Congenital anomalies of coronary arteries: Diagnosis with 64 slice multidetector CT

Acute chest pain suggestive of acute coronary syndrome is a frequent complaint in the emergency department. Acute coronary syndromes include myocardial infarction and unstable angina. Being able to establish the diagnosis rapidly and accurately may be lifesaving. A cardiac workup is indicated in this subset of patients in the acute setting, even if there are no ischemic changes on electrocardiography. If the clinical examination and initial cardiac workup suggest that a patient is having myocardial ischemia, the patient will usually be urgently referred for invasive coronary angiography and revascularization. In stable patients without evidence of ST elevation and ongoing myocardial ischemia, an initially conservative approach is sometimes considered. Cardiac risk stratification of this subgroup of patients who are at low and intermediate risk for coronary artery disease is recommended before discharge, and imaging is necessary to exclude ischemia as an etiology. Noninvasive cardiac imaging modalities include chest radiography, single photon-emission CT myocardial perfusion imaging, echocardiography, multidetector CT, PET, and MRI. Noncardiac etiologies of chest pain include aortic dissection, aortic aneurysm, pulmonary embolism, pericardial disease, and lung parenchymal disease. Noninvasive cardiac imaging in patients who are at low and intermediate risk for coronary artery disease may improve confidence regarding the safety of discharge from the emergency department. In addition to risk stratification, noncoronary etiologies for chest pain can be established with imaging.

ACR Appropriateness Criteria® on Chest Pain, Suggestive of Acute Coronary Syndrome

Clinical evidence has emphasized the importance of coronary plaques’ characteristics, rather than lumen stenosis, for the outcome of cardiovascular events. Coronary computed tomographic angiography (CCTA) has a well-established role as a non-invasive tool for assessing plaques. The aim of this study was to compare clinical characteristics and CCTA-derived information of stable patients with non-severe plaques in predicting major adverse cardiac events (MACEs) during follow-up. We retrospectively selected 371 patients (64% male) who underwent CCTA in our center from March 2016 to January 2021 with Coronary Artery Disease—Reporting and Data System (CAD-RADS) 0 to 3. Of those, 198 patients (53% male) had CAD-RADS 0 to 1. Among them, 183 (49%) had normal pericoronary fat attenuation index (pFAI), while 15 (60% male) had pFAI ≥ 70.1 Hounsfield unit (HU). The remaining 173 patients (76% male) had CAD-RADS 2 to 3 and were divided into patients with at least one low attenuation plaque (LAP) and patients without LAPs (n-LAP). Compared to n-LAP, patients with LAPs had higher pFAI (p = 0.005) and had more plaques than patients with n-LAP. Presence of LAPs was significantly higher in elderly (p < 0.001), males (p < 0.001) and patients with traditional risk factors (hypertension p = 0.0001, hyperlipemia p = 0.0003, smoking p = 0.0003, diabetes p = <0.0001, familiarity p = 0.0007). Among patients with CAD-RADS 0 to 1, the ones with pFAI ≥ 70.1 HU were more often hyperlipidemic (p = 0.05) and smokers (p = 0.007). Follow-up (25,4 months, range: 17.6–39.2 months) demonstrated that LAP and pFAI ≥ 70.1 significantly and independently (p = 0.04) predisposed to outcomes (overall mortality and interventional procedures). There is an added value of CCTA-derived features in stratifying cardiovascular risk in low- to intermediate-risk patients with non-severe, non-calcified coronary plaques. This is of utmost clinical relevance as it is possible to identify a subset of patients with increased risk who need strengthening in therapeutic management and closer follow-up even in the absence of severe CAD. Further studies are needed to evaluate the effect of medical treatments on pericoronary inflammation and plaque composition.

/pdf/added-value-of-ccta-derived-features-to-predict-maces-in-1ge9x08b.pdf

Added Value of CCTA-Derived Features to Predict MACEs in Stable Patients Undergoing Coronary Computed Tomography

Free-form radiology reports associated with coronary computed tomography angiography (CCTA) include nuanced and complicated linguistics to report cardiovascular disease. Standardization and interpr...

Bridging the Gap between Structured and Free-form Radiology Reporting: A Case-study on Coronary CT Angiography

Zusammenfassung Die CT(Computertomographie)-Koronarangiographie (cCTA) ist bei Patienten mit niedriger und mittlerer Vortestwahrscheinlichkeit für eine koronare Herzkrankheit (KHK) eine sichere Möglichkeit zum nicht-invasiven Ausschluss signifikanter Koronarstenosen und ermöglicht darüber hinaus auch deren funktionelle und morphologische Beurteilung. Der Stellenwert der cCTA wurde durch die 2019 publizierte ESC(European Society of Cardiology)-Leitlinie zu Diagnose und Management des chronischen Koronarsyndroms gestärkt und hat dadurch eine erhebliche Aufwertung erfahren. Die Bestimmung des Agatston-Scores ist eine klinisch etablierte Methodik zur Quantifizierung des Koronarkalks und hat Einfluss auf die Einleitung einer medikamentösen Therapie. Durch Technologien wie die Einführung der EKG-kontrollierten Dosismodulation und der iterativen Bildrekonstruktion kann die cCTA mit hoher Bildqualität und niedriger Strahlendosis durchgeführt werden. Die alleinige anatomische Darstellung von Koronarstenosen wird derzeit um innovative Techniken wie die myokardiale CT-Perfusion oder CT-FFR (fraktionelle Flussreserve) erweitert, jedoch ist der klinische Stellenwert dieser Methoden noch nicht abschließend geklärt. Die cCTA könnte sich zu einem Weichensteller hinsichtlich der Indikationsstellung für eine invasive Koronardiagnostik/-intervention entwickeln. 

https://link.springer.com/content/pdf/10.1007/s00059-022-05098-7.pdf

Morphologische und funktionelle Diagnostik der koronaren Herzkrankheit mittels Computertomographie

Current strategies for the triage of patients who have chest pain but normal initial cardiac enzyme levels and nondiagnostic electrocardiograms do not permit efficient risk stratification. The potentially fatal consequences and high malpractice costs of missed acute coronary syndromes lead every year to the unnecessary hospital admission of about 2.8 million patients who present with acute chest pain in emergency departments in the United States. Most of these patients are at very low risk for an acute coronary syndrome. However, the standard clinical work-up does not provide information about the presence and extent of coronary artery disease. In most patients (80%‐94%) with an acute coronary syndrome, a significant coronary artery stenosis can be detected with selective coronary angiography. High levels of diagnostic accuracy also have been established for the detection of significant coronary artery stenosis with the use of 16- and 64-section multidetector computed tomography (CT) in patients with stable angina. Preliminary data indicate that multidetector CT also can help quantify and characterize coronary atherosclerotic plaque and that the CT findings are in good agreement with those at intravascular ultrasonography. Although multidetector CT provides accurate information about the presence of coronary artery disease, large blinded observational studies are warranted to identify CT characteristics with high accuracy for diagnosis of acute coronary syndromes. Such information would enable the conduct of randomized controlled trials to determine whether the detection of coronary stenosis and plaque with multidetector CT improves triage and reduces the costs or increases the cost-effectiveness of management of acute chest pain. © RSNA, 2006

https://pubs.rsna.org/doi/pdf/10.1148/rg.264055709

Cardiac CT in Emer- gency Department Patients with Acute Chest Pain 1

Cardiac CT in Emer- gency Department Patients with Acute

Clinical History A 45-year-old female with a history of hypertension, dyslipidemia and morbid obesity managed with gastric bypass resulting in 120 pound weight loss, presented to an outside hospital with chest pain and anterolateral ST-segment elevations on electrocardiogram. She was in her usual state of health until the day prior to presentation when she woke up with left chest, shoulder, and jaw pain associated with diaphoresis. Her chest pain spontaneously resolved in 30 minutes but recurred the next day. Emergent invasive coronary angiography (ICA) revealed a dual-left anterior descending (LAD) system with sluggish flow in the smaller, septal LAD, but no culprit vessel was apparent. The patient was presumed to have focal myocarditis involving the anterolateral wall.

Multimodality imaging to clarify an atypical presentation of branch vessel coronary occlusion

Longitudinal FDG-PET/CT Study Focal Arterial Inflammation Precedes Subsequent Calcification in the Same Location: A

/pdf/effective-reporting-in-cardiac-ct-angiography-improvement-28dat709dl.pdf

Effective Reporting in Cardiac CT Angiography: Improvement via Collaborative Peer Review

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