Responsible use of computed tomography in the evaluation of coronary artery disease and chest pain

Abstract

Many options are available to clinicians for the noninvasive evaluation of the cardiovascular system and patient concerns about chest discomfort. Cardiac computed tomography (CT) is a rapidly advancing field of noninvasive imaging. Computed tomography incorporates coronary artery calcium scoring, coronary angiography, ventricular functional analysis, and information about noncardiac thoracic anatomy. We searched the PubMed database and Google from inception to September 2009 for resources on the accuracy, risk, and predictive capacity of coronary artery calcium scoring and CT coronary angiography and have reviewed them herein. Cardiac CT provides diagnostic information comparable to echocardiography, nuclear myocardial perfusion imaging, positron emission tomography, and magnetic resonance imaging. A cardiac CT study can be completed in minutes. In patients with a nondiagnostic stress test result, cardiac CT can preclude the need for invasive angiography. Prognostic information portends excellent outcomes in patients with normal study results. Use of cardiac CT can reduce health care costs and length of emergency department stays for patients with chest pain. Cardiac CT examination provides clinically relevant information at a radiation dose similar to well-established technologies, such as nuclear myocardial perfusion imaging. Advances in technique can reduce radiation dose by 90%. With appropriate patient selection, cardiac CT can accurately diagnose heart disease, markedly decrease health care costs, and reliably predict clinical outcomes.

FIGURE.

Responsible use of cardiac computed tomography in evaluating chest pain. This flow diagram incorporates coronary computed tomographic angiography (CTA) in a suggested framework for evaluating a patient with acute chest pain. See the American Heart Association criteria for further detail on the assessment of pretest probability. CAD = coronary artery disease; ECG = electrocardiogram; echo = echocardiography; SPECT = single-photon emission computed tomography. Data from J Am Coll Radiol.