Cardiac CT angiography in current practice: An American society for preventive cardiology clinical practice statement✰

Abstract

In this clinical practice statement, we represent a summary of the current evidence and clinical applications of cardiac computed tomography (CT) in evaluation of coronary artery disease (CAD), from an expert panel organized by the American Society for Preventive Cardiology (ASPC), and appraises the current use and indications of cardiac CT in clinical practice. Cardiac CT is emerging as a front line non-invasive diagnostic test for CAD, with evidence supporting the clinical utility of cardiac CT in diagnosis and prevention. CCTA offers several advantages beyond other testing modalities, due to its ability to identify and characterize coronary stenosis severity and pathophysiological changes in coronary atherosclerosis and stenosis, aiding in early diagnosis, prognosis and management of CAD. This document further explores the emerging applications of CCTA based on functional assessment using CT derived fractional flow reserve, peri‑coronary inflammation and artificial intelligence (AI) that can provide personalized risk assessment and guide targeted treatment. We sought to provide an expert consensus based on the latest evidence and best available clinical practice guidelines regarding the role of CCTA as an essential tool in cardiovascular prevention - applicable to risk assessment and early diagnosis and management, noting potential areas for future investigation.

Fig. 1

Three dimensional, volume rendered image of the coronary arteries revealing largely normal vessels. The negative predictive power exceeds 99% for obstructive disease.

Fig. 2

Coronary CT angiogram of the left anterior descending artery (LAD) demonstrated (a) topologically in volume rendered technique, (b) visually in curved multiplanar reformat, and (c) quantitatively in straightened multiplanar reformat across different 3D views. This patient demonstrates high atherosclerotic plaque burden that is comprised primarily of non-calcified (yellow and red) rather than calcified plaque (blue).The ability to visualize both stenosis and plaque makes this modality unique among non-invasive imaging tests.

Fig. 3

A 62 year old man with atypical chest pain. Computed tomographic angiography reveals severe atherosclerosis (mostly calcified plaque) without obstructive disease. The image demonstrates the ability to visualize the lumen clearly despite high calcium burdens.

Central Figure Legend: (A1) Presence of positive remodeling (yellow arrows) and low attenuation plaques (LAP, red arrow) are the most important determinants of plaque vulnerability. (A2) Stable plaques lack both these features. Major adverse cardiac events by the presence of 1 or both features in a follow up of — patients for 2 years (A3), and 300 patients for up to 10 years. (A4) Patients with HRP had 45 and 10 folds higher likelihood of adverse outcomes, respectively. Presence of obstructive disease over and above HRP features (A5) and interval progression in plaque magnitude (A6) increased the likelihood of adverse events further. Greater number of adverse plaque characteristics were associated with greater of adverse outcomes (A7) and the HRP characteristics were associated with abnormal fractional flow reserve regardless of luminal stenosis (A8). (Reprinted with permission of Elsevier from.)