Review articleThe Expanding Role of Computed Tomography in the Assessment of Coronary Artery Disease and Cardiac Anatomy
Section snippets
Coronary Artery Calcium Score
Coronary atherosclerosis typically does not cause symptoms until there is at least a 70% vessel stenosis. Therefore, we cannot rely on symptoms to identify patients with early or mild atherosclerosis. Unfortunately, myocardial infarctions or sudden deaths are often the initial manifestations of CAD. The majority of acute coronary syndromes (ACS) are caused by nonobstructive coronary lesions. Therefore, early identification of individuals with asymptomatic atherosclerosis can allow targeted
Technical Aspects
Cardiac CT is performed with electrocardiographic gating so that images can be obtained during diastole, when cardiac motion is minimal (Figure 2). Image quality is significantly improved if the heart rate is less than 65 beats/min during the scan. Pretreatment with β-blocking agents is frequently used for this purpose. In the absence of contraindications, sublingual nitroglycerine should be given prior to scanning to produce maximal coronary dilation. In contrast to all forms of stress
Radiation Exposure and Biosafety
Both measurement of calcium score and CTA expose the patients to ionizing radiation. In the recent past, the effective dose of CTA was approximately 12 mSv (range, 2–30 mSv) depending on equipment and technique (Einstein et al., 2007, Hausleiter et al., 2009). This effective radiation dose is similar or less than that incurred during a Tc99 nuclear stress test (Einstein et al. 2007).
Currently, institutions using prospective triggering or tube current modulation in conjunction with reduction in
Appropriateness Criteria and Guidelines for CT
Guidelines for the use of cardiac CT have recently been published (Greenland et al. 2010). According to these guidelines, it is reasonable to measure CAC for cardiovascular risk assessment in asymptomatic adults at an intermediate risk (class IIa). In contrast, patients at low risk should not undergo CAC measurement for screening (class III). Appropriateness criteria for coronary CTA were recently updated (Taylor et al. 2010). According to these criteria, it is appropriate to perform CTA for
Summary
CT is quickly evolving into a remarkably useful imaging tool for evaluating the burden of atherosclerosis and the severity of CAD. Although still new and somewhat controversial, it seems likely that the ability to noninvasively and rapidly visualize the coronary arteries and the heart will make CT a first-line test in the assessment of many patients with known or suspected heart disease. Understanding the strengths and limitations of this new technology will allow clinicians to utilize CT in a
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