTA as a class 1 recommendation for diagnosing coronary artery disease in symptomatic patients with low clinical likelihood. If clinical likelihood is high or an at least moderate stenosis is detected with cCTA, noninvasive functional (stress) imaging is preferred. There is a large body of evidence for CT‑P and CT-FFR as functional tests.
Conclusion:
In the current guidelines, cCTA is highly recommended for the diagnosis of coronary artery disease. The functional CT techniques CT‑P and CT-FFR have shown high diagnostic accuracy for myocardial ischemia of coronary stenoses in many clinical studies. However, these methods are not part of current guidelines yet and clinical adoption is still low.
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