The assessment concluded that "The evidence is consistent with prior physiologic data and long-held beliefs that identifying stenoses is insufficient to determine when revascularization is likely to have benefit. The investigators also concluded that although CCTA was associated with a lower risk of MI, it had a similar risk of all-cause mortality. Curr Diab Rep. 2004;4(1):20-25. Curr Atheroscler Rep. 2016;18(11):64. 2013;99(15):1113-1117. J Am Coll Cardiol. slightly 'softer' than a simple high-pass filter. 2015;66(21):2315-2323. Unstable angina not previously stabilized by medical therapy. In: EBM Guidelines. Systematic review of the clinical effectiveness and cost-effectiveness of 64-slice or higher computed tomography angiography as an alternative to invasive coronary angiography in the investigation of coronary artery disease. There was significantly lower radiation exposure for the DHP group (3.65 [1.29] vs 23.57 [10.32] mSv). 64-Slice computed tomography angiography in the diagnosis and assessment of coronary artery disease: Systematic review and meta-analysis. The reconstruction interval is thus determined by the software from the raw data the scanner obtained. PLoS ONE. 2014;270(1):74-81. Illustration of helical CT reconstruction of successive slices. Therefore, at present, the application of CCTA for risk assessment of individuals without CPS should not be justified. In combination with iterative reconstruction techniques, high-pitch spiral acquisition allows for cardiac CT with sub-milliSievert doses". In fact, the two phenomena are somewhat related - we can use noisier kernels in situations where the inherent contrast Liew GY, Feneley MP, Worthley SG. Improved noninvasive coronary angiography in morbidly obese patients with dual-source computed tomography. Horizon Scanning Technology Briefing. These researchers collected data on risk factors and performed scanning for CAC in a population-based sample of 6,722 men and women, of whom 38.6 % were white, 27.6 % were black, 21.9 % were Hispanic, and 11.9 % were Chinese. Ann Emerg Med. In particular, some small lung nodules may appear calcified on sharp kernel images, when they are truly not. Arrhythmias have presented a challenge due to motion artifact resulting from irregular rhythm; however, studies are now showing that newer generation CT scanners are capable of providing quality images for patients with AF. asymptomatic persons with an intermediate (10 % to 20 %) 10-year risk of cardiac events based on Framingham Risk Scoring or Pooled Cohort Equations (see Appendix). In step-and-shoot CT, slice thickness and slice spacing are the same - each time 1996;78:1220-1223. Treating providers are solely responsible for medical advice and treatment of members. Improvements in risk stratification for the occurrence of cardiovascular disease by imaging subclinical atherosclerosis: A systematic review. Circulation. A systematic literature review of spiral and electron beam computed tomography: With particular reference to clinical applications in hepatic lesions, pulmonary embolus, and coronary artery disease. None of the participants with a negative CCTA had myocardial infarction or died within 30 days. Coronary CT angiography in obese patients using 3(rd) generation dual-source CT: effect of body mass index on image quality. The z-position Marwick TH. Circulation. Electron-beam and helical computed tomography for coronary artery disease. Finnish Medical Society Duodecim. (For details on Framingham Risk Scoring, see appendix to CPB 0381 - Cardiac Disease Risk Tests.) Clinical and cost effectiveness of CT and MRI for selected clinical disorders: Results of two systematic reviews. ; Society for Cardiovascular Angiography and Interventions. BlueCross BlueShield Association (BCBSA), Technology Evaluation Center (TEC). Technology Report No. Hulten E, Bittencourt MS, Singh A, et al. This decouples the selection of slice thickness from slice spacing (reconstruction interval). Image: ; American Heart Association. Ontario Ministry of Health and Long-Term Care, Medical Advisory Secretariat (MAS). The mean effective dose was 9.5 ± 3.9 mSv for group 1, 11.4 ± 4.7 mSv for group 2 and 14.0 ± 6.4 mSv for group 3. Criqui MH, Denenberg JO, Ix JH, et al. HeartFlow FFRCT for estimating fractional flow reserve from coronary CT angiography. ; SCOT-HEART Investigators.. Use of coronary computed tomographic angiography to guide management of patients with coronary disease. Learn more about open access options. Naghavi M, Madjid M, Khan MR, et al. "Filtered BP Reconstruction"). 30 degrees The end point was the occurrence of cardiac events (cardiac death, nonfatal myocardial infarction, unstable angina requiring hospitalization, and coronary re-vascularization later than 90 days after CCTA). Newer generation CT scanners have emerged which allows for faster, higher-quality images. A total of 2,133 (49.2 %) subjects, who were classified as low-risk by the NCEP guideline, of 4,339 consecutive middle-aged asymptomatic subjects who underwent CCTA with 64-slice scanners as part of a general health evaluation were included in this study. Finally, CCTA was associated with improved clinical outcomes when instituted in the immediate post-discharge evaluation of patients with acute chest pain discharged from the ED as reported in the CATCH trial. Meta-analysis of comparative diagnostic performance of magnetic resonance imaging and multislice computed tomography for noninvasive coronary angiography. In ultrafast CT, an electron-beam is magnetically steered along stationary tungsten rings to produce a rotating X-ray beam. 2013;17(9):1-243. 49. Detrano R, Wong ND, Doherty TM, et al. The kernel, also known as a convolution algorithm, refers to the process used to modify the frequency contents of projection data prior to back projection during image reconstruction in a CT scanner 1.This process corrects the image by reducing blurring 1.The kernel affects the appearance of image structures by sharpening the image. Min JK, Koo BK, Erglis A, et al. Especially, 75.0 % (21 of 28) of subjects with significant stenosis and 94.4 % (17 of 18) of subjects with significant stenosis caused by NCP were young adults. National Health Service Quality Improvement Scotland (NHS QIS). Significant improvements were observed in noise (p < 0.0001), contrast-to-noise ratio (p = 0.0038), and signal-to-noise ratio (p = 0.030). A statement for health professionals from the American Heart Association Writing Group. In fact, when referral to angiography is based on the results of EBCT, referrals will be made for very few patients with normal results while many referrals will be made for those with abnormal results. Dedic A, Lubbers MM, Schaap J, et al. Eur Radiol. : The FFR(CT) RIPCORD Study. 2007;49(8):863-871. 1 A total of 213 consecutive asymptomatic subjects (113 males; mean age of 53.6 +/- 12.4 years) with more than 1 risk factor and an inconclusive or unfeasible non-invasive stress test result underwent CACS and CTCA in an out-patient setting. However, considering very low event rate for those patients, CCTA should not be performed in low-risk asymptomatic subjects, although CCTA might have the potential for identification of high-risk groups in the selected subjects regarded as a minimal-risk group by NCEP guideline. Correlation of calcium measurement with low dose 64-slice CT and angiographic stenosis in patients with suspected coronary artery disease. Cardiac troponin I appears to be more specific than cardiac troponin T or creatine kinase MB subunits in the diagnosis of acute myocardial infarction. The outcome will be that, in clinical practice, the observed sensitivity of EBCT will be increased, and the observed specificity will be reduced. 1997;96:1122-1129. Waltham, MA: UpToDate; reviewed July 2017. The Prospective Multicenter Imaging Study for Evaluation of chest pain (PROMISE) trial was a pragmatic trial that recruited a large cohort from USA and Canadian centres to determine whether an initial assessment of suspected stable CAD using CTCA reduces major adverse cardiovascular events (Douglas, et al, 2015). Cardiol. All patients underwent conventional coronary angiography (CAG). FFR is currently measured invasively using a pressure wire placed across a narrowed artery. Of course, these images are also viewed at different window settings because of the Helical CT is much faster than step-and-shoot and is the standard method used in CT in the modern era. A 2012 randomized trial by Hoffman and colleagues (ROMICAT II) compared the effectiveness of CCTA with that of standard evaluation in individuals suggestive of acute coronary syndrome in the emergency room. Well, real CT data contains noise. Links to various non-Aetna sites are provided for your convenience only. The primary endpoint of length of hospital stay was significantly reduced in the CCTA cohort. Thus, we want to use a hard (sharp) kernel to accentuate these features. Silver Spring, MD: FDA; August 24, 2016. Cumulative 6-month costs were slightly higher with CCTA: difference $462 (95% CI: $303 to $621). 2017;69(14):1761-1770. ", No study reported that calcification measuring (plaque characterization) reduces the incidence of coronary events or death.". ; PLATFORM Investigators.. Quality-of-life and economic outcomes of assessing fractional flow reserve with computed tomography angiography: PLATFORM. Finnish Medical Society Duodecim. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Cologne, Germany; DIMDI; 2006. metal implants). You can reconstruct at any Coronary calcium scoring for long-term mortality prediction in patients with and without a family history of coronary disease. Pwee KH. Chicago, IL: BCBSA; November 2011;26(9). Spiral CT was reported to have a sensitivity of 74 % and a specificity of 70 % compared to ultrafast CT. Detrano (1999) demonstrated that the addition of EBCT data provided no added value to the risk of coronary artery disease risk determined by the Framingham and National Cholesterol Education Program risk models. Arad Y, Spadaro LA, Goodman K, et al. All subjects had AF longer than 1 year. Expert Analysis. Clinical value. N Engl J Med. Health Technol Assess. Finnish Medical Society Duodecim. The authors concluded that "CCTA with DSCT using a modified scan protocol and adjustable temporal reconstructions provides diagnostic image quality in >90% of morbidly obese patients.". Although a greater amount of calcium may indicate a greater likelihood of obstructive disease, studies have shown that site-specificity and exact 1:1 correlations are not well predicted, that is, ultrafast CT can not define the location or amount of obstruction with sufficient accuracy to be of use in predicting risk of coronary artery disease, in diagnosing coronary artery disease, or in planning surgical treatment. Refinements in detector technology allow new CT scanners to obtain multiple slices in a single rotation. Volume 76, Issue 4 New Content Alerts Special Issues. Electron beam computed tomography coronary calcium as a predictor of coronary events. (Even single-detector row CT has 2008;118(5):586-606. Outcomes of anatomical versus functional testing for coronary artery disease. You can see this effect in the simulator on the right-most panel. Buenos Aires, Argentina: Institute for Clinical Effectiveness and Health Policy (IECS); 2005. Current Issue. Evaluation of asymptomatic persons at an intermediate pre-test probability of coronary heart disease or atherosclerotic cardiovascular disease by Framingham risk scoring or Pooled Cohort Equations (see Appendix) who have an equivocal or uninterpretable exercise or pharmacological stress test or have resting electrocardiogram (ECG) changes (such as left bundle branch block (LBBB), pathologic q-waves, or right bundle branch block (RBBB) with left anterior fascicular block (LAFB) in which coronary artery disease (CAD) is a possible etiology. Nieman K, van Geuns RJ, Wielopolski P, et al. Heart. Tomographic (plaque) imaging: State of the art. Appropriate indications for computed tomography coronary angiography. 60 degrees 1996;27:285-290. Coronary atherosclerosis assessment by coronary CT angiography in asymptomatic diabetic population: A critical systematic review of the literature and future perspectives. than backprojection, and the most common of these at the difference (or 'error') in the reconstruction, you can make a better guess. Coronary artery calcification: Pathophysiology, epidemiology, imaging methods, and clinical implications. Redberg RF, Shaw LJ. ; American Heart Association Task Force on Practice Guidelines. Multi-slice CT is a technical advance over spiral CT, and uses multiple rows of detector arrays to rapidly obtain multiple slices with one pass. ; American College of Physicians. Curr Atheroscler Rep. 2004;6(1):20-26. 2010;140(2):249-252. (Abbara et al, 2016). multiple detectors along the gantry, but it has only one row, i.e. 1999;3(18):i-iv, 1-118. The critical issue that defines the utility (or lack thereof) of ultrafast CT is its prognostic value. Technology Overview No. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. They enrolled patients presenting with symptoms suggestive of an ACS at the ED of 5 community and 2 university hospitals in the Netherlands. Ultrafast CT is being investigated for this proposed use. The authors’ view is shared by Redberg and Shaw (2002) who stated that widespread use of EBCT is not recommended. 2007;298(3):317-323. Per-patient values for CTCA were 100 %, 98 %, 97 %, and 100 %, respectively (p < 0.05). Image quality was considered diagnostic in 97.6 % of examinations. CCTA also identified a high risk cohort of patients with extensive nonobstructive CAD in whom statin therapy was associated with a significant reduction in cardiovascular death and non-fatal MI (HR=0.18, p=0.011) (Hulten et al, 2014). Radiology. The AUCs for the prediction of both major coronary events and any coronary event were higher when the calcium score was added to the standard risk factors. Fig. Woodard PK, White RD, Abbara S, et al; Expert Panel on Cardiac Imaging. The addition of CCTA early in the evaluation of patients presenting acutely to the emergency department with chest pain has been extensively studied in prospective, multicenter trials. 2 Cone beam computed tomography (or CBCT, also referred to as C-arm CT, cone beam volume CT, flat panel CT or Digital Volume Tomography (DVT)) is a medical imaging technique consisting of X-ray computed tomography where the X-rays are divergent, forming a cone.. CBCT has become increasingly important in treatment planning and diagnosis in implant dentistry, ENT, orthopedics, and … Curzen NP, Nolan J, Zaman AG, et al. The CCTA allows for more precise risk stratification beyond simple epicardial stenosis for appropriately selecting patients who benefit from revascularization. 1994;89(1):285-290. A similar reduction in non-fatal MI was observed in the prospective, multicenter PROMISE trial, which randomized over 10,000 intermediate pre-test risk patients with stable chest pain symptoms to a strategy of functional testing or CCTA as the initial diagnostic evaluation. 2011;26(3):307-316. J Am Coll Cardiol. J Am Coll Cardiol. 2012;156(6):438-444. Radiology. Jiang B, Wang J, Lv X, Cai W. Dual-source CT versus single-source 64-section CT angiography for coronary artery disease: A meta-analysis. 2016;72(4):377-383. Ultrafast computed tomography as a diagnostic modality in the detection of coronary artery disease: A multicenter study. Am Heart J. Computed tomography coronary angiography has a high diagnostic accuracy for the detection of non-obstructive and obstructive CAD in high-risk asymptomatic patients with inconclusive or unfeasible stress test results. 2009;3(1):35-42. Jorgensen et al (2017) conducted an observational, non-randomized study to compare functional testing to CCTA in patients with stable coronary artery disease. Additionally, the opposite effect was observed in patients without high-risk CAD referred for revascularization compared with medical therapy (2.3% vs 1.0%, p=0.0138). In addition, several reports suggested the potential benefit of using CCTA for screening for SCA in asymptomatic diabetic patients, which might dramatically decrease the incidence of cardiovascular events. Left: Soft kernel smoothes the image. The prevalence of healthy eating (p=0.002) and lower rates of obesity (p=0.040) were also observed following CCTA when compared to functional testing (SCOT-HEART investigators, 2015). 1.5 Comparison of coronary computed tomography angiography-derived vs invasive fractional flow reserve assessment: Meta-analysis with subgroup evaluation of intermediate stenosis. Pletcher MJ, Tice JA, Pignone M, Browner WS. The specific adjustments are dependent on the scanner specifications (Abbara et al, 2016). 2010;121(22):2509-2543. In a prospective, multicenter trial of 500 patients randomized to hs-troponin based evaluation and disposition to CCTA, there was no difference in the primary endpoint of patients identified with significant CAD requiring revascularization. The authors found that scans were of diagnostic quality in 47 (94%) patients using the "best reconstruction" compared with 38 (76%) patients using quarter-scan reconstruction. Ma and colleagues (2010) examined the relationship between coronary calcium score (CCS) and angiographic stenosis on a patient-based or vessel-based analysis. MSAC Application 1105. Data from CACS (threshold for positive image: Agatston score 1/100/1,000) and CTCA were compared with CAG regarding the degree of CAD (non-obstructive/obstructive; less than/greater than or = 50 % lumen reduction). Medical Technology Guidance 32. Prognostic value of coronary calcification and angiographic stenoses in patients undergoing coronary angiography. The authors reviewed the PROMISE trial outcomes and noted that although the findings are insufficient to conclude the possibility of either harm or benefit from the use of CCTA, a particularly salient feature was that although catheterization was performed in more CCTA patients in the 90 days following noninvasive testing, the likelihood of nonsignificant CAD was significantly lower in the CCTA group (3.4% vs. 4.3%; p = 0.02). Prognostic value of coronary computed tomographic angiography in comparison with calcium scoring and clinical risk scores. Assessment Report. quality but increases the radiation dose to the patient as more positions are being radiated. The mean calcium score was 151 +/- 403 and the prevalence of obstructive CAD was 17 % (8 % 1-vessel and 10 % 2-vessel disease). CNR was consistently adequate in all groups but decreased for groups 2 and 3 in comparison to group 1 as well as for group 3 compared to group 2 (p = 0.001, respectively). Journal Metrics. 2004;164(12):1285-1292. Evidence-Based Medicine [CD-ROM]. Documentation of ischemia around the time of revascularization is important to the appropriate use criteria (AUC) for percutaneous coronary interventions (PCI). Each patient served as their own control. Non-cardiac and cancer death rates were not significantly different between patients with and without incidental findings. No major differences among racial and ethnic groups in the predictive value of calcium scores were detected. Health Technology Literature Review. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); February 2004. In MDCT, pitch is calculated by dividing the table movement by the entire beam width. Bethesda, MD: American College of Cardiology Foundation (ACCF); March 2002. Kim KJ, Choi SI, Lee MS, et al. Report IRR No. 2006;114:1761-1791. Additionally, in patients with nonobstructive CAD, those treated with statin therapy had a mortality reduction compared to those without atherosclerotic plaque on CCTA. 1996;94:928-931. Filtered Backprojection. The use of CCTA does seem to increase the rates of revascularization when compared to functional testing, both in the stable chest pain and ED population (Hulten, 2017). Helical multidetector row CT has some additional artifacts that are not seen in single detector row step-and-shoot CT. On the other hand, the significantly reduced scan time reduces motion artifact. Assessment of coronary artery disease by cardiac computed tomography. 1997;79:128-133. 2013;267(1):76-85. Change the fan beam angle and see how that affects the field of view. Helsinki, Finland: Duodecim Medical Publications Ltd.; September 13, 2004. Data in 2,800 consecutive symptomatic patients undergoing CCTA at tertiary hospital centers suggested that CAD burden, even in the absence of a severe stenosis by CCTA, resulted in intensification of primary prevention medical therapy by providers.