Future Directions for Computed Tomographic Coronary Angiography and Cardiac Computed Tomography

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US Cardiology, 2007;4(1):60-2

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Cardiac computed tomography (CT), and in particular computed tomographic coronary angiography (CTCA), stand poised to revolutionize the way in which cardiac pathology is diagnosed, and change the way in which decisions are made with regards to invasive treatment of cardiac disease. In particular, the diagnosis of coronary disease (the number one killer of patients in modern societies) will be strongly influenced in the coming years by this type of technology. However, there are many areas in cardiology and cardiovascular disease that will be influenced by this new technology.
For most cardiac patients, the central question relates to the presence or absence of coronary artery disease (CAD) (i.e. coronary atherosclerosis). For patients who have chest pain, the main question is whether or not that pain is a sign that there are significant flow-limiting blockages in the coronary arteries. For asymptomatic patients, the question is usually one of estimation of future risk of developing blockages or having a myocardial infarction (MI). Traditionally, it has been relatively easy to triage the patients with chest pain through a combination of clinical history, the physical exam, and utilizing stress testing. Strong suspicion for coronary disease based on symptoms would lead to invasive angiography. Likewise, a ‘high-risk’ stress test would indicate that angiography would be helpful. In patients with moderate pre-test probability, or in patients in whom a stress test is equivocal, CTCA provides an alternative route to choose from, rather than simply moving forward with invasive testing. In the asymptomatic patient, or low-risk patient, the estimation of future risk is much more difficult to define. Patients who are (by definition) asymptomatic tend to have more ‘false-positive’ stress tests. In a patient with risk factors for CAD, a positive stress test tends to lead to unnecessary invasive cardiac catheterizations. In this situation, it may be advantageous to forego stress testing in favor of CTCA in order to define the presence or absence of coronary plaque. In the asymptomatic patient, a negative CT coronary angiogram would reassure the patient, while the discovery of plaque allows the physician to concentrate on risk-factor modification with medications and does not usually lead to further testing (see Figure 1). This particular aspect of CTCA makes it a likely candidate as the ‘test of choice’ in patients whose occupation means it is important to know whether they have high-risk anatomy.1

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