Detection of relevant extracardiac findings on coronary computed tomography angiography vs. invasive coronary angiography

Abstract

Objectives To compare the detection of relevant extracardiac findings (ECFs) on coronary computed tomography angiography (CTA) and invasive coronary angiography (ICA) and evaluate the potential clinical benefit of their detection. Methods This is the prespecified subanalysis of ECFs in patients presenting with a clinical indication for ICA based on atypical angina and suspected coronary artery disease (CAD) included in the prospective single-center randomized controlled Coronary Artery Disease Management (CAD-Man) study. ECFs requiring immediate therapy and/or further workup including additional imaging were defined as clinically relevant. We evaluated the scope of ECFs in 329 patients and analyzed the potential clinical benefit of their detection. Results ECFs were detected in 107 of 329 patients (32.5%; CTA: 101/167, 60.5%; ICA: 6/162, 3.7%; p < .001). Fifty-nine patients had clinically relevant ECFs (17.9%; CTA: 55/167, 32.9%; ICA: 4/162, 2.5%; p < .001). In the CTA group, ECFs potentially explained atypical chest pain in 13 of 101 patients with ECFs (12.9%). After initiation of therapy, chest pain improved in 4 (4.0%) and resolved in 7 patients (6.9%). Follow-up imaging was recommended in 33 (10.0%; CTA: 30/167, 18.0%; ICA: 3/162, 1.9%) and additional clinic consultation in 26 patients (7.9%; CTA: 25/167, 15.0%; ICA: 1/162, 0.6%). Malignancy was newly diagnosed in one patient (0.3%; CTA: 1/167, 0.6%; ICA: 0). Conclusions In this randomized study, CTA but not ICA detected clinically relevant ECFs that may point to possible other causes of chest pain in patients without CAD. Thus, CTA might preclude the need for ICA in those patients. Trial registration NCT Unique ID: 00844220 Key Points • CTA detects ten times more clinically relevant ECFs than ICA. • Actionable clinically relevant ECFs affect patient management and therapy and may thus improve chest pain. • Detection of ECFs explaining chest pain on CTA might preclude the need for performing ICA.

German Radiological Society and the Professional Association of German Radiologists Position Paper on Coronary computed tomography: Clinical Evidence and Quality of Patient Care in Chronic Coronary Syndrome

“…In one study on emergency care by Onuma et al, an alternative extracardiac disease was able to be identified as the cause of acute angina pectoris symptoms in 16 % of patients based on cardiac cross-sectional imaging so that further imaging was not necessary [121]. Dewey et al were able to confirm this with 12.9 % detected extracardiac causes for atypical angina pectoris [122]. In a further study by Lehmann et al, extracardiac findings changed management in 1.3 % of patients and provided an alternative explanation for angina pectoris symptoms in 4.1 % of patients [123].…”

“…In einer Studie zur Notfallversorgung von Onuma et al konnte basierend auf der kardialen Schnittbildgebung bei 16 % der Patienten eine alternative, extrakardiale Erkrankung als Ursache einer akuten Angina-pectoris-Symptomatik identifiziert werden, sodass eine weitere bildgebende Diagnostik nicht notwendig war 121 . Dewey et al konnten dies mit 12,9 % detektierter extrakardialer Ursachen für eine atypische Angia pectoris bestätigen 122 . In einer weiteren Studie von Lehmann et al änderten extrakardiale Befunde das Krankenhausmanagement bei 1,3 % der Patienten und lieferten eine alternative Erklärung für eine Angina-pectoris-Symptomatik bei 4,1 % der Patienten 123 .…”

Positionspapier von DRG und BDR zur Computertomographie des Herzens: Klinische Evidenz und Versorgungsqualität beim chronischen Koronarsyndrom

“…Dewey et al. konnten dies mit 12,9 % detektierter extrakardialer Ursachen für eine atypische Angina pectoris bestätigen [ 122 ]. In einer weiteren Studie von Lehmann et al.…”

Technical Considerations for Dynamic Myocardial Computed Tomography Perfusion as Part of a Comprehensive Evaluation of Coronary Artery Disease Using Computed Tomography

“…The cardiac CTA should be evaluated and reported according to SCCT guidelines 68. This includes reporting of potential extracardiac findings and detection of additional or alternative potential causes of chest pain when excluding significant CAD 69…”

“…68 This includes reporting of potential extracardiac findings and detection of additional or alternative potential causes of chest pain when excluding significant CAD. 69 In addition to coronary evaluation, the cardiac CTA can be used for evaluation of myocardial attenuation at rest if no delayed acquisition is performed. 70 The presence of myocardial infarction should be evaluated using multiplanar reformat or minimum intensity projection with a slice thickness of 5 to 10 mm and a narrow window width and window level (eg, W 200, L 100 to 150 depending on mean myocardial attenuation).…”