Good news on coronary computed tomographic angiography: answers that have questions!
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Good news on coronary computed tomographic
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Good News On Coronary Computed Tomographic
This editorial refers to ‘Non-invasive diagnosis of ischaemic heart failure using 64-slice computed tomography’†
by S. Ghostine et al., on page 2133
An increasing number of studies have examined the role of coronary computed tomographic angiography (CCTA) in assessing
patients with known...
European Heart Journal (2008) 29, 2070–2072 EDITORIAL
doi:10.1093/eurheartj/ehn338
Good news on coronary computed tomographic
angiography: answers that have questions!
Birgit Kantor 1*, Nandan S. Anavekar 1, and Thomas C. Gerber2
1
Mayo Clinic, Rochester, MN 55905, USA; and 2Mayo Clinic, Jacksonville, FL 32224, USA
Online publish-ahead-of-print 18 July 2008
This editorial refers to ‘Non-invasive diagnosis of ischae- diagnostic accuracy of CCTA in predicting .50% diameter ste-
mic heart failure using 64-slice computed tomography’† noses detected on SCA. Cardiomyopathy was classified as ischae-
by S. Ghostine et al., on page 2133 mic if coronary stenoses were present in the left main coronary
artery or the proximal left anterior descending artery, or in 2
An increasing number of studies have examined the role of coron- of the remaining coronary artery segments.
ary computed tomographic angiography (CCTA) in assessing Based on the SCA findings, 43 patients (46%) had at least one
patients with known or suspected coronary artery disease .50% diameter stenosis. Of those, 31 patients (33%) had a
(CAD) relative to established evaluation approaches. The diagnos- degree of CAD suggesting ischaemic cardiomyopathy. Sixty-two
tic and predictive value of stress electrocardiography, stress patients (67%) had non-ischaemic cardiomyopathy. CCTA cor-
imaging, and invasive, selective coronary angiography (SCA) is rectly identified 42 of 43 patients (sensitivity, 98%) with any signifi-
documented by a large body of evidence, and their use to guide cant CAD and correctly classified 28 of 31 patients (sensitivity,
patient management is codified in clinical guidelines. To date, no 90%) with presumably ischaemic cardiomyopathy. Absence of
convincing evidence suggests that the diagnostic or predictive any significant CAD was correctly predicted by 45 of 46 negative
value of CCTA is superior or even equivalent. Consequently, no CCTAs (NPV, 98%), and CAD suggesting ischaemic cardiomyop-
first-line indications for CCTA exist.1,2 However, there may be athy was correctly excluded by 59 of 62 negative CCTAs
niche applications where CCTA could be a potentially effective (NPV, 95%).
and cost-saving alternative to more established imaging techniques. This work expands current knowledge on the use of cardiac CT
Studies comparing CCTA with SCA have universally shown a high in patients with cardiomyopathy. Coronary artery calcification on
negative predictive value (NPV).3 As a result, a ‘negative’ CCTA cardiac CT imaging without contrast enhancement can identify
excludes CAD with very high certainty if image quality is diagnostic ischaemic cardiomyopathy with a sensitivity of 97– 98% and an
and most coronary segments are well seen, particularly in popu- NPV of 95– 98%.5 However, information on the severity and dis-
lations with a low prevalence of CAD. A valid argument can be tribution of CAD provided by coronary calcium imaging alone is
made that patients with low pre-test probability do not need limited. A previous study of CCTA in a lower number (n ¼ 61)
testing at all. However, there are clinical scenarios in which SCA is of heart failure patients6 used older 16-slice multidetector CT
often performed because proving the absence of CAD has import- scanners but found results similar to the current study: at a preva-
ant diagnostic or therapeutic implications, or because the diagnostic lence of 28%, the sensitivity for detecting CAD in 870 coronary
accuracy of conventional stress testing is reduced. Ghostine et al. 4 segments was 99%, and the specificity 96%.
address the potential use of CCTA in one of these scenarios. A few aspects of the current work by Ghostine et al. 4 deserve
discussion. The prevalence of CAD in the authors’ cohort was
higher than in other studies of patients with unexplained cardio-
CCTA for the assessment of myopathy. Yet, the uncorrected likelihood ratio of ischaemic cardi-
omyopathy being present was 18.7 for a positive CCTA and 0.1 for
unexplained cardiomyopathy a negative CCTA, suggesting good evidence for both ruling in and
The authors examined the role of 64-slice multidetector CCTA in ruling out disease.
non-invasively classifying symptomatic left ventricular (LV) dysfunc- At least moderate renal insufficiency is present in 50% of
tion as ischaemic or non-ischaemic. They determined, in 93 patients with heart failure. This frequent association may be an
consecutive heart failure patients without known CAD, the important limitation for the potential role of CCTA because of
The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.
* Corresponding author. Email: kantor.birgit@mayo.edu
†
doi:10.1093/eurheartj/ehn072
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org.
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