- Advances in cardiac CT contrast injection and acquisition protocols
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- The role of cardiac imaging in clinical practice
- The role of cardiac imaging in clinical practice - NPS MedicineWise
All told, 25 percent of these patients were given a different diagnosis after receiving this test compared to just 1 percent of patients who received standard care alone.
The clarification of diagnoses resulted in two significant secondary endpoint measures. Plans for subsequent testing were altered in 15 percent of patients receiving a CT scan compared with just 1 percent of patients in the control group. About 23 percent of patients receiving the CT scan had a change in treatment to correspond with the new diagnosis versus only 5 percent in the control group.
Advances in cardiac CT contrast injection and acquisition protocols
There was no difference between the groups in either symptom severity at six weeks or subsequent hospitalizations. Newby was surprised that after just 20 months of follow-up, there appeared to be a 38 percent reduction in the number of heart attacks in patients who received a CT scan compared with the control group 26 versus 42, respectively , suggesting that clarification of diagnosis and treatment plans may lower the risk of future heart attacks. However, the rate of heart attack in both groups was low and failed to reach statistical significance.
Researchers caution that further follow-up data are needed before any definitive conclusions can be drawn regarding the effect of CT scans on cardiovascular outcomes. Still, they said the data suggest that CT scans significantly clarify the diagnosis and lead to more timely focused treatments, which may in turn affect cardiovascular outcomes. Interestingly, while the use of CT scans appeared to boost the certainty of the diagnosis of angina due to coronary artery disease, the overall frequency of this diagnosis was reduced.
Newby explained this occurred because they identified more incorrect diagnoses of angina due to coronary artery disease than previously unrecognized cases of this condition. Coronary artery disease remains the leading cause of death for men and women in the United States. It occurs when plaque builds up in the arteries that supply blood to the heart.
Angina is a symptom of coronary artery disease and is often described as squeezing, pressure, heaviness or tightness in the chest.
Chest pain due to coronary artery disease affects an estimated 9. News Cardiovascular Clinical Studies July 10, The U. News Cardiovascular Clinical Studies July 03, News Cardiovascular Clinical Studies November 19, Food and Drug Administration FDA is proposing to add an exception to informed consent requirements for Feature Cardiovascular Clinical Studies May 14, News Cardiovascular Clinical Studies May 14, May 14, — The opioid drug epidemic is impacting cardiology, with a new study finding the number of patients hosp. News Cardiovascular Clinical Studies March 15, The anatomic extent of disease on coronary CTA has also been demonstrated to have prognostic implications.
In addition to detecting both obstructive and nonobstructive disease and providing an indication of plaque burden on both a per-vessel and per-patient level, coronary CTA provides the opportunity for detailed characterization of plaque morphology.
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The detection of CT-defined high-risk plaque features such as positive remodeling and low attenuation plaque the latter a CT-surrogate for lipid core , can aid prediction of future acute coronary events. In a more recent study, the same authors reported that plaque progression in terms of volume and the development of high-risk plaque features from non-high-risk plaque led to an increased risk of acute coronary syndromes.
This suggests that serial changes in disease features and composition may help to refine patient risk. Recent development of sophisticated semi-automated software capable of detailed objective plaque characterisation may facilitate the application of serial coronary CTA in this role Figure 2. Regarding quantification of plaque features and plaque burden, adverse plaque features detected by coronary CTA also provide incremental information over stenosis assessment in predicting abnormal fractional flow reserve in the catheterization laboratory 10,11 and in predicting myocardial ischemia by positron emission tomography.
Potentially, the presence of plaques with high-risk characteristics could add to stenosis assessment in guiding referral for invasive coronary angiography. Despite its high diagnostic accuracy in determining the presence of obstructive disease, a limitation of coronary CTA is a reduced accuracy in the grading of intermediate stenoses, especially in the presence of dense calcification.
Further, large randomized trials have shown that revascularization based on anatomic stenosis alone does not improve outcomes. CT perfusion can assess myocardial perfusion by measuring CT contrast enhancement before and after pharmacological stress. The CORE Coronary Artery Evaluation Using Row Multidetector CT Angiography study investigated the diagnostic accuracy of coronary CTA with CT perfusion in predicting hemodynamically significant coronary stenosis, using invasive coronary angiography and single photon emission computed tomography as gold standard.
The results demonstrated the high accuracy of this approach, with an improved prediction of hemodynamically significant CAD when CT perfusion was added to CTA alone. The principal approach developed to date for this assessment applies computational fluid dynamics to model and predict fractional flow reserve from conventionally acquired CTA. This method is applied to standardly acquired coronary CTA without need for additional radiation, medication, or image acquisition. The integration of FFR CT measurements, however, may help direct patients more likely to require revascularization to the catheterization laboratory.
The role of cardiac imaging in clinical practice
Unlike CT perfusion, FFR CT has not yet been demonstrated to be effective in vessels with coronary stents or in bypassed coronary vessels. Dense coronary calcification, which results difficulty in assessing stenosis, may be problematic. A further limitation is the relatively high cost of the procedure. In the stable symptomatic population, the role of coronary CT angiography is growing as an initial test of choice in symptomatic patients with suspected CAD.
The recent The National Institute for Health and Care Excellence guidelines, published in the United Kingdom, have recommended offering coronary CT angiography as a first-line test in patients with suspected stable angina. This recommendation has placed coronary CTA at the forefront of diagnostic imaging in this selected group of patients, ahead of any functional imaging strategy. Providing strong evidence in support of this recommendation were the results of the recent SCOT-HEART Scottish Computed Tomography of the HEART study, which demonstrated that the adoption of coronary CTA in addition to standard care led to improved clarity of the diagnosis of angina secondary to coronary heart disease, changes in therapy, and more appropriate referrals for invasive angiography.
The role of cardiac imaging in clinical practice - NPS MedicineWise
A landmark analysis of the trial demonstrated that there was a halving of fatal and non-fatal myocardial infarction in the CTA arm. The above considerations suggest that coronary CTA is well-positioned to become a gatekeeper to the catheterization laboratory; however, its application in this regard is not always simple. The influence of coronary CTA on subsequent management is illustrated in case examples in Figure 3. When the findings are completely normal, treatment and subsequent testing is clear. The identification of nonobstructive CAD can prompt the use of aggressive evidence-based therapies, which is likely to ultimately improve long-term outcomes.
When proximal high-grade stenosis is found, referral for invasive coronary angiography would be indicated Figures