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Noninvasive Detection of Coronary Artery Stenoses with Multislice Computed Tomography or Magnetic Resonance Imaging

Marc Dewey, MD; Florian Teige, MD; Dirk Schnapauff, MD; Michael Laule, MD; Adrian C. Borges, MD; Klaus-Dieter Wernecke, PhD; Tania Schink, MS; Gert Baumann, MD; Wolfgang Rutsch, MD; Patrik Rogalla, MD; Matthias Taupitz, MD; and Bernd Hamm, MD
[+] Article and Author Information

From Humboldt-Universität, Berlin, Germany.


Note: This paper was presented in part in abstract form (no. 1706CA-p) at the conference of the Radiological Society of North America, Chicago, Illinois, 27 November to 3 December 2004.

Acknowledgments: The authors thank the technicians of the 3 laboratories for facilitating the performance of the trial. The following investigators also helped collect the conventional angiographic data unless otherwise noted: Hans-Peter Dübel, MD; Volker Gliech, MD; Arne Kieback, MD; Eva Schönenberger, MD (conception and design); and Heinz Theres, MD.

Grant Support: The study was initiated by the investigators (investigator-sponsored study) and was supported in part by a grant from GE Healthcare (formerly Amersham Buchler), which covered the cost of the multislice CT and MRI examinations.

Potential Financial Conflicts of Interest: Dr. Dewey has received grant support from GE Healthcare (for the present study) and lecture fees from Toshiba Medical Systems. Dr. Dewey is a principal investigator of an ongoing multicenter study (CorE64) on multislice CT coronary angiography sponsored by Toshiba Medical Systems. Dr. Rogalla has received lecture fees from Toshiba Medical Systems. Dr. Hamm has received grant support from GE Healthcare (for the present study), Schering, Siemens Medical Solutions, GE Healthcare, and Toshiba Medical Systems, and lecture fees from Siemens Medical Solutions and Schering.

Requests for Single Reprints: Marc Dewey, MD, Department of Radiology, Charité Medical School, Humboldt-Universität zu Berlin, Schumannstrasse 20/21, 10117 Berlin, Germany; e-mail, marc.dewey@charite.de.

Current Author Addresses: Drs. Dewey, Teige, Schnapauff, Rogalla, Taupitz, and Hamm: Department of Radiology, Charité Medical School, Humboldt-Universität zu Berlin, Schumannstrasse 20/21, 10117 Berlin, Germany.

Drs. Laule, Borges, Baumann, and Rutsch: Department of Cardiology, Charité Medical School, Humboldt-Universität zu Berlin, Schumannstrasse 20/21, 10117 Berlin, Germany.

Dr. Wernecke and Ms. Schink: Department of Medical Statistics, Charité Medical School, Humboldt-Universität zu Berlin, Schumannstrasse 20/21, 10117 Berlin, Germany.

Author Contributions: Conception and design: M. Dewey, G. Baumann, W. Rutsch, B. Hamm.

Analysis and interpretation of the data: M. Dewey, F. Teige, D. Schnapauff, M. Laule, A.C. Borges, K.-D. Wernecke, T. Schink, P. Rogalla, M. Taupitz.

Drafting of the article: M. Dewey.

Critical revision of the article for important intellectual content: F. Teige, D. Schnapauff, M. Laule, A.C. Borges, K.-D. Wernecke, T. Schink, G. Baumann, W. Rutsch, P. Rogalla, M. Taupitz, B. Hamm.

Final approval of the article: M. Dewey, F. Teige, D. Schnapauff, M. Laule, A.C. Borges, K.-D. Wernecke, T. Schink, G. Baumann, W. Rutsch, M. Taupitz, B. Hamm.

Statistical expertise: M. Dewey, K.-D. Wernecke, T. Schink.

Obtaining of funding: M. Dewey, B. Hamm.

Administrative, technical, or logistic support: F. Teige, D. Schnapauff.

Collection and assembly of data: M. Dewey, F. Teige, D. Schnapauff.


Ann Intern Med. 2006;145(6):407-415. doi:10.7326/0003-4819-145-6-200609190-00004
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During the study period, 183 patients were eligible for inclusion. Of these, 1 patient was excluded because of previous enrollment in another study, 35 declined to participate, and 17 had to be excluded because of time constraints before planned coronary angiography. Of the 130 remaining patients, 1 was found on multislice CT to have pulmonary embolism; thus, study participation was discontinued. After exclusions, 129 patients completed the study (Figure 1).

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Appendix Figure.
American Heart Association classification of coronary artery segmental anatomy.

Coronary artery segments are numbered 1 through 15. Minor branches, such as the conus (CB), sinus node (SN), ventricular (V), acute marginal (AM), atrioventricular node (AV), and atrial circumflex (AC) branches, are indicated in the diagram only for general orientation. These branches may or may not be visualized in the individual patient. Those whose origins can vary widely are shown unattached to the parent artery. Circ = left circumflex coronary artery; D1 = first diagonal branch; D2 = second diagonal branch; LAD = left anterior descending coronary artery; main LCA = left main coronary artery; OM = obtuse marginal branch; PD = posterior descending branch; PL = posterolateral branch; RCA = right coronary artery; RPD = right posterior descending branch. Adapted from Austen et al. (19).

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Figure 1.
Flow diagram of patient recruitment and examination according to the Standards for Reporting of Diagnostic Accuracy statement.

Per-patient results are presented according to findings of conventional coronary angiography by using all 15 coronary artery segments for multislice computed tomography (MSCT) and only the 8 proximal and middle segments for magnetic resonance imaging (MRI). Adapted from Bossuyt et al. (13). CT = computed tomography.

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Figure 2.
Stenosis of the left anterior descending coronary artery in a 43-year-old man with typical angina.

A. Stenosis on the conventional angiogram (arrow). B and C. Stenosis on 3-dimensional reconstructions obtained from multislice computed tomography and magnetic resonance imaging, respectively.

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Figure 3.
Per-patient post-test probabilities after multislice computed tomography (CT) and magnetic resonance imaging (MRI) for hypothetical populations with different prevalences of disease according to the Bayes theorem based on sensitivities and specificities inTable 4.

To identify first implications of the results for clinical decision making (according to Bayesian interpretation), we calculated the post-test probability after positive and negative findings on multislice CT and MRI for populations with different pretest probabilities of coronary artery disease.

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Elderly Patients Are the Achilles'Heel of Non-invasive Coronary Angiography
Posted on October 10, 2006
Gianluca Rigatelli
Service of Cardiovascular Diagnosis and Interventions, Rovigo General Hospital, Rovigo, Italy
Conflict of Interest: None Declared

We read with interest the article of Dewey et al [1] about non invasive coronary angiography, but although I found it extremely elegant , I believe we should clarify some points before giving recomandations about non invasive coronary angiography. While CMR had great promise as a radiation-free and contrast-free "one- stop" procedure, as nicely demonstrated by Dewey et al, its technology currently lags behind CTA in the non-invasive imaging of coronary artery but to use only CT as non invasive modality poses some limits. Firstly, elderly patients (age >70 years old) are the most likely to suffer from coronary artery disease (CAD), and as matter of fact, they are the 77% of patients investigated for CAD in our institution. Secondly, the elderly patients have high incidence of coronary calcium deposits [2]: dense calcification could result in overestimating the severity of the lesion (false positive) or prevent assessment of the lesion (considered as underestimate or false negative by the authors) [3- 4]. The false positive results might lead to unnecessary invasive coronary angiography and the underestimated results gives false assurance to the patient who might need coronary interventions. Moreover, despite the patient radiation exposure to CT angiography is similar than coronary angiography alone, the amount of contrast used in a false positive CTA plus invasive coronary angiography could be prohibitive for the elderly patient population with borderline renal function. Thirdly, as recently suggested [5], in patients with suspected CAD, the pretest likelihood of disease, a clinical assessment, becomes the most important determinant of the initial test. If the likelihood is very low, no testing is needed. However, even if the likelihood is low, recent data suggest provocatively that assessment of early atherosclerosis is likely to be the most useful and cost-effective test because the majority of acute myocardial infarction is caused by mild plaques without calcification. In the elderly patients with high likelihood of CAD, myocardial perfusion SPECT may be the initial test of choice, since a high proportion of these patients has too much coronary calcium deposits to allow accurate assessment of coronary stenoses. PET/CT or SPECT/CT could emerge as important modalities combining the advantages of each modality. CT angiography may be preferable in case of surgical revascularized patients, who has been already evaluated for both coronary and peripheral vascular distributions and may benefit from a non-invasive control of graft patency [5]. Finally, the conclusive assumption of Dewey et al about effectiveness of non-invasive angiography before conventional coronary angiography, in my opinion is somewhat optimistic at the moment: in coronary artery management an image technique is really useful when it can guide coronary interventions, the essence of coronary artery management. This certainly will append In the next 5-10 years, when 125 and 240 slice MDCTs would be normal standard of care for detecting coronary artery stenoses.

References

1. Dewey M, Teige F, Schnapauff D et al. Noninvasive detection of coronary artery stenoses with multislice computed tomography or magnetic resonance imaging- Ann Intern Med 2006; 145:407-15.

2. Cordeiro MA, Miller JM, Schmidt A, Lardo AC, Rosen BD, Bush DE, Brinker JA, Bluemke DA, Shapiro EP, Lima JA. Non-invasive half millimetre 32 detector row computed tomography angiography accurately excludes significant stenoses in patients with advanced coronary artery disease and high calcium scores. Heart. 2006; 92:589-97.

3. de Feyter PJ. Can multislice CT detect coronary artery disease accurately? Nat Clin Pract Cardiovasc Med. 2005 Nov;2:560-1.

4. Beck T, Burgstahler C, Reimann A, Kuettner A, Heuschmid M, Kopp AF, Schroeder S. Technology insight: possible applications of multislice computed tomography in clinical cardiology. Nat Clin Pract Cardiovasc Med. 2005; 2:361-8.

5. Berman DS, Hachamovitch R, Shaw LJ, Friedman JD, Hayes SW, Thomson LE, Fieno DS, Germano G, Slomka P, Wong ND, Kang X, Rozanski A. Roles of Nuclear Cardiology, Cardiac Computed Tomography, and Cardiac Magnetic Resonance: Assessment of Patients with Suspected Coronary Artery Disease. J Nucl Med. 2006;47:74-82.

Conflict of Interest:

None declared

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