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Published on: August 28, 2018
Diagnostic performance of coronary CT angiography to diagnose acute spontaneous coronary artery dissection
Lukas J Moser1, Tristan T Demmert1, Konstantin Klambauer1
1Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
Insights
Coronary CT angiography (coronary CTA) shows low sensitivity for diagnosing spontaneous coronary artery dissection (SCAD), but high specificity. This imaging may help defer invasive coronary angiography in select SCAD cases.
Area of Science:
- Cardiovascular Imaging
- Diagnostic Performance
- Interventional Cardiology
Background:
- Spontaneous coronary artery dissection (SCAD) diagnosis relies on invasive coronary angiography (ICA).
- Limited data exists on coronary CT angiography (coronary CTA) diagnostic performance for SCAD.
- This study aimed to assess coronary CTA's accuracy in diagnosing acute SCAD.
Purpose of the Study:
- Evaluate the diagnostic performance of coronary CTA in identifying acute SCAD.
- Compare coronary CTA findings with ICA as the gold standard.
- Analyze factors influencing diagnostic accuracy, including lesion location and myocardial hypodensity.
Main Methods:
- Prospective single-center study of 52 SCAD patients and 70 controls.
- Coronary CTA performed on all participants; ICA used as reference standard.
- Two blinded readers assessed coronary CTA for SCAD, calculating sensitivity, specificity, and accuracy.
Main Results:
- Coronary CTA demonstrated low patient-level sensitivity (52-58%) but high specificity (97%) for SCAD diagnosis.
- Accuracy was higher for proximal SCAD (93-94%) compared to distal SCAD (76-80%).
- Myocardial hypodensity improved sensitivity but decreased specificity.
Conclusions:
- Coronary CTA exhibits poor sensitivity but high specificity for SCAD diagnosis, regardless of lesion location.
- Coronary CTA may assist in deferring invasive coronary angiography in specific SCAD cases, particularly when conservative management is planned.
Background:
The diagnosis of spontaneous coronary artery dissection (SCAD) is made with invasive coronary angiography (ICA). The literature on the diagnostic performance of coronary CT angiography (coronary CTA) is sparse. The purpose of this study was to evaluate the performance of coronary CTA for the diagnosis of acute SCAD.
Methods:
This prospective single-center study included 52 patients with SCAD confirmed by ICA and 70 patients with chest pain but without SCAD (control group), who all underwent coronary CTA. Two independent readers evaluated coronary CTA for SCAD, including vessel abnormalities and myocardial hypodensity. Accuracy, sensitivity, and specificity with 95 % confidence intervals (CI) were calculated using ICA as the reference standard. Coronary CTA imaging features of SCAD were correlated with diagnostic confidence using multivariable regression analysis. Interreader agreement was determined by Cohen's Kappa.
Results:
Patient-level sensitivity of coronary CTA to diagnose SCAD ranged from 52 % (CI:38 %-66 %)-58 % (CI:43 %-71 %), with a specificity of 97 % (CI:90 %-100 %) and accuracy of 78 % (CI:69 %-85 %) and 80 % (CI:72 %-87 %) for both readers (Kappa = 0.891). Sensitivity and accuracy were higher for proximal (sensitivity 67 % (CI:38 %-88 %) and 73 % (CI:45 %-92 %); accuracy 93 % (CI:87 %-97 %) and 94 % (CI:89 %-98 %)) than for distal SCAD (sensitivity 40 % (CI:26 %-56 %) and 49 % (CI:34 %-64 %); accuracy 76 % (CI:68 %-83 %) and 80 % (CI:71 %-86 %)), while specificity was high irrespective of location (97 %; CI:91 %-99 %, resp.100 %). Additional myocardial hypodensity increased readers' confidence (beta coefficient -0.38; p = 0.11 for reader 1, and beta coefficient of -0.90; p = 0.004 for reader 2) and sensitivity (71 % (CI:57 %-83 %) and 65 % (CI:51 %-78 %), respectively), while reducing specificity (both 91 %, CI:82 %-97 %).
Conclusion:
Coronary CTA has a poor sensitivity for the diagnosis of SCAD, while specificity is high irrespective of SCAD location. Patients with coronary CTA positive for SCAD might be deferred from ICA after careful consideration and when conservative management is intended.
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