Jill E. Jacobs

Patient management after noninvasive cardiac imaging: Results from SPARC (Study of myocardial perfusion and coronary anatomy imaging roles in coronary artery disease)

OBJECTIVES This study examined short-term cardiac catheterization rates and medication changes after cardiac imaging. BACKGROUND Noninvasive cardiac imaging is widely used in coronary artery disease, but its effects on subsequent patient management are unclear. METHODS We assessed the 90-day post-test rates of catheterization and medication changes in a prospective registry of 1,703 patients without a documented history of coronary artery disease and an intermediate to high likelihood of coronary artery disease undergoing cardiac single-photon emission computed tomography, positron emission tomography, or 64-slice coronary computed tomography angiography. RESULTS Baseline medication use was relatively infrequent. At 90 days, 9.6% of patients underwent catheterization. The rates of catheterization and medication changes increased in proportion to test abnormality findings. Among patients with the most severe test result findings, 38% to 61% were not referred to catheterization, 20% to 30% were not receiving aspirin, 35% to 44% were not receiving a beta-blocker, and 20% to 25% were not receiving a lipid-lowering agent at 90 days after the index test. Risk-adjusted analyses revealed that compared with stress single-photon emission computed tomography or positron emission tomography, changes in aspirin and lipid-lowering agent use was greater after computed tomography angiography, as was the 90-day catheterization referral rate in the setting of normal/nonobstructive and mildly abnormal test results. CONCLUSIONS Overall, noninvasive testing had only a modest impact on clinical management of patients referred for clinical testing. Although post-imaging use of cardiac catheterization and medical therapy increased in proportion to the degree of abnormality findings, the frequency of catheterization and medication change suggests possible undertreatment of higher risk patients. Patients were more likely to undergo cardiac catheterization after computed tomography angiography than after single-photon emission computed tomography or positron emission tomography after normal/nonobstructive and mildly abnormal study findings. (Study of Perfusion and Anatomys Role in Coronary Artery [CAD] [SPARC]; NCT00321399).

2013 ACCF/ACR/ASE/ASNC/SCCT/SCMR appropriate utilization of cardiovascular imaging in heart failure: A joint report of the American college of radiology appropriateness criteria committee and the American college of cardiology foundation appropriate use criteria task force

Peter Alagona, MD[⁎][1] Gerard Aurigemma, MD[‡][2] Javed Butler, MD, MPH[§][3] Don Casey, MD, MPH, MBA[∥][4] Ricardo Cury, MD[#][5] Scott Flamm, MD[¶][6] Tim Gardner, MD[⁎⁎][7] Rajesh Krishnamurthy, MD[††][8] Joseph Messer, MD[⁎][1] Michael W. Rich, MD[‡‡][9] Henry

Dual-Source Versus Single-Source Cardiac CT Angiography : Comparison of Diagnostic Image Quality

OBJECTIVE Dual-source CT improves temporal resolution, and theoretically improves the diagnostic image quality of coronary artery examinations without requiring preexamination beta-blockade. The purpose of our study was to show the improved diagnostic image quality of dual-source CT compared with single-source CT despite the absence of preexamination beta-blockade in the dual-source CT group. MATERIALS AND METHODS We performed a retrospective analysis of consecutive patients who underwent coronary artery evaluation with either single-source CT or dual-source CT at our institution between February 2005 and October 2006. Examination reports were analyzed for the presence of image artifacts, and image quality was graded on a 3-point scale (no, mild, or severe artifact). Type of artifact (motion, calcium, quantum mottle) was also noted. RESULTS Examinations (339 single-source CT and 126 dual-source CT) of 465 patients were analyzed. Artifact was reported in 39.8% of examinations using single-source CT and in 29.4% of examinations using dual-source CT (p < 0.05). The number of examinations with motion artifact was significantly higher with single-source CT than with dual-source CT (15.9% vs 4.8%; p < 0.001) despite significantly higher heart rates in the dual-source CT group (59.4 +/- 8.4 vs 68.6 +/- 14.6 beats per minute; p < 0.001). No patients in the dual-source CT group received preexamination beta-blockade compared with 81% of patients in the single-source CT group. The presence of severe (nondiagnostic) calcium artifact was also significantly reduced in the dual-source CT group (13.0% vs 3.2%; p < 0.001). CONCLUSION Dual-source CT provides significantly better diagnostic image quality than single-source CT despite higher heart rates in the dual-source CT group. These findings support the use of dual-source CT for coronary artery imaging without the need for preexamination beta-blockade.

Ventricular diverticula on cardiac CT: more common than previously thought.

OBJECTIVE We describe the findings of contrast-enhanced gated cardiac CT in 15 patients with 23 incidentally noted cardiac ventricular diverticula. CONCLUSION Cardiac diverticula most commonly occur in the left ventricle but have been reported to occur in all chambers of the heart. Despite reports of their rare occurrence, cardiac ventricular diverticula are fairly common findings in patients undergoing cardiac MDCT angiography.

Coronary CT angiography with 64-MDCT: assessment of vessel visibility.

OBJECTIVE The objective of our study was to evaluate the image quality of 64-MDCT for coronary angiography. SUBJECTS AND METHODS Fifty consecutive CT coronary angiograms obtained on a 64-MDCT scanner were independently reviewed by two reviewers. Segments were scored as showing no motion (score of 1), minimal motion (2), moderate motion (3), respiratory motion (4), or vessel blurring (5). Opacification was graded as good (score of 1) or limited (2). Segments < 2 mm were graded as well seen; or as poorly seen or not seen. The scores for motion artifact, opacification, and visibility were combined for overall vessel assessment. Segments with a motion score of 1 or 2 that had good opacification and were well seen were judged to be assessable. RESULTS A total of 714 segments were analyzed in 50 patients. Seven hundred segments were assessed in all patients (segments 1-3, 11-20, 4, or 27), and a ramus intermedius segment was evaluated in 14 patients. Combining the scores for both reviewers, the average motion score was 1 for 619 segments (86.7%), the average motion score for all segments in an individual patient was 1.14 (range, 1-3.35), and the average opacification score for all segments in a patient was 1.02 (range, 1-1.38). A total of 374 segments were less than 2 mm in diameter. Combining the scores for both reviewers, an average of 36 segments (5.0% of 714) could not be identified by the reviewers, 319.5 segments (85.4%) were well seen, and 18.5 segments (4.9%) were poorly seen. Overall, an average of 637 segments (89.2%) were judged assessable by the reviewers. On a per-patient basis, 10 or more vessel segments were judged assessable in 47 patients (94%). CONCLUSION On 64-MDCT, 89% of coronary artery segments are assessable. Ten or more vessel segments are assessable in 94% of patients.

ACC/AHA/ASE/ASNC/HRS/IAC/Mended Hearts/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR/SNMMI 2014 health policy statement on use of noninvasive cardiovascular imaging: a report of the American College of Cardiology Clinical Quality Committee.

Joseph P. Drozda, Jr, MD, FACC, Chair Deepak L. Bhatt, MD, MPH, FACC Joseph G. Cacchione, MD, FACC Blair D. Erb, Jr, MD, FACC Thomas A. Haffey, DO, FACC Robert A. Harrington, MD, FACC[†††][1] Jerry D. Kennett, MD, MACC Richard J. Kovacs, MD, FACC Harlan M. Krumholz, MD, SM, FACC

CT of inflammatory disease of the colon

CT plays an important role in the evaluation of patients with suspected colonic inflammation. High-resolution, thin-section imaging of the gastrointestinal tract allows assessment of both the intraluminal and extraluminal components of colonic disease, thereby enabling radiologists to detect and stage colonic pathology accurately. In addition, CT can be used to guide percutaneous drainage of abscess collections, often obviating the need for surgical intervention. This article describes CT techniques for diagnosing inflammatory diseases of the colon as well as the typical CT appearances.

Prospective-triggered sequential dual-source end-systolic coronary CT angiography for patients with atrial fibrillation: A feasibility study

BACKGROUND Obtaining diagnostic coronary CT angiography with low radiation exposure in patients with irregular heart rhythms such as atrial fibrillation (AF) remains challenging. OBJECTIVE We evaluated image quality and inter-reader variability with the use of prospective electrocardiographic (ECG)-triggered sequential dual-source acquisition at end systole for coronary artery disease (CAD) evaluation in patients with AF. METHODS Thirty consecutive patients with AF who underwent prospective ECG-triggered sequential dual-source acquisition were evaluated. Images were reconstructed every 50 milliseconds from 250 to 400 milliseconds after the R wave. Two independent, blinded readers evaluated the coronaries for image quality on a 5-point scale (worst to best) and stenosis on 5-point semiquantitative (none to severe) and binary scales (>50% or <50%). Diagnostic image quality was graded for each reconstruction. RESULTS Eleven patients (37%) had significant (≥50% stenosis) CAD. Average heart rate was 82 ± 20 beats/min and variability range was 71 ± 22 beats/min. Mean effective radiation dose was 6.5 ± 2.4 mSv. Diagnostic image quality was noted in 97.9% of 304 coronary segments with median image quality of 3.0. The 300-millisecond reconstruction phase provided the highest image quality; 70% of patients showed diagnostic image quality. Combination of all phases (250-400 milliseconds) performed significantly better than single or other phase combinations (P < 0.0005 for all comparisons). Inter-reader variability for stenosis detection was excellent, with 98.4% concordance by using a binary scale (50% stenosis cutoff). CONCLUSIONS Prospective ECG-triggered sequential dual-source CT acquisition with the use of end-systolic acquisition provides diagnostic image quality with potentially low radiation doses for evaluation of CAD in patients with AF. Use of multiple end-systolic phases over a 150-millisecond window improves diagnostic image quality.

Coronary CTA assessment of coronary anomalies

Coronary anomalies occur in <1% of the general population and can range from a benign incidental finding to the cause of sudden cardiac death. The coronary anomalies are classified here according to the traditional grouping into those of origin and course, intrinsic arterial anatomy, and termination. Classic coronary anomalies of origin and course include those in which a coronary artery originates from the contralateral aortic sinus or the pulmonary artery with anomalous course. Single coronary artery anomalies, in which single coronary artery branches to supply the entire coronary tree, are also included in this category. Anomalies of intrinsic arterial anatomy are a broad class that includes myocardial bridges, coronary ectasia and aneurysms, subendocardial coursing arteries, and coronary artery duplication. Coronary anomalies of termination are those in which a coronary artery terminates in a fistulous connection to a great vessel or cardiac chamber. In the case of those anomalies associated with a risk of sudden cardiac death, the relevant imaging features on CT angiography (CTA) associated with poorer prognosis are reviewed. Recent guidelines and appropriateness criteria favor the use of coronary CTA for the evaluation of coronary anomalies. Although invasive angiography has historically been used to diagnose coronary anomalies, multidetector CT imaging techniques have now become an accurate noninvasive alternative. Cardiac CTA provides excellent spatial and temporal resolution, allowing accurate anatomical assessment of these anomalies.

Low-dose, prospective triggered high-pitch spiral coronary computed tomography angiography: comparison with retrospective spiral technique.

RATIONALE AND OBJECTIVES Cardiac computed tomographic angiography algorithms emphasize radiation reduction while maintaining diagnostic image quality (IQ). The aim of this study was to evaluate IQ and interreader variability using prospective electrocardiographically triggered high-pitch spiral cardiac computed tomographic angiography (FLASH-CT) compared to retrospective electrocardiographic gating (RETRO-CT) for coronary artery disease evaluation in a patient population including overweight and obese individuals. MATERIALS AND METHODS Seventy patients (24 women; mean age, 60 years) matched for gender, age, body mass index (27.4 ± 5.5 kg/m(2)), and calcium score (184 ± 328) underwent cardiac computed tomographic angiography, 35 with FLASH-CT (Definition Flash) and 35 with RETRO-CT (Somatom Definition). Images were reconstructed using standard protocols and least motion phase for RETRO-CT acquisitions. Two independent, blinded readers evaluated the coronary arteries using an 18-segment model, grading IQ on a 5-point, Likert-type scale and coronary stenosis on a 5-point semiquantitative and binary scale. RESULTS Effective radiation dose (1.50 vs 17.3 mSv, P < .0001) and mean heart rate (58 vs 62 beats/min, P < .05) were significantly lower for FLASH-CT compared to RETRO-CT. Seven hundred forty segments (> 1.5 mm) were evaluated. There was no significant difference between FLASH-CT and RETRO-CT scans in overall per-segment IQ (3.11 ± 0.75 vs 3.10 ± 0.82, P = .94). FLASH-CT had noninferior IQ relative to RETRO-CT (95% confidence interval, -0.25 to 0.26). There was no significant difference in interreader variability in diagnosis between FLASH-CT and RETRO-CT for all coronary segments (77.5% vs 78.2%, P = .83). CONCLUSIONS FLASH-CT is an acceptable coronary computed tomographic angiographic method for reducing radiation dose without compromising IQ for a patient population including overweight and obese individuals.