Produção Nacional
Revisado por pares
Coronary Computed Tomography Angiography in the Evaluation of Chest Pain of Suspected Cardiac Origin
2016; Lippincott Williams & Wilkins; Volume: 133; Issue: 20 Linguagem: Inglês
10.1161/circulationaha.116.017593
ISSN1524-4539
AutoresMárcio Sommer Bittencourt, Edward Hulten, Vikas Veeranna, Ron Blankstein,
Tópico(s)Advanced MRI Techniques and Applications
ResumoHomeCirculationVol. 133, No. 20Coronary Computed Tomography Angiography in the Evaluation of Chest Pain of Suspected Cardiac Origin Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessResearch ArticlePDF/EPUBCoronary Computed Tomography Angiography in the Evaluation of Chest Pain of Suspected Cardiac Origin Marcio Sommer Bittencourt, MD, MPH, PhD Edward A. Hulten, MD, MPH Vikas Veeranna, and MD Ron BlanksteinMD Marcio Sommer BittencourtMarcio Sommer Bittencourt From Center for Clinical and Epidemiological Research, University Hospital & São Paulo State Cancer Institute, University of São Paulo School of Medicine, Brazil (M.S.B.);Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil (M.S.B.);Cardiology Service, Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, MD (E.A.H.); andCardiovascular Imaging Program, Departments of Medicine and Radiology; Brigham and Women's Hospital; Harvard Medical School, Boston, MA (V.V., R.B.). , Edward A. HultenEdward A. Hulten From Center for Clinical and Epidemiological Research, University Hospital & São Paulo State Cancer Institute, University of São Paulo School of Medicine, Brazil (M.S.B.);Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil (M.S.B.);Cardiology Service, Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, MD (E.A.H.); andCardiovascular Imaging Program, Departments of Medicine and Radiology; Brigham and Women's Hospital; Harvard Medical School, Boston, MA (V.V., R.B.). , Vikas VeerannaVikas Veeranna From Center for Clinical and Epidemiological Research, University Hospital & São Paulo State Cancer Institute, University of São Paulo School of Medicine, Brazil (M.S.B.);Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil (M.S.B.);Cardiology Service, Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, MD (E.A.H.); andCardiovascular Imaging Program, Departments of Medicine and Radiology; Brigham and Women's Hospital; Harvard Medical School, Boston, MA (V.V., R.B.). , and Ron BlanksteinRon Blankstein From Center for Clinical and Epidemiological Research, University Hospital & São Paulo State Cancer Institute, University of São Paulo School of Medicine, Brazil (M.S.B.);Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil (M.S.B.);Cardiology Service, Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, MD (E.A.H.); andCardiovascular Imaging Program, Departments of Medicine and Radiology; Brigham and Women's Hospital; Harvard Medical School, Boston, MA (V.V., R.B.). Originally published17 May 2016https://doi.org/10.1161/CIRCULATIONAHA.116.017593Circulation. 2016;133:1963–1968Case Presentation: A 54-year-old man with history of dyslipidemia is evaluated in the outpatient setting for several months of intermittent atypical chest pain. He is not on any medical therapy. His resting heart rate in the office is 70 beats per minute. His outpatient cardiologist is wondering if coronary computed tomography angiography may be useful for further evaluation.Test SelectionBecause of the high prevalence of coronary artery disease (CAD) and the lack of specific diagnostic clinical signs and symptoms, current guidelines recommend a Bayesian approach, using pretest probability scores for evaluating patients with stable chest pain of suspected cardiac origin.1–3For individuals with an intermediate pretest probability of obstructive CAD, a noninvasive test is usually recommended. Current test options have become increasingly complex and range from anatomic evaluation via coronary computed tomography angiography (CTA) to functional imaging tests to evaluate ischemia, including exercise treadmill testing with or without nuclear (positron emission tomography or single-photon emission computed tomography) or echocardiographic imaging. In patients who are unable to exercise, pharmacological testing with imaging can be performed. Test selection often varies according to local availability and expertise, and patient characteristics, as well. Although both coronary CTA and various functional testing strategies are considered appropriate for the initial evaluation of patients with intermediate pretest probability of obstructive CAD, selecting the most optimal testing strategy can be challenging. Table 1 lists various patient factors to consider when selecting optimal candidates for coronary CTA who are more likely to have diagnostic quality images, and a clinical benefit from the examination, as well.Table 1. Patient Factors to Consider When Selecting Optimal Candidates for Coronary CTANo previous CADIntermediate probabilityRegular heart rhythmAble to achieve low heart rate (eg, <65 bpm) with medicationsAge <70 yBMI 30 mL·kg–1·1.73m–2No contrast allergyBMI indicates body mass index; CAD, coronary artery disease; and CTA, computed tomography angiography.Diagnostic and Prognostic Role of Coronary CTAMultiple studies have established the high accuracy of coronary CTA to diagnose obstructive CAD in comparison with invasive coronary angiography (ICA).4 A recent meta-analysis demonstrated that coronary CTA has a higher sensitivity and specificity in comparison with either exercise stress test (sensitivity, 98% versus 67%; specificity, 82% versus 46%) or single-photon emission computed tomography (sensitivity, 99% versus 73%; specificity, 71% versus 48%).5 Notably, in the Coronary Artery Evaluation Using 64-Row Multidetector Computed Tomography Angiography (CORE-64) study, coronary CTA and ICA had a similar ability to predict the indication of revascularization within 30 days, suggesting that coronary CTA is also able to identify patients who are likely to require interventional procedures.6Beyond its diagnostic value, data from coronary CTA independently predict the risk of incident myocardial infarction, cardiovascular death, all-cause death, unstable angina, and urgent revascularization at a follow-up, ranging from 1 to 4 years.7 In addition to evaluating the burden of obstructive CAD,8,9 patients with extensive (>4 segments) nonobstructive disease have adverse prognoses.9,10 In fact, individuals with extensive multivessel nonobstructive disease detected either noninvasively by CTA9 or by ICA11 may have event rates similar to individuals who have single-vessel obstructive CAD.Realizing the fundamental limitations of focusing on stenosis, and the fact that some coronary events may occur at the site of previously nonobstructive lesions, various CTA studies have identified high-risk plaque characteristics associated with an increased risk of incident events, namely, low-attenuation plaques (<30 Hounsfield units), positive remodeling, spotty calcifications, and the napkin-ring sign.12 The risk portended by these features appears to increase when a single lesion has multiple such characteristics.13 In addition, lesions that demonstrate these characteristics are more likely to be flow limiting when assessed by invasive fractional flow reserve.14Patient Management Based on Coronary CTA ResultsWith coronary CTA, clinicians can confidently rule out CAD among approximately one-third of clinically referred patients who demonstrate normal coronary arteries with no evidence of plaque or stenosis. Such patients do not require any additional testing or treatment for CAD (Table 2).15 Among one-third to one-half, coronary CTA may only demonstrate nonobstructive CAD (ie, 4 coronary segments) is associated with a lower rate of cardiovascular death or myocardial infarction. A study by Chow et al17 corroborated the benefit of statins among individuals with nonobstructive CAD. Although randomized, controlled trials have not been performed, individuals with nonobstructive plaque, particularly those with more extensive disease,9 have increased risk and should be considered for aggressive primary prevention strategies, including moderate- to high-intensity statins.Table 2. Proposed Patient Management Considerations According to Coronary CTA FindingsCoronary CTA FindingsSuggested Patient ManagementNormal or minimal plaqueNo further testing requiredMedical management – as per primary prevention guidelinesExtensive nonobstructive diseaseLifestyle interventions, statins, and aspirin, unless contraindicationsAnti-ischemic pharmacological treatments to reduce symptoms usually not needed (consider microvascular disease)Non–high-risk obstructive diseaseLifestyle interventions, statins, and aspirin, unless contraindicationsAnti-ischemic pharmacological treatments to reduce symptomsIntervention restricted to selected cases, mostly if extensive ischemia or refractory symptomsHigh-risk obstructive diseaseLifestyle interventions, statins, and aspirin, unless contraindicationsAnti-ischemic pharmacological treatments to reduce symptomsIntervention should be considered, particularly if extensive ischemia or refractory symptomsCTA indicates computed tomography angiography.Download figureDownload PowerPointFigure 1. Coronary CTA images of case. Overall, this case shows a moderate amount of coronary plaque. There is mild (25%–50%) stenosis of the mid-RCA and minimal stenosis (0%–25%), as well, of the proximal LAD and the proximal left circumflex (LCx). The segment involvement score was 5. CTA indicates computed tomography angiography; LAD, left anterior descending artery; and RCA, right coronary artery.If obstructive CAD is documented on coronary CTA, the patient should be treated according to current guidelines for stable CAD (Table 2).2 ICA is not recommended for all individuals with obstructive CAD on coronary CTA. American College of Cardiology/American Heart Association guidelines on stable CAD18 state that ICA should be reserved for individuals with unacceptable ischemic symptoms, despite optimal medical therapy, or when noninvasive imaging tests indicate severe disease likely to benefit from percutaneous or surgical revascularization. Some high-risk features detected on coronary CTA are presented in Table 3. Although current evidence suggests that coronary CTA may identify plaque characteristics associated with increased risk of events irrespective of obstructive disease,12,13 no study to date has tested the value of interventions based solely on those findings.Table 3. High-Risk Features on Coronary CTAEvaluation of stenosisMultivessel obstructive CAD (≥70% stenosis)Left main stenosis (≥50% stenosis)Evaluation of plaque characteristicsLow-attenuation plaques ( 3 mm)\proximal stents when excellent image quality can be obtained.23Patients with previous coronary artery bypass graft may be evaluated for graft patency by CTA, because graft vessels are larger and less mobile than native coronary arteries.23 However, care should be taken with the interpretation of disease in native vessels of these patients, because most post–coronary artery bypass graft patients have heavily calcified vessels, which reduce the accuracy of CTA.Future StudiesDespite the well-established high negative predictive value of CTA, various emerging techniques seek to improve the specificity of diagnosing flow-limiting CAD, thereby avoiding inappropriate referrals to catheterization.24 Initial studies using hybrid nuclear perfusion with CTA were time consuming and had unproven benefit for routine use. However, selective use of such functional testing following abnormal CTA remains clinically useful in many scenarios. In selected patients, pharmacological stress perfusion computerized tomography may be added to rest CTA. This evolving technique is not yet widely available, and, similar to nuclear perfusion imaging, results in a higher radiation exposure.Rather than performing a separate functional assessment as above, another technique that has evolved derives functional information from the CTA data. Some studies measure the transluminal attenuation gradient across the coronary artery, based on the premise that a physiological stenosis reduces contrast to the distal artery. A more sophisticated approach is computerized tomography fractional flow reserve (FFRCT), which uses computational flow modeling to simulate hyperemic flow based on myocardial and coronary anatomy acquired during routine CTA. The recently reported Prospective Longitudinal Trial of FFRct: Outcome and Resource Impacts (PLATFORM) study21 evaluated patients with planned ICA and demonstrated an effective gatekeeper role of FFRCT, with a 61% reduction in the rate of ICA in the FFRCT arm. The results of this study reinforce the notion that the increased use of noninvasive testing before invasive angiography may result in a significant reduction in the use of coronary angiography and revascularization. FFRCT is currently limited by its cost, its complexity necessitating off-site processing, and time. Although initial studies regarding FFRCT are promising, more data on how this test performs in routine clinical use are required before wider adoption.With respect to radiation dose, consistent doses <5 mSv are now routinely achieved at many centers, reflecting ≈70% to 80% dose reduction that has occurred over the past decade.Case ResolutionThe patient had an intermediate pretest probability of having obstructive CAD. He underwent a coronary CTA (Figure 1) which demonstrated a moderate amount of nonobstructive plaque (<50%) stenosis extending across 5 segments and involving all 3 coronary arteries. He was subsequently treated with statin therapy, and lifestyle changes, as well, for the prevention of coronary heart disease events.ConclusionCoronary CTA is a useful test for the initial investigation of chest pain of suspected cardiac origin among patients with intermediate pretest probability, and those with inconclusive previous stress testing, as well. Beyond the exclusion of significant disease, coronary CTA provides detailed information on the presence, extent, and severity of CAD. In light of the prognostic information provided by these measures, and the results of recent trials, as well, CTA results should be incorporated in patient management decision making, including guiding the need for pharmacological therapy, and defining candidates for additional noninvasive or invasive testing, as well.DisclosuresThe opinions and assertions contained herein are the authors' alone and do not represent the views of the Walter Reed National Military Medical Center, the US Army, or the Department of Defense.FootnotesCorrespondence to Ron Blankstein, MD, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115. E-mail [email protected]References1. 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May 17, 2016Vol 133, Issue 20Article InformationMetrics Download: 946 © 2016 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.116.017593PMID: 27185023 Originally publishedMay 17, 2016 Keywordsprevention & controldiagnostic techniques, cardiovascularcardiovascular diseasescardiac imaging techniquesPDF download SubjectsComputerized Tomography (CT)PrognosisCardiovascular DiseaseImagingSecondary Prevention
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