Pim J. de Feyter

MSCT Coronary Angiography is a fast developing non-invasive diagnostic technique that can detect a coronary stenosis. The detection of a coronary stenosis is hampered by limited image quality and by motion artefacts and extensive calcifications. However, MSCT-coronary angiography is highly reliable to rule out coronary stenosis. The role of MSCT-coronary angiography in the diagnostic work-up of coronary artery disease needs further research.

This editorial refers to ‘All-cause mortality benefit of coronary revascularization vs. medical therapy in patients without known coronary artery disease undergoing computed tomographic angiography: results from CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter Registry)’†, by J.K. Min et al., on page 3088

Purpose To investigate the predictive value of 64-slice computed tomography coronary angiography (CTCA) for major adverse cardiac events (MACEs) in patients with suspected or known coronary artery disease (CAD). Materials and Methods Seven hundred and sixty-seven consecutive patients (496 men, age 62±11 y) with suspected or known heart disease referred to an outpatient clinic underwent 64-slice CTCA. The patients were followed for the occurrence of MACE (ie, cardiac death, nonfatal myocardial infarction, unstable angina). Results Eleven thousand five hundred and sixty-four coronary segments were assessed. Of these, 178 (1.5%) were not assessable because of insufficient image quality. Overall, CTCA revealed the absence of CAD in 219 (28.5%) patients, nonobstructive CAD (coronary plaque ≤50%) in 282 (36.8%) patients, and obstructive CAD in 266 (34.7%) patients. A total of 21 major cardiac events (4 cardiac deaths, 12 myocardial infarctions, and 5 unstable angina) occurred during a mean follow-up of 20 months. One noncardiac death occurred. Seventeen events occurred in the group of patients with obstructive CAD, and 4 events occurred in the group with nonobstructive CAD. The event rate was 0% among patients with normal coronary arteries at CTCA. In multivariate analysis, the presence of obstructive CAD and diabetes were the only independent predictors of MACE. Conclusions Coronary plaque evaluation by CTCA provides an independent prognostic value for the prediction of MACE. Patients with normal CTCA findings have an excellent prognosis at follow-up.

To determine and compare the prognostic value of cardiac computed tomographic (CT) angiography, coronary calcium scoring, and exercise electrocardiography (ECG) in patients with chest pain who are suspected of having coronary artery disease (CAD). This study complied with the Declaration of Helsinki, and the local ethics committee approved the study. Patients (n = 471) without known CAD underwent exercise ECG and dual-source CT at a rapid assessment outpatient chest pain clinic. Coronary calcification and the presence of 50% or greater coronary stenosis (in one or more vessels) were assessed with CT. Exercise ECG results were classified as normal, ischemic, or nondiagnostic. The primary outcome was a major adverse cardiac event (MACE), defined as cardiac death, nonfatal myocardial infarction, or unstable angina requiring hospitalization and revascularization beyond 6 months. Univariable and multivariable Cox regression analysis was used to determine the prognostic values, while clinical impact was assessed with the net reclassification improvement metric. Follow-up was completed for 424 (90%) patients; the mean duration of follow-up was 2.6 years. A total of 44 MACEs occurred in 30 patients. Four of the MACEs were cardiac deaths and six were nonfatal myocardial infarctions. The presence of coronary calcification (hazard ratio [HR], 8.22 [95% confidence interval {CI}: 1.96, 34.51]), obstructive CAD (HR, 6.22 [95% CI: 2.77, 13.99]), and nondiagnostic stress test results (HR, 3.00 [95% CI: 1.26, 7.14]) were univariable predictors of MACEs. In the multivariable model, CT angiography findings (HR, 5.0 [95% CI: 1.7, 14.5]) and nondiagnostic exercise ECG results (HR, 2.9 [95% CI: 1.2, 7.0]) remained independent predictors of MACEs. CT angiography findings showed incremental value beyond clinical predictors and stress testing (global χ(2), 37.7 vs 13.7; P < .001), whereas coronary calcium scores did not have further incremental value (global χ(2), 38.2 vs 37.7; P = .40). CT angiography findings are a strong predictor of future adverse events, showing incremental value over clinical predictors, stress testing, and coronary calcium scores. http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.11110744/-/DC1.

This editorial refers to ‘Coronary CT angiography characteristics of culprit lesions in acute coronary syndromes not related to plaque rupture as defined by optical coherence tomography and angioscopy’^†, by Y. Ozaki et al., on page 2814

The author has no funding, financial relationships, or conflicts of interest to disclose.

Contrast-enhanced CT coronary angiography (CTCA) has evolved as a reliable alternative imaging modality technique and may be the preferred initial diagnostic test in patients with stable angina with intermediate pre-test probability of CAD. However, because CTCA is moderately predictive for indicating the functional significance of a lesion, the combination of anatomic and functional imaging will become increasingly important. The technology will continue to improve with better spatial and temporal resolution at low radiation exposure, and CTCA may eventually replace invasive coronary angiography. The establishment of the precise role of CTCA in the diagnosis and management of patients with stable angina requires high-quality randomised study designs with clinical outcomes as a primary outcome.