The role of multi-slice computed tomography in stable angina management: a current perspective

Abstract

Contrast-enhanced CT coronary angiography (CTCA) has evolved as a reliable alternative imaging modality technique and may be the preferred initial diagnostic test in patients with stable angina with intermediate pre-test probability of CAD. However, because CTCA is moderately predictive for indicating the functional significance of a lesion, the combination of anatomic and functional imaging will become increasingly important. The technology will continue to improve with better spatial and temporal resolution at low radiation exposure, and CTCA may eventually replace invasive coronary angiography. The establishment of the precise role of CTCA in the diagnosis and management of patients with stable angina requires high-quality randomised study designs with clinical outcomes as a primary outcome.

Fig. 1

Established diagnostic algorithm. If risk factor diabetes or hypertension is present, patients are categorised to high pre-test probability category. CTCA computed tomography coronary angiography; ECG electrocardiography; ICA invasive coronary angiography. Ischaemic testing includes stress myocardial perfusion imaging; SPECT or single photon emission computed tomography [relative flow], PET or positron emission tomography [absolute flow], MRI or magnetic resonance imaging [flow reserve]; stress echocardiography [wall motion]

Fig. 2

The ischaemic cascade. Myocardial dysfunction occurs in a predictable sequence of events which is detectable prior to clinical symptoms

Fig. 3

Relation between pre- and post-test probability. Diagnostic accuracy improves with a test with a higher sensitivity and specificity. Bayesian theory has shown that the value of non-invasive testing is greatest in patients with an intermediate pre-test probability of having CAD. Assume certainty level. Very low pre-test probability (<5%): uncertainty will not be achieved. Low pre-test probability (5–10%): only certainty with a negative test result. Intermediate pre-test probability: (10–90%): certainty with a negative and positive test result. High pre-test probability: (>90%): only certainty with a positive test result

Fig. 4

Alternative diagnostic algorithm. * If risk factor diabetes or hypertension is present, patients are categorised to high pre-test probability category. CCS: coronary calcium score (expressed as Agatston Score), CTCA: computed tomography coronary angiography, ICA: invasive coronary angiography, RCA: right coronary artery, Cx: left circumflex artery, LM: left main, LAD: left anterior descending artery, 3-VD: three-vessel disease. Ischaemic testing includes stress myocardial perfusion imaging: SPECT or single photon emission computed tomography [relative flow], PET or positron emission tomography [absolute flow], MRI or magnetic resonance imaging [flow reserve]; stress echocardiography [wall motion]