J Cardiovasc Ultrasound.  2015 Dec;23(4):204-208. 10.4250/jcu.2015.23.4.204.

How to Utilize Coronary Computed Tomography Angiography in the Treatment of Coronary Artery Disease

Affiliations
  • 1Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. jhchoimd@gmail.com
  • 2Department of Emergency Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Abstract

Coronary computed tomography angiography (CCTA) has high negative predictive power for detecting coronary artery disease. However CCTA is limited by moderate positive predictive power in the detection of myocardial ischemia. This is not unexpected because the diameter of a stenosis is a poor indicator of myocardial ischemia and discrepancy between the severity of stenosis and noninvasive tests is not uncommon. The value of stenosis for predicting future development of acute coronary syndrome represented by plaque rupture has been questioned. CCTA identifies the characteristics of high-risk plaque including positive remodeling, low density plaque and spotty or micro-calcification. Also, additional evaluation of myocardial ischemia using computational flow dynamics, and luminal attenuation gradient are expected to increase both diagnostic performance for hemodynamically significant stenosis and the predictive power for future cardiovascular risk. Technical advances in CCTA would enable evaluation of both coronary artery stenosis and myocardial ischemia simultaneously with high predictive performance, and would improve vastly the clinical value of CCTA.

Keyword

Coronary CT angiography; Prognosis; Coronary artery disease; Atherosclerosis; Functional ischemia; Myocardial mass

MeSH Terms

Acute Coronary Syndrome
Angiography*
Atherosclerosis
Constriction, Pathologic
Coronary Artery Disease*
Coronary Stenosis
Coronary Vessels*
Myocardial Ischemia
Phenobarbital
Prognosis
Rupture
Phenobarbital

Figure

  • Fig. 1 Anatomical versus physiological evaluation of coronary atherosclerosis. TCFA: thin-cap fibroatheroma.

  • Fig. 2 Characteristics of coronary atherosclerotic plaque detected on CCTA. A: Severe stenosis. B: Positive remodeling. C: Partially calcified or "spotty" calcification. D: Low attenuated plaque (< 30 HU). CCTA: coronary computed tomography angiography, HU: Hounsfield unit.

  • Fig. 3 Risk assessment of coronary artery disease in the future. APPROACH: Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease, FFR: fractional flow reserve, PCI: percutaneous coronary intervention, SYNTAX: Synergy between PCI with Taxus and Cardiac Surgery.


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