| 1. Di Fiore DP, Beltrame JF. Chest pain in patients with 'normal angiography': could it be cardiac?. [Review]. Int. j. evid.-based healthc.. 11(1):56-68, 2013 Mar. |
Review/Other-Dx |
N/A |
To provide a brief overview of the important clinical considerations in this common presentation and particularly focus on coronary vasomotor disorders (i.e. those involving an inappropriate vasoconstriction or impaired vasodilation) that need to be considered. |
No results stated in abstract. |
4 |
| 2. Beache GM, Mohammed TH, Hurwitz Koweek LM, et al. ACR Appropriateness Criteria® Acute Nonspecific Chest Pain-Low Probability of Coronary Artery Disease. J Am Coll Radiol 2020;17:S346-S54. |
Review/Other-Tx |
N/A |
Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for acute nonspecific chest pain-low probability of coronary artery disease. |
No results stated in abstract. |
4 |
| 3. Shah AB, Kirsch J, Bolen MA, et al. ACR Appropriateness Criteria® Chronic Chest Pain-Noncardiac Etiology Unlikely-Low to Intermediate Probability of Coronary Artery Disease. J Am Coll Radiol 2018;15:S283-S90. |
Review/Other-Dx |
N/A |
Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for chronic chest pain, noncardiac etiology unlikely, low to intermediate probability of coronary artery disease. |
No results stated in abstract. |
4 |
| 4. McKavanagh P, Lusk L, Ball PA, et al. A comparison of Diamond Forrester and coronary calcium scores as gatekeepers for investigations of stable chest pain. Int J Cardiovasc Imaging. 29(7):1547-55, 2013 Oct. |
Observational-Dx |
250 patients |
To determine if calcium scores (CS) could act as a more effective gatekeeper than Diamond Forrester (DF) in the assessment of patients with suspected coronary artery disease (CAD). |
The mean DF was 47.8 and mean CS 172.5. Of the 144 patients with non-anginal pain 19.4 % had significant disease (>50 % stenosis). In general the DF over estimated the presence of CAD whereas the CS reclassified patients to lower risk groups, with 91 in the high risk DF category compared to 26 in the CS. Both receiver operating curve and McNemar Bowker test analysis suggested the DF was less accurate in the prediction of CAD compared to CS [Formula: see text] Projected downstream investigations were also calculated, with the cost per number of significant stenoses identified cheaper with the CS criteria. |
3 |
| 5. Versteylen MO, Joosen IA, Shaw LJ, Narula J, Hofstra L. Comparison of Framingham, PROCAM, SCORE, and Diamond Forrester to predict coronary atherosclerosis and cardiovascular events. J Nucl Cardiol. 18(5):904-11, 2011 Oct. |
Observational-Dx |
1296 patients |
To study four frequently used risk scores in their ability to predict for coronary artery disease (CAD) and major adverse cardiovascular events in patients presenting with stable chest pain at the cardiology outpatient clinic. |
Framingham (FRS), PROCAM, SCORE risk score, and Diamond Forrester pre-test probability were calculated. All patients were followed up for a mean 19 +/- 9 months for all cardiovascular events (mortality, acute coronary syndrome, revascularization >90 days after CCTA). In ROC-analysis for prediction of significant CAD, the areas under the curve for FRS; 0.68 (95% confidence interval: 0.64-0.72) and for SCORE; 0.69 (95% confidence interval: 0.65-0.72) were significantly higher than for PROCAM; 0.64 (95% confidence interval: 0.61-0.68; P </= .001), as well as marginally higher than for Diamond Forrester; 0.65 (95% confidence interval: 0.61-0.68; P </= .05). Low FRS category showed the lowest number of patients with significant CAD, compared to patients with low risk using PROCAM, SCORE or Diamond Forrester (P < .001). Also, low FRS category showed less events (compared to PROCAM and SCORE; P < .001, for Diamond Forrester; P = .14). |
3 |
| 6. Wasfy MM, Brady TJ, Abbara S, et al. Comparison of the Diamond-Forrester method and Duke Clinical Score to predict obstructive coronary artery disease by computed tomographic angiography. Am J Cardiol 2012;109:998-1004. |
Observational-Dx |
114 patients |
To evaluate the ability of the Diamond and Forrester method (DFM) and the Duke Clinical Score (DCS) to predict obstructive coronary artery disease (CAD) on coronary computed tomographic angiography (CCTA) and the effect of these different risk scores on the appropriateness level using the 2010 Appropriate Use Criteria. |
The CCTA results were classified as revealing obstructive (>/=70% stenosis), nonobstructive (<70%), or no CAD. When the patients' risk was classified using the DFM, 18% were low, 65% intermediate, and 17% high risk. When using the DCS, 53% of patients had a reclassification of their risk, most of whom changed from intermediate to either low or high risk (50% low, 19% intermediate, 35% high risk). The net reclassification improvement for the prediction of obstructive CAD was 51% (p = 0.01). Of the 37 patients who were reclassified as low risk, 36 (97%) lacked obstructive CAD. Appropriateness for CCTA was reclassified for 13% of patients when using the DCS instead of the DFM, and the number of appropriate examinations was significantly fewer (68% vs 55%, p <0.001). |
2 |
| 7. Fordyce CB, Newby DE, Douglas PS. Diagnostic Strategies for the Evaluation of Chest Pain: Clinical Implications From SCOT-HEART and PROMISE. [Review]. J Am Coll Cardiol. 67(7):843-52, 2016 Feb 23. |
Review/Other-Dx |
N/A |
To discuss the data generated from these 2 pivotal trials to better inform the practicing clinician in the selection of noninvasive testing for stable chest pain. Similarities and differences between SCOT-HEART and PROMISE are highlighted, and clinical and practical implications are discussed. Both trials show that coronary computed tomography angiography should have a greater role in the diagnostic pathway of patients with stable chest pain. |
No results stated in abstract |
4 |
| 8. Alderman EL, Corley SD, Fisher LD, et al. Five-year angiographic follow-up of factors associated with progression of coronary artery disease in the Coronary Artery Surgery Study (CASS). CASS Participating Investigators and Staff. J Am Coll Cardiol 1993;22:1141-54. |
Experimental-Tx |
298 patients |
To analyze five year follow up coronary angiography as part of the CASS. |
For nonbypassed segments, right coronary artery and left anterior descending artery proximal and midlocations were associated with disease progression. For stenosis-containing segments, the initial severity, a non-left anterior descending artery location and increased treadmill duration predicted progression. Segment occlusion was associated with initial lesion severity, right coronary artery location and subsequent interval myocardial infarction. There were few predictors of progression or occlusion in bypassed arteries, other than initial lesion severity. |
1 |
| 9. Chen SL, Xu B, Chen JB, et al. Diagnostic accuracy of quantitative angiographic and intravascular ultrasound parameters predicting the functional significance of single de novo lesions. Int J Cardiol 2013;168:1364-9. |
Observational-Dx |
323 patients |
To determine the best cutoff value of angiographic and intravascular ultrasound (IVUS) parameters for defining fractional flow reserve (FFR) <0.8 in patients with single coronary artery lesion. |
FFR<0.8 was in 54.2%. Minimal lumen area (MLA), plaque burden (PB), lesion length (LL) and lesion at left anterior descending artery (LAD) were four predictors of FFR<0.8. LL had less value in predicting FFR<0.8. The cutoff values of PB and MLA for FFR<0.8 were 72.7% and 2.97 mm(2). MLA and PB had similar high diagnostic value for vessel size = 3 mm (cutoff values: 3.02 mm(2) and 80.7%), proximal LAD lesion (cutoff values: 3.04 mm(2) and 76.5%) and unstable angina (2.82 mm(2) and 71.9%). Combination of MLA (2.82 mm(2)) and PB (80.6%) had increased diagnostic value for distal LAD lesion. Only PB (71%) had higher diagnostic value for diabetic patients. MLA and PB could not predict FFR<0.8 for vessel size<3mm, and non-LAD lesion. |
2 |
| 10. Tonino PA, Fearon WF, De Bruyne B, et al. Angiographic versus functional severity of coronary artery stenoses in the FAME study fractional flow reserve versus angiography in multivessel evaluation. J Am Coll Cardiol. 2010;55(25):2816-2821. |
Observational-Dx |
509 patients |
To investigate the relationship between angiographic and functional severity of coronary artery stenoses in the FAME (Fractional Flow Reserve Versus Angiography in Multivessel Evaluation) study. |
Before FFR measurement, these lesions were categorized into 50% to 70% (47% of all lesions), 71% to 90% (39% of all lesions), and 91% to 99% (15% of all lesions) diameter stenosis by visual assessment. In the category 50% to 70% stenosis, 35% were functionally significant (FFR <or=0.80) and 65% were not (FFR >0.80). In the category 71% to 90% stenosis, 80% were functionally significant and 20% were not. In the category of subtotal stenoses, 96% were functionally significant. Of all 509 patients with angiographically defined multivessel disease, only 235 (46%) had functional multivessel disease (>or=2 coronary arteries with an FFR <or=0.80). |
3 |
| 11. Tinana A, Mintz GS, Weissman NJ. Volumetric intravascular ultrasound quantification of the amount of atherosclerosis and calcium in nonstenotic arterial segments. Am J Cardiol 2002;89:757-60. |
Review/Other-Dx |
19 patients |
To compare the plaque volumes found within the length of the stenoses to the plaque volume of the adjacent nonstenotic segments. |
No abstract available. |
4 |
| 12. Sarwar A, Shaw LJ, Shapiro MD, et al. Diagnostic and prognostic value of absence of coronary artery calcification. JACC Cardiovasc Imaging. 2009;2(6):675-688. |
Review/Other-Dx |
49 studies |
To systematically assessed the diagnostic and prognostic value of absence of coronary artery calcification (CAC) in asymptomatic and symptomatic individuals. |
A systematic review of published articles revealed 49 studies that fulfilled our criteria for inclusion. These included 13 studies assessing the relationship of CAC with adverse cardiovascular outcomes in 64,873 asymptomatic patients. In this cohort, 146 of 25,903 patients without CAC (0.56%) had a cardiovascular event during a mean follow-up period of 51 months. In the 7 studies assessing the prognostic value of CAC in a symptomatic population, 1.80% of patients without CAC had a cardiovascular event. Overall, 18 studies demonstrated that the presence of any CAC had a pooled sensitivity and negative predictive value of 98% and 93%, respectively, for detection of significant coronary artery disease on invasive coronary angiography. In 4,870 individuals undergoing myocardial perfusion and CAC testing, in the absence of CAC, only 6% demonstrated any sign of ischemia. Finally, 3 studies demonstrated that absence of CAC had a negative predictive value of 99% for ruling out acute coronary syndrome. |
4 |
| 13. Wang X, Le EPV, Rajani NK, et al. A zero coronary artery calcium score in patients with stable chest pain is associated with a good prognosis, despite risk of non-calcified plaques. Open Heart 2019;6:e000945. |
Observational-Dx |
1,753 patients |
To estimate the prevalence of non-calcified coronary artery disease (CAD) in patients with suspected stable angina and a zero coronary artery calcification (CAC) score, and to assess the prognostic significance of a zero CAC in these symptomatic patients. |
A total of 915 of 1753 (52.2%) patients (mean age 56.8 ± 12.0 years; 46.2% male) had a zero CAC score. Of the 751 (82.1%) patients with a zero CAC in whom CTCA was performed, 674 (89.7%) had normal coronary arteries, 63 (8.4%) had non-calcified CAD with < 50% stenosis and 14 (1.9%) had = 50% stenosis in at least one coronary artery. The negative predictive value of a zero CAC for excluding a = 50% CTCA stenosis was 98.1%. Over a median follow-up period of 2.2 years (range 1.0-7.0 years), the absolute annualised rates of MACE were as follows: zero CAC 1.9 per 1000 person-years and non-zero CAC 7.4 per 1000 person-years (HR 3.8, p = 0.009). However, after adjusting for age, gender and cardiovascular risk factors using a multivariable Cox proportional hazards model, there was no statistically significant difference in the risk of MACE between the two patient cohorts (p = 0.19). After adjusting for age, gender and cardiovascular risk factors, the HR for all-cause mortality among the zero CAC cohort vers non-zero CAC was 2.1 (p = 0.27). |
2 |
| 14. Budoff MJ, Mayrhofer T, Ferencik M, et al. Prognostic Value of Coronary Artery Calcium in the PROMISE Study (Prospective Multicenter Imaging Study for Evaluation of Chest Pain). Circulation. 136(21):1993-2005, 2017 Nov 21. |
Observational-Dx |
8,811 patients |
To evaluate the comparative prognostic ability of functional testing (FT) to coronary artery calcium (CAC) in a large cohort of symptomatic low-intermediate risk patients. |
Overall, the distribution of normal or mildly, moderately or severely abnormal test results was significantly different between FT and CAC (FT = normal 3588 [78.0%], mild 432 [9.4%], moderate 217 [4.7%], severe 365 [7.9%]; CAC = normal 1,457 [34.6%], mild 1340 [31.8%], moderate 772 [18.3%], severe 640 [15.2%], p <0.0001). Moderate and severe abnormalities in both arms robustly predicted events (moderate: CAC HR 3.14, 95% CI 1.81–5.44 and FT HR 2.65, 95% CI 1.46–4.83; severe: CAC HR 3.56, 95% CI 1.99–6.36 and FT HR 3.88, 95% CI 2.58–5.85. In the CAC arm, the majority of events (n=112/133; 84%) occurred in patients with any positive CAC test (score >0) whereas less than half of events occurred in patients with mild, moderate or severely abnormal FT (n=57/132; 43%) (p<0.001). In contrast, any abnormality on FT was significantly more specific for predicting events (78.6% for FT vs 35.2% for CAC, p<0.001). Overall discriminatory ability in predicting the primary endpoint of mortality, nonfatal myocardial infarction, and unstable angina hospitalization was similar and fair for both CAC and FT (c-statistic, 0.67 vs. 0.64). Coronary computed tomographic angiography provided significantly better prognostic information compared to FT and CAC testing (C-index: 0.72). |
2 |
| 15. Gottlieb I, Miller JM, Arbab-Zadeh A, et al. The absence of coronary calcification does not exclude obstructive coronary artery disease or the need for revascularization in patients referred for conventional coronary angiography. J Am Coll Cardiol 2010;55:627-34. |
Observational-Dx |
291 patients |
To evaluate the prevalence of obstructive and nonobstructive coronary artery disease (CAD) in a multicenter international trial involving patients with suspected CAD and calcium score (CS) = 0 clinically referred for conventional coronary angiography (CCA), as well as to evaluate the rate of clinically driven revascularization in those patients. |
In all, 291 patients were included, of whom 214 (73%) were male, and the mean age was 59.3 ± 10.0 years. A total of 14 (5%) patients had low, 218 (75%) had intermediate, and 59 (20%) had high pre-test probability of obstructive coronary artery disease. The overall prevalence of =50% stenosis was 56%. A total of 72 patients had CS = 0, among whom 14 (19%) had at least 1 =50% stenosis. The overall sensitivity for CS = 0 to predict the absence of =50% stenosis was 45%, specificity was 91%, negative predictive value was 68%, and positive predictive value was 81%. Additionally, revascularization was performed in 9 (12.5%) CS = 0 patients within 30 days of the CS. From a total of 383 vessels without any coronary calcification, 47 (12%) presented with =50% stenosis; and from a total of 64 totally occluded vessels, 13 (20%) had no calcium. |
2 |
| 16. Lubbers M, Dedic A, Coenen A, et al. Calcium imaging and selective computed tomography angiography in comparison to functional testing for suspected coronary artery disease: the multicentre, randomized CRESCENT trial. Eur Heart J. 2016;37(15):1232-1243. |
Observational-Dx |
350 patients |
To compare the effectiveness and safety of a cardiac computed tomography (CT) algorithm with functional testing in patients with symptoms suggestive of coronary artery disease (CAD). |
Between April 2011 and July 2013, 350 patients with stable angina, referred to the outpatient clinic of four Dutch hospitals, were prospectively randomized between cardiac CT and functional testing (2 : 1 ratio). The tiered cardiac CT protocol included a calcium scan followed by CT angiography if the Agatston calcium score was between 1 and 400. Patients with test-specific contraindications were not excluded from study participation. By 1 year, fewer patients randomized to cardiac CT reported anginal complaints (P = 0.012). The cumulative radiation dose was slightly higher in the CT group (6.6 +/- 8.7 vs. 6.1 +/- 9.3 mSv; P < 0.0001). After 1.2 years, event-free survival was 96.7% for patients randomized to CT and 89.8% for patients randomized to functional testing (P = 0.011). After CT, the final diagnosis was established sooner (P < 0.0001), and additional downstream testing was required less frequently (25 vs. 53%, P < 0.0001), resulting in lower cumulative diagnostic costs (euro369 vs. euro440; P < 0.0001). |
1 |
| 17. Schenker MP, Dorbala S, Hong EC, et al. Interrelation of coronary calcification, myocardial ischemia, and outcomes in patients with intermediate likelihood of coronary artery disease: a combined positron emission tomography/computed tomography study. Circulation 2008;117:1693-700. |
Observational-Dx |
621 patients |
To discuss interrelation of coronary calcification, myocardial ischemia, and outcomes in patients with intermediate likelihood of coronary artery disease: a combined positron emission tomography/computed tomography study |
We evaluated 695 consecutive intermediate-risk patients undergoing combined rest-stress rubidium 82 positron emission tomography (PET) perfusion imaging and CAC scoring on a hybrid PET-computed tomography (CT) scanner. The frequency of abnormal scans among patients with a CAC score > or = 400 was higher than that in patients with a CAC score of 1 to 399 (48.5% versus 21.7%, P<0.001). Multivariate logistic regression supported the concept of a threshold CAC score > or = 400 governing this relationship (odds ratio 2.91, P<0.001); however, the frequency of ischemia among patients with no CAC was 16.0%, and its absence only afforded a negative predictive value of 84.0%. Risk-adjusted survival analysis demonstrated a stepwise increase in event rates (death and myocardial infarction) with increasing CAC scores in patients with and without ischemia on PET myocardial perfusion imaging. Among patients with normal PET myocardial perfusion imaging, the annualized event rate in patients with no CAC was lower than in those with a CAC score > or = 1000 (2.6% versus 12.3%, respectively). Likewise, in patients with ischemia on PET myocardial perfusion imaging, the annualized event rate in those with no CAC was lower than among patients with a CAC score > or = 1000 (8.2% versus 22.1%). |
3 |
| 18. George RT, Arbab-Zadeh A, Miller JM, et al. Computed tomography myocardial perfusion imaging with 320-row detector computed tomography accurately detects myocardial ischemia in patients with obstructive coronary artery disease. Circ Cardiovasc Imaging 2012;5:333-40. |
Observational-Dx |
50 patients |
To assess the accuracy of 320-row computed tomography perfusion imaging (CTP) to detect atherosclerosis causing myocardial ischemia. |
CTA alone was a limited predictor of myocardial ischemia compared with SPECT, with a sensitivity, specificity, positive (PPV) and negative predictive value (NPV) of 56%, 75%, 56%, and 75%, and the area under the receiver operator characteristic curve (AUC) was 0.65 (95% CI, 0.51-0.78, P=0.07). CTP was a better predictor of myocardial ischemia, with a sensitivity, specificity, PPV, and NPV of 72%, 91%, 81%, and 85%, with an AUC of 0.81 (95% CI, 0.68-0.91, P<0.001), and was an excellent predictor of myocardial ischemia on SPECT-MPI in the presence of stenosis (>/=50% on CTA), with a sensitivity, specificity, PPV, and NPV of 100%, 81%, 50%, and 100%, with an AUC of 0.92 (95% CI, 0.80-0.97, P<0.001). The radiation dose for the comprehensive cardiac CT protocol and SPECT were 13.8+/-2.9 and 13.1+/-1.7; respectively (P=0.15). |
2 |
| 19. Bettencourt N, Chiribiri A, Schuster A, et al. Direct comparison of cardiac magnetic resonance and multidetector computed tomography stress-rest perfusion imaging for detection of coronary artery disease. J Am Coll Cardiol 2013;61:1099-107. |
Observational-Dx |
101 patients |
To compare the diagnostic performance of a multidetector computed tomography (MDCT) integrated protocol (IP) including coronary angiography (CTA) and stress-rest perfusion (CTP) with cardiac magnetic resonance myocardial perfusion imaging (CMR-Perf) for detection of functionally significant coronary artery disease (CAD). |
On a patient-based model, the MDCT-IP had a sensitivity, specificity, positive and negative predictive values of 89%, 83%, 80% and 90%, respectively (global accuracy 85%). These results were closely related with those achieved by CMR-Perf: 89%, 88%, 85% and 91%, respectively (global accuracy 88%). When comparing test accuracies using noninferiority analysis, differences greater than 11% in favour of CMR-Perf can be confidently excluded. |
1 |
| 20. Cury RC, Kitt TM, Feaheny K, et al. A randomized, multicenter, multivendor study of myocardial perfusion imaging with regadenoson CT perfusion vs single photon emission CT. J Cardiovasc Comput Tomogr 2015;9:103-12 e1-2. |
Experimental-Dx |
124 patients |
To evaluate whether regadenoson Myocardial CT perfusion (CTP) is noninferior to regadenoson single photon emission CT (SPECT) for the detection or exclusion of myocardial ischemia. |
Patients (men = 45 years; women = 50 years) with known or suspected coronary artery disease (n = 124) were randomized to 1 of 2 diagnostic sequences: rest and regadenoson SPECT on day 1, then regadenoson CTP and rest CTP (and coronary CT angiography [CTA]) (CTA; same acquisition) on day 2 or regadenoson CTP and rest CTP (and CTA) on Day 1, then rest and regadenoson SPECT on day 2. Scanning platforms included 64-, 128-, 256-, and 320-slice systems. The primary analysis examined the agreement rate between CTP and SPECT for detecting or excluding reversible ischemia in = 2 myocardial segments as assessed by independent, blinded readers. |
3 |
| 21. George RT, Arbab-Zadeh A, Miller JM, et al. Adenosine stress 64- and 256-row detector computed tomography angiography and perfusion imaging: a pilot study evaluating the transmural extent of perfusion abnormalities to predict atherosclerosis causing myocardial ischemia. Circ Cardiovasc Imaging 2009;2:174-82. |
Observational-Dx |
40 patients |
To test whether adenosine stress computed tomography myocardial perfusion imaging (CTP), when added to CTA, can predict perfusion abnormalities caused by obstructive atherosclerosis. |
CTA and quantitative coronary angiography were evaluated for stenoses > or =50%, and SPECT-MPI was evaluated for fixed and reversible perfusion deficits using a 17-segment model. CTP images were analyzed for the transmural differences in perfusion using the transmural perfusion ratio (subendocardial attenuation density/subepicardial attenuation density). The sensitivity, specificity, positive predictive value, and negative predictive value for the combination of CTA and CTP to detect obstructive atherosclerosis causing perfusion abnormalities using the combination of quantitative coronary angiography and SPECT as the gold standard was 86%, 92%, 92%, and 85% in the per-patient analysis and 79%, 91%, 75%, and 92% in the per vessel/territory analysis, respectively. |
2 |
| 22. George RT, Mehra VC, Chen MY, et al. Myocardial CT perfusion imaging and SPECT for the diagnosis of coronary artery disease: a head-to-head comparison from the CORE320 multicenter diagnostic performance study. Radiology 2014;272:407-16. |
Observational-Dx |
381 patients |
To compare the diagnostic performance of myocardial computed tomographic (CT) perfusion imaging and single photon emission computed tomography (SPECT) perfusion imaging in the diagnosis of anatomically significant coronary artery disease (CAD) as depicted at invasive coronary angiography. |
CAD was diagnosed in 229 of the 381 patients (60%). The per-patient sensitivity and specificity for the diagnosis of CAD (stenosis =50%) were 88% (202 of 229 patients) and 55% (83 of 152 patients), respectively, for CT perfusion imaging and 62% (143 of 229 patients) and 67% (102 of 152 patients) for SPECT, with Az values of 0.78 (95% confidence interval: 0.74, 0.82) and 0.69 (95% confidence interval: 0.64, 0.74) (P = .001). The sensitivity of CT perfusion imaging for single- and multivessel CAD was higher than that of SPECT, with sensitivities for left main, three-vessel, two-vessel, and one-vessel disease of 92%, 92%, 89%, and 83%, respectively, for CT perfusion imaging and 75%, 79%, 68%, and 41%, respectively, for SPECT. |
2 |
| 23. Magalhaes TA, Kishi S, George RT, et al. Combined coronary angiography and myocardial perfusion by computed tomography in the identification of flow-limiting stenosis - The CORE320 study: An integrated analysis of CT coronary angiography and myocardial perfusion. J Cardiovasc Comput Tomogr. 2015;9(5):438-445. |
Observational-Dx |
381 patients |
To investigate the accuracy of a combined coronary CTA and myocardial CTP comprehensive protocol compared to coronary CTA alone, using a combination of invasive coronary angiography and single photon emission CT as reference. |
Mean patient age was 62 +/- 6 years (66% male), 27% with prior history of myocardial infarction. In a per-patient analysis, sensitivity for CTA alone was 93%, specificity was 54%, positive predictive value was 55%, negative predictive value was 93%, and overall accuracy was 69%. After combining CTA and CTP, sensitivity was 78%, specificity was 73%, negative predictive value was 64%, positive predictive value was 0.85%, and overall accuracy was 75%. In a per-vessel analysis, overall accuracy of CTA alone was 73% compared to 79% for the combination of CTA and CTP (P < .0001 for difference). |
2 |
| 24. Mano Y, Anzai T, Yoshizawa A, Itabashi Y, Ohki T. Role of non-electrocardiogram-gated contrast-enhanced computed tomography in the diagnosis of acute coronary syndrome. Heart Vessels. 30(1):1-8, 2015 Jan. |
Observational-Dx |
154 patients |
To determine the role of non-electrocardiogram-gated contrast-enhanced computed tomography in the diagnosis of acute coronary syndrome. |
We retrospectively investigated 154 consecutive patients who required non-ECG-gated CT to differentiate AAD and PE in the emergency department, but had no evidence of them on CT. Furthermore, a subanalysis was performed in the patients who were subsequently suspected of ACS and underwent emergent invasive coronary angiography followed by CT. We evaluated left ventricular enhancement to detect myocardial perfusion deficit by calculating Hounsfield units, and the results were compared with ultimate diagnoses and angiography findings. A perfusion deficit was detected in 43 patients, among whom 26 were ultimately diagnosed with acute myocardial infarction (AMI); 24 patients required emergent revascularization. The subanalysis indicated that perfusion abnormalities corresponded with the territory of the culprit artery in all except one patient. In the remaining 111 patients without perfusion deficit, only two required emergent revascularization, and their levels of creatine kinase MB were not elevated. The sensitivity, specificity, and positive and negative predictive values of non-ECG-gated CT in predicting AMI/emergent revascularization were 93 %, 87 %, 61 %, and 98 %/92 %, 85 %, 56 %, and 98 %, respectively. Non-ECG-gated CT facilitates the diagnosis of ACS and the decision on emergent catheterization, providing information on the ischemic myocardial area by detection of a localized decrease in left ventricular enhancement. |
3 |
| 25. Budoff MJ, Dowe D, Jollis JG, et al. Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial. J Am Coll Cardiol. 2008;52(21):1724-1732. |
Experimental-Dx |
230 patients |
To evaluate the diagnostic accuracy of electrocardiographically gated 64-multidetector row coronary computed tomographic angiography (CCTA) in individuals without known coronary artery disease (CAD). |
On a patient-based model, the sensitivity, specificity, and positive and negative predictive values to detect > or =50% or > or =70% stenosis were 95%, 83%, 64%, and 99%, respectively, and 94%, 83%, 48%, 99%, respectively. No differences in sensitivity and specificity were noted for nonobese compared with obese subjects or for heart rates < or =65 beats/min compared with >65 beats/min, whereas calcium scores >400 reduced specificity significantly. |
1 |
| 26. Meijboom WB, Meijs MF, Schuijf JD, et al. Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study. J Am Coll Cardiol. 2008;52(25):2135-2144. |
Observational-Dx |
360 patients |
To determine the diagnostic accuracy of 64-slice CCTA to detect or rule out significant CAD. |
The prevalence among patients of having at least 1 significant stenosis was 68%. In a patient-based analysis, the sensitivity for detecting patients with significant CAD was 99% (95% CI: 98% to 100%), specificity was 64% (95% CI: 55% to 73%), PPV was 86% (95% CI: 82% to 90%), and NPV was 97% (95% CI: 94% to 100%). In a segment-based analysis, the sensitivity was 88% (95% CI: 85% to 91%), specificity was 90% (95% CI: 89% to 92%), PPV was 47% (95% CI: 44% to 51%), and NPV was 99% (95% CI: 98% to 99%). |
2 |
| 27. Miller JM, Rochitte CE, Dewey M, et al. Diagnostic performance of coronary angiography by 64-row CT. N Engl J Med. 2008;359(22):2324-2336. |
Observational-Dx |
291 patients |
To examine the accuracy of MDCT angiography involving 64 detectors. |
The patient-based diagnostic accuracy of quantitative CT angiography for detecting or ruling out stenoses of 50% or more according to conventional angiography revealed an AUC of 0.93 (95% CI, 0.90 to 0.96), with a sensitivity of 85% (95% CI, 79 to 90), a specificity of 90% (95% CI, 83 to 94), a PPV of 91% (95% CI, 86 to 95), and a NPV of 83% (95% CI, 75 to 89). CT angiography was similar to conventional angiography in its ability to identify patients who subsequently underwent revascularization: the AUC was 0.84 (95% CI, 0.79 to 0.88) for MDCT angiography and 0.82 (95% CI, 0.77 to 0.86) for conventional angiography. A per-vessel analysis of 866 vessels yielded an AUC of 0.91 (95% CI, 0.88 to 0.93). Disease severity ascertained by CT and conventional angiography was well correlated (r=0.81; 95% CI, 0.76 to 0.84). Two patients had important reactions to contrast medium after CT angiography. |
1 |
| 28. Schlattmann P, Schuetz GM, Dewey M. Influence of coronary artery disease prevalence on predictive values of coronary CT angiography: a meta-regression analysis. Eur Radiol 2011;21:1904-13. |
Meta-analysis |
89 studies; 7,516 patients |
To evaluate the impact of coronary artery disease (CAD) prevalence on the predictive values of coronary CT angiography. |
The summary negative and positive predictive values of coronary CT angiography were 93.7% (95% confidence interval [CI] 92.8-94.5%) and 87.5% (95% CI, 86.5-88.5%), respectively. With 95% confidence, negative and positive predictive values higher than 90% and 70% were available with CT for a CAD prevalence of 18-63%. CT systems with >16 detector rows met these requirements for the positive (P < 0.01) and negative (P < 0.05) predictive values in a significantly broader range than systems with </=16 detector rows. |
M |
| 29. Haase R, Schlattmann P, Gueret P, et al. Diagnosis of obstructive coronary artery disease using computed tomography angiography in patients with stable chest pain depending on clinical probability and in clinically important subgroups: meta-analysis of individual patient data. BMJ. 365:l1945, 2019 06 12. |
Meta-analysis |
65 studies |
To determine whether coronary computed tomography angiography (CTA) should be performed in patients with any clinical probability of coronary artery disease (CAD), and whether the diagnostic performance differs between subgroups of patients. |
Individual patient data from 5332 patients from 65 prospective diagnostic accuracy studies were retrieved. For a pretest probability range of 7-67%, the treat threshold of more than 50% and the no-treat threshold of less than 15% post-test probability were obtained using CTA. At a pretest probability of 7%, the positive predictive value of CTA was 50.9% (95% confidence interval 43.3% to 57.7%) and the negative predictive value of CTA was 97.8% (96.4% to 98.7%); corresponding values at a pretest probability of 67% were 82.7% (78.3% to 86.2%) and 85.0% (80.2% to 88.9%), respectively. The overall sensitivity of CTA was 95.2% (92.6% to 96.9%) and the specificity was 79.2% (74.9% to 82.9%). CTA using more than 64 detector rows was associated with a higher empirical sensitivity than CTA using up to 64 rows (93.4% v 86.5%, P=0.002) and specificity (84.4% v 72.6%, P<0.001). The area under the receiver-operating-characteristic curve for CTA was 0.897 (0.889 to 0.906), and the diagnostic performance of CTA was slightly lower in women than in with men (area under the curve 0.874 (0.858 to 0.890) v 0.907 (0.897 to 0.916), P<0.001). The diagnostic performance of CTA was slightly lower in patients older than 75 (0.864 (0.834 to 0.894), P=0.018 v all other age groups) and was not significantly influenced by angina pectoris type (typical angina 0.895 (0.873 to 0.917), atypical angina 0.898 (0.884 to 0.913), non-anginal chest pain 0.884 (0.870 to 0.899), other chest discomfort 0.915 (0.897 to 0.934)). |
Good |
| 30. Arbab-Zadeh A, Miller JM, Rochitte CE, et al. Diagnostic accuracy of computed tomography coronary angiography according to pre-test probability of coronary artery disease and severity of coronary arterial calcification. The CORE-64 (Coronary Artery Evaluation Using 64-Row Multidetector Computed Tomography Angiography) International Multicenter Study. J Am Coll Cardiol 2012;59:379-87. |
Observational-Dx |
371 patients |
To assess the impact of patient population characteristics on accuracy by computed tomography angiography (CTA) to detect obstructive coronary artery disease (CAD). |
Analysis of patient-based quantitative CTA accuracy revealed an AUC of 0.93 (95% confidence interval [CI]: 0.90 to 0.95). The AUC remained 0.93 (95% CI: 0.90 to 0.96) after excluding patients with known CAD but decreased to 0.81 (95% CI: 0.71 to 0.89) in patients with calcium score >/=600 (p = 0.077). While AUCs were similar (0.93, 0.92, and 0.93, respectively) for patients with intermediate, high pre-test probability for CAD, and known CAD, negative predictive values were different: 0.90, 0.83, and 0.50, respectively. Negative predictive values decreased from 0.93 to 0.75 for patients with calcium score <100 or >/=100, respectively (p = 0.053). |
2 |
| 31. Abdulla J, Abildstrom SZ, Gotzsche O, Christensen E, Kober L, Torp-Pedersen C. 64-multislice detector computed tomography coronary angiography as potential alternative to conventional coronary angiography: a systematic review and meta-analysis. Eur Heart J 2007;28:3042-50. |
Meta-analysis |
27 studies; 1,740 patients |
To evaluate the diagnostic accuracy of 64-slice multi-detector computed tomography coronary angiography (64-SCTA) compared with the standard reference conventional coronary angiography (CCA). |
Based on a systematic search, 27 studies including 1740 patients were eligible for meta-analyses. Nineteen studies examined native coronary arteries (n = 1,251), four studies examined coronary artery by-pass grafts (CABG) (n = 271), and five studies examined coronary stents (n = 270). Overall 18 920 segments were assessable and 810 (4%) were unassessable. The prevalence of native coronary artery stenosis in per-segment (19 studies) and per-patients (13 studies) populations were 19 and 57.5% respectively. Accuracy tests with 95% confidence intervals comparing 64-SCTA vs. CCA showed that sensitivity, specificity, positive predictive and negative predictive values for native coronary arteries were 86(85-87), 96(95.5-96.5), 83, and 96.5% by per-segment analysis; 97.5(96-99), 91(87.5-94), 93, and 96.5% by per-patient analysis; 98.5(96-99.5), 96(93.5-97.5), 92 and 99% for CABGs; 80(70-88.5), 95(92-97), 80, and 95% for stent restenosis; and 87(86.5-88), 96(95.5-96.5), 83.5, and 97% by overall per-segment analysis. |
M |
| 32. The SCOT-HEART investigators. CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): an open-label, parallel-group, multicentre trial. The Lancet 2015;385:2383-91. |
Observational-Dx |
4,146 patients |
To assess the effect of CT coronary angiography (CTCA) on the diagnosis, management, and outcome of patients referred to the cardiology clinic with suspected angina due to coronary heart disease. |
Between Nov 18, 2010, and Sept 24, 2014, we randomly assigned 4146 (42%) of 9849 patients who had been referred for assessment of suspected angina due to coronary heart disease. 47% of participants had a baseline clinic diagnosis of coronary heart disease and 36% had angina due to coronary heart disease. At 6 weeks, CTCA reclassified the diagnosis of coronary heart disease in 558 (27%) patients and the diagnosis of angina due to coronary heart disease in 481 (23%) patients (standard care 22 [1%] and 23 [1%]; p<0·0001). Although both the certainty (relative risk [RR] 2·56, 95% CI 2·33–2·79; p<0·0001) and frequency of coronary heart disease increased (1·09, 1·02–1·17; p=0·0172), the certainty increased (1·79, 1·62–1·96; p<0·0001) and frequency seemed to decrease (0·93, 0·85–1·02; p=0·1289) for the diagnosis of angina due to coronary heart disease. This changed planned investigations (15% vs 1%; p<0·0001) and treatments (23% vs 5%; p<0·0001) but did not affect 6-week symptom severity or subsequent admittances to hospital for chest pain. After 1·7 years, CTCA was associated with a 38% reduction in fatal and non-fatal myocardial infarction (26 vs 42, HR 0·62, 95% CI 0·38–1·01; p=0·0527), but this was not significant. |
2 |
| 33. Koo BK, Erglis A, Doh JH, et al. Diagnosis of ischemia-causing coronary stenoses by noninvasive fractional flow reserve computed from coronary computed tomographic angiograms. Results from the prospective multicenter DISCOVER-FLOW (Diagnosis of Ischemia-Causing Stenoses Obtained Via Noninvasive Fractional Flow Reserve) study. J Am Coll Cardiol 2011;58:1989-97. |
Experimental-Dx |
103 patients |
To determine the diagnostic performance of a new method for quantifying fractional flow reserve (FFR) with computational fluid dynamics (CFD) applied to coronary computed tomography angiography (CCTA) data in patients with suspected or known coronary artery disease (CAD). |
Fifty-six percent of patients had >/=1 vessel with FFR </=0.80. On a per-vessel basis, the accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were 84.3%, 87.9%, 82.2%, 73.9%, 92.2%, respectively, for FFR(CT) and were 58.5%, 91.4%, 39.6%, 46.5%, 88.9%, respectively, for CCTA stenosis. The area under the receiver-operator characteristics curve was 0.90 for FFR(CT) and 0.75 for CCTA (p = 0.001). The FFR(CT) and FFR were well correlated (r = 0.717, p < 0.001) with a slight underestimation by FFR(CT) (0.022 +/- 0.116, p = 0.016). |
2 |
| 34. Taylor CA, Fonte TA, Min JK. Computational fluid dynamics applied to cardiac computed tomography for noninvasive quantification of fractional flow reserve: scientific basis. J Am Coll Cardiol 2013;61:2233-41. |
Review/Other-Dx |
N/A |
To discuss the review on the scientific principles that underlie computational fluid dynamics applied to cardiac computed tomography for noninvasive quantification of fractional flow reserve. |
No results stated in the abstract |
4 |
| 35. Hlatky MA, De Bruyne B, Pontone G, et al. Quality-of-Life and Economic Outcomes of Assessing Fractional Flow Reserve With Computed Tomography Angiography: PLATFORM. J Am Coll Cardiol. 66(21):2315-23, 2015 Dec 01. |
Observational-Dx |
584 patients |
To determine the effect on cost and quality of life (QOL) of using computed tomography (FFRCT) instead of usual care to evaluate stable patients with symptoms suspicious for coronary disease. |
In the 584 patients, 74% had atypical angina, and the pre-test probability of coronary disease was 49%. In the planned invasive stratum, mean costs were 32% lower among the FFRCT patients than among the usual care patients ($7,343 vs. $10,734 p < 0.0001). In the noninvasive stratum, mean costs were not significantly different between the FFRCT patients and the usual care patients ($2,679 vs. $2,137; p = 0.26). In a sensitivity analysis, when the cost weight of FFRCT was set to 7 times that of computed tomography angiography, the FFRCT group still had lower costs than the usual care group in the invasive testing stratum ($8,619 vs. $ 10,734; p < 0.0001), whereas in the noninvasive testing stratum, when the cost weight of FFRCT was set to one-half that of computed tomography angiography, the FFRCT group had higher costs than the usual care group ($2,766 vs. $2,137; p = 0.02). Each QOL score improved in the overall study population (p < 0.0001). In the noninvasive stratum, QOL scores improved more in FFRCT patients than in usual care patients: Seattle Angina Questionnaire 19.5 versus 11.4, p = 0.003; EuroQOL 0.08 versus 0.03, p = 0.002; and visual analog scale 4.1 versus 2.3, p = 0.82. In the invasive cohort, the improvements in QOL were similar in the FFRCT and usual care patients. |
2 |
| 36. Norgaard BL, Leipsic J, Gaur S, et al. Diagnostic performance of noninvasive fractional flow reserve derived from coronary computed tomography angiography in suspected coronary artery disease: the NXT trial (Analysis of Coronary Blood Flow Using CT Angiography: Next Steps). J Am Coll Cardiol 2014;63:1145-55. |
Observational-Dx |
254 patients |
To determine the diagnostic performance of noninvasive fractional flow reserve (FFR) derived from standard acquired coronary computed tomography angiography (CTA) datasets (FFR(CT)) for the diagnosis of myocardial ischemia in patients with suspected stable coronary artery disease (CAD). |
The area under the receiver-operating characteristic curve for FFR(CT) was 0.90 (95% confidence interval [CI]: 0.87 to 0.94) versus 0.81 (95% CI: 0.76 to 0.87) for coronary CTA (p = 0.0008). Per-patient sensitivity and specificity (95% CI) to identify myocardial ischemia were 86% (95% CI: 77% to 92%) and 79% (95% CI: 72% to 84%) for FFR(CT) versus 94% (86 to 97) and 34% (95% CI: 27% to 41%) for coronary CTA, and 64% (95% CI: 53% to 74%) and 83% (95% CI: 77% to 88%) for ICA, respectively. In patients (n = 235) with intermediate stenosis (95% CI: 30% to 70%), the diagnostic accuracy of FFR(CT) remained high. |
2 |
| 37. Danad I, Szymonifka J, Twisk JWR, et al. Diagnostic performance of cardiac imaging methods to diagnose ischaemia-causing coronary artery disease when directly compared with fractional flow reserve as a reference standard: a meta-analysis. Eur Heart J 2017;38:991-98. |
Meta-analysis |
23 studies |
The aim of this study was to determine the diagnostic performance of single-photon emission computed tomography (SPECT), stress echocardiography (SE), invasive coronary angiography (ICA), coronary computed tomography angiography (CCTA), fractional flow reserve (FFR) derived from CCTA (FFRCT), and cardiac magnetic resonance (MRI) imaging when directly compared with an FFR reference standard. |
PubMed and Web of Knowledge were searched for investigations published between 1 January 2002 and 28 February 2015. Studies performing FFR in at least 75% of coronary vessels for the diagnosis of ischaemic coronary artery disease (CAD) were included. Twenty-three articles reporting on 3788 patients and 5323 vessels were identified. Meta-analysis was performed for pooled sensitivity, specificity, likelihood ratios (LR), diagnostic odds ratio, and summary receiver operating characteristic curves. In contrast to ICA, CCTA, and FFRCT reports, studies evaluating SPECT, SE, and MRI were largely retrospective, single-centre and with generally smaller study samples. On a per-patient basis, the sensitivity of CCTA (90%, 95% CI: 86-93), FFRCT (90%, 95% CI: 85-93), and MRI (90%, 95% CI: 75-97) were higher than for SPECT (70%, 95% CI: 59-80), SE (77%, 95% CI: 61-88), and ICA (69%, 95% CI: 65-75). The highest and lowest per-patient specificity was observed for MRI (94%, 95% CI: 79-99) and for CCTA (39%, 95% CI: 34-44), respectively. Similar specificities were noted for SPECT (78%, 95% CI: 68-87), SE (75%, 95% CI: 63-85), FFRCT (71%, 95% CI: 65-75%), and ICA (67%, 95% CI: 63-71). On a per-vessel basis, the highest sensitivity was for CCTA (pooled sensitivity, 91%: 88-93), MRI (91%: 84-95), and FFRCT (83%, 78-87), with lower sensitivities for ICA (71%, 69-74), and SPECT (57%: 49-64). Per-vessel specificity was highest for MRI (85%, 79-89), FFRCT (78%: 78-81), and SPECT (75%: 69-80), whereas ICA (66%: 64-68) and CCTA (58%: 55-61) yielded a lower specificity. |
Good |
| 38. Zhuang B, Wang S, Zhao S, Lu M. Computed tomography angiography-derived fractional flow reserve (CT-FFR) for the detection of myocardial ischemia with invasive fractional flow reserve as reference: systematic review and meta-analysis. Eur Radiol 2020;30:712-25. |
Meta-analysis |
16 studies |
To carry out a meta-analysis to derive reliable assessment of the diagnostic performances of fractional flow reserve (FFRCT) and compare the diagnostic accuracy with coronary computed tomography angiography (CCTA) using FFR as reference. |
Sixteen studies published between 2011 and 2019 were included with a total of 1852 patients and 2731 vessels. The pooled sensitivity and specificity for FFRCT at the per-patient level was 89% (95% CI, 85–92%) and 71% (95% CI, 61–80%), respectively, while on the per-vessel basis was 85% (95% CI, 82–88%) and 82% (95% CI, 75–87%), respectively. No apparent difference in the sensitivity at per-patient and per-vessel level between FFRCT and CCTA was observed (0.89 versus 0.93 at per-patient; 0.85 versus 0.88 at per-vessel). However, the specificity of FFRCT was higher than CCTA (0.71 versus 0.32 at per-patient analysis; 0.82 versus 0.46 at per-vessel analysis). |
Good |
| 39. Patel MR, Norgaard BL, Fairbairn TA, et al. 1-Year Impact on Medical Practice and Clinical Outcomes of FFRCT: The ADVANCE Registry. JACC Cardiovasc Imaging 2020;13:97-105. |
Observational-Dx |
5,083 patients |
To evaluate the relationship of fractional flow reserve derived from coronary CTA (FFRCT) with downstream care and clinical outcomes from the 1-year data from the international ADVANCE (Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care) Registry of patients undergoing coronary computed tomography angiography (CTA). |
At 1 year, 449 patients did not have follow-up data. Revascularization occurred in 1,208 (38.40%) patients with an FFRCT =0.80 and in 89 (5.60%) with an FFRCT >0.80 (relative risk [RR]: 6.87; 95% confidence interval [CI]: 5.59 to 8.45; p < 0.001). MACE occurred in 55 patients, 43 events occurred in patients with an FFRCT =0.80 and 12 occurred in those with an FFRCT >0.80 (RR: 1.81; 95% CI: 0.96 to 3.43; p = 0.06). Time to first event (all-cause death or MI) occurred in 38 (1.20%) patients with an FFRCT =0.80 compared with 10 (0.60%) patients with an FFRCT >0.80 (RR: 1.92; 95% CI: 0.96 to 3.85; p = 0.06). Time to first event (cardiovascular death or MI) occurred cardiovascular death or MI occurred more in patients with an FFRCT =0.80 compared with patients with an FFRCT >0.80 (25 [0.80%] vs. 3 [0.20%]; RR: 4.22; 95% CI: 1.28 to 13.95; p = 0.01). |
3 |
| 40. Sakuma H, Ichikawa Y, Chino S, Hirano T, Makino K, Takeda K. Detection of coronary artery stenosis with whole-heart coronary magnetic resonance angiography. J Am Coll Cardiol 2006;48:1946-50. |
Observational-Dx |
131 patients |
To determine the diagnostic performance of whole-heart coronary magnetic resonance (MR) angiography for detecting significant coronary artery disease. |
The acquisition of MR angiography was completed in 113 (86%) of 131 patients, with an imaging time averaged at 12.9 +/- 4.3 min. On a patient-based analysis, the sensitivity, specificity, positive and negative predictive value, and accuracy of MR angiography were 82% (95% confidence interval [CI] 69% to 91%), 90% (95% CI 79% to 96%), 88% (95% CI 74% to 95%), 86% (95% CI 75% to 93%), and 87% (95% CI 79% to 92%), respectively. These values in the individual segments were 78% (95% CI 68% to 85%), 96% (95% CI 95% to 97%), 69% (95% CI 60% to 77%), 98% (95% CI 96% to 98%), and 94% (95% CI 96% to 96%). |
3 |
| 41. Kato S, Kitagawa K, Ishida N, et al. Assessment of coronary artery disease using magnetic resonance coronary angiography: a national multicenter trial. J Am Coll Cardiol. 56(12):983-91, 2010 Sep 14. |
Observational-Dx |
138 Patients |
To determine the diagnostic performance of 1.5-T whole-heart coronary magnetic resonance angiography (MRA) in patients with suspected coronary artery disease (CAD). |
Acquisition of whole-heart coronary MRA images was performed in 127 (92%) of 138 patients with an average imaging time of 9.5 ± 3.5 min. The areas under the receiver-operator characteristic curve from MRA images according to vessel- and patient-based analyses were 0.91 (95% confidence interval [CI]: 0.87 to 0.95) and 0.87 (95% CI: 0.81 to 0.93), respectively. The sensitivity, specificity, positive and negative predictive values, and accuracy of MRA according to a patient-based analysis were 88% (49 of 56, 95% CI: 75% to 94%), 72% (51 of 71, 95% CI: 60% to 82%), 71% (49 of 69, 95% CI: 59% to 81%), 88% (51 of 58, 95% CI: 76% to 95%), and 79% (100 of 127, 95% CI: 72% to 86%), respectively. |
2 |
| 42. Bettencourt N, Ferreira N, Chiribiri A, et al. Additive value of magnetic resonance coronary angiography in a comprehensive cardiac magnetic resonance stress-rest protocol for detection of functionally significant coronary artery disease: a pilot study. Circ Cardiovasc Imaging. 2013;6(5):730-738. |
Observational-Dx |
43 patients |
To evaluate the additive diagnostic value of a 3-dimensional whole-heart MRCA integration into a 1.5T CMR-MPI/LGE protocol for the detection of functionally significant coronary artery disease. |
Diagnostic performances of MRCA, CMR-MPI/LGE, and MRCA+CMR-MPI/LGE integration were determined having XA+fractional flow reserve as standard for coronary artery disease (>/=90% stenosis/occlusion or fractional flow reserve </= 0.80 in vessels>2 mm). MRCA inclusion into the CMR protocol was associated with a mean increase of 7.9 +/- 4.69 (0-17.7) minutes in total examination duration (14%). On patient-based analysis, MRCA had 96% sensitivity, 68% specificity, positive predictive value of 79%, and negative predictive value of 93%. CMR-MPI/LGE had 79% sensitivity, 95% specificity, positive predictive value of 95%, and negative predictive value of 78%. Integration of MRCA with CMR-MPI/LGE further improved CMR performance to 96% sensitivity, 89% specificity, positive predictive value of 92%, and negative predictive value of 94%, with a global accuracy of 93%. |
2 |
| 43. Barbier CE, Bjerner T, Johansson L, Lind L, Ahlstrom H. Myocardial scars more frequent than expected: magnetic resonance imaging detects potential risk group. J Am Coll Cardiol 2006;48:765-71. |
Review/Other-Dx |
259 patients |
To investigate the prevalence of clinically recognized myocardial infarctions (RMIs) and unrecognized myocardial infarctions (UMIs) in 70-year-old subjects, assessed with magnetic resonance imaging (MRI), and to relate the findings to cardiac function and morbidity. |
The images from 248 subjects (123 women, 125 men) were assessable. Myocardial infarction scars were found in 60 subjects (24.2%), in 49 of whom (19.8%) they were UMIs. The volumes of the UMIs were significantly smaller than those of the RMIs. There was an increased frequency of chest pain symptoms among the subjects with UMI or RMI compared with those without MI scars. Ejection fraction was significantly lower and LV mass significantly larger in the subjects with UMI or RMI than in those without MI scars. |
4 |
| 44. Catalano O, Moro G, Perotti M, et al. Late gadolinium enhancement by cardiovascular magnetic resonance is complementary to left ventricle ejection fraction in predicting prognosis of patients with stable coronary artery disease. J Cardiovasc Magn Reson 2012;14:29. |
Observational-Dx |
376 patients |
To assess whether the extent of late gadolinium enhancement (LGE) is an independent predictor of adverse cardiac outcome beyond conventional risk factors, including left ventricle ejection fraction (LVEF). |
LGE and LVEF showed the strongest univariate associations with end-points (HR: 13.61 [95%C.I.: 7.32-25.31] for LGE = 45% of LV mass; and 12.34 [6.80-22.38] for LVEF = 30%; p < 0.0001). Multivariate analysis identified baseline LVEF, loop diuretic therapy, moderate-severe mitral regurgitation and pulmonary hypertension as significant predictors among conventional risk factors. According to a step-wise approach, LGE showed strong association with prognosis as well (5.25 [2.64-10.43]; p < 0.0001). LGE significantly improved the model predictability (chi-square 239 vs 221, F-test p < 0.0001) with an additive effect on the prognostic power of LVEF, which however retained its prognostic power (4.89 [2.50-09.56]; p < 0.0001). Patients with LGE = 45% and/or LVEF = 30% had much worse prognosis compared to patients without risk factors (annual event rates of 43% vs 3%; p < 0.0001). Interestingly LGE was a significant predictor when all cause mortality was analyzed as the only endpoint. |
2 |
| 45. Abbasi SA, Ertel A, Shah RV, et al. Impact of cardiovascular magnetic resonance on management and clinical decision-making in heart failure patients. J Cardiovasc Magn Reson 2013;15:89. |
Observational-Dx |
150 patients |
To evaluate the impact of cardiovascular magnetic resonance (CMR) on clinical management and diagnosis in patients with heart failure. |
Overall, CMR had a significant clinical impact in 65% of patients. This included an entirely new diagnosis in 30% of cases and a change in management in 52%. CMR results directly led to angiography in 9% and to the performance of percutaneous coronary intervention in 7%. In a multivariable model that included clinical and imaging parameters, presence of late gadolinium enhancement (LGE) was the only independent predictor of "significant clinical impact" (OR 6.72, 95% CI 2.56-17.60, p=0.0001). |
2 |
| 46. Bikiri E, Mereles D, Voss A, et al. Dobutamine stress cardiac magnetic resonance versus echocardiography for the assessment of outcome in patients with suspected or known coronary artery disease. Are the two imaging modalities comparable? Int J Cardiol 2014;171:153-60. |
Observational-Dx |
1,852 patients |
To compare the value of Dobutamine stress echocardiography (DSE) with that provided by Dobutamine Cardiac Magnetic Resonance (DCMR) for the non-invasive risk stratification of patients with suspected or known coronary artery disease (CAD). |
Follow-up data were available in 1852 patients who completed either DSE (n=884) or DCMR (n=884) during a mean follow-up duration of 4.1±2.4 and 3.9±1.9years, respectively (p=NS). Matched patients exhibited an overall high risk profile (69±9years; 69% male, 70% history of CAD and 26% diabetes mellitus in both groups). Using multivariable analysis, both modalities successfully identified patients with inducible ischemia at higher risk for subsequent hard cardiac events, surpassing the value of conventional risk factors like age, male gender and diabetes (HR=9.2; 95%CI=5.6-14.9 for DCMR versus 2.5; 95%CI=1.7-3.7 for DSE). By testing for interaction the predictive capacity of DCMR was higher than that provided by DSE (p=0.02). Patients with negative DCMR exhibited lower event rates compared to those with negative DSE (annual hard cardiac event rate of 0.8% versus 3.2%, p=0.002). |
3 |
| 47. Wallace EL, Morgan TM, Walsh TF, et al. Dobutamine cardiac magnetic resonance results predict cardiac prognosis in women with known or suspected ischemic heart disease. JACC Cardiovasc Imaging 2009;2:299-307. |
Observational-Dx |
266 patients |
To determine the prognostic utility of dobutamine cardiac magnetic resonance (DCMR) stress test results in women. |
Women were contacted an average of 6.2 +/- 1.6 (median 6.2, range 0.8 to 10.4) years after DCMR; 27% of the women experienced an inducible LVWM abnormality during testing. In those with and without inducible LVWM abnormalities, the proportion of women with cardiac events were 63% versus 30%, respectively, (hazard ratio [HR]: 2.7; 95% confidence interval [CI]: 1.8 to 4.3 for the presence of inducible LVWM abnormalities p < 0.0001). The proportion of women with myocardial infarction (MI) and cardiac death were 33.3% and 7.5%, respectively. This resulted in a HR for MI and cardiac death of 4.1 (95% CI: 2.2 to 9.4) for those with versus those without inducible LVWM abnormalities; p < 0.0001. A subgroup analysis was performed in women without a history of coronary artery disease and in those with LVWM abnormalities, DCMR remained an adverse predictor of cardiac events (HR: 4.0, 95% CI: 1.8 to 9.0, p = 0.003). |
2 |
| 48. Shah R, Heydari B, Coelho-Filho O, et al. Stress cardiac magnetic resonance imaging provides effective cardiac risk reclassification in patients with known or suspected stable coronary artery disease. Circulation 2013;128:605-14. |
Observational-Dx |
815 patients |
To test the hypothesis that stress cardiac magnetic resonance (CMR) would effectively reclassify patients across American College of Cardiology (ACC)/American Heart Association (AHA) (ACC/AHA)-recommended cardiac risk categories, the basis for management decisions in these patients |
In a cohort of 815 consecutive patients referred for evaluation of myocardial ischemia, we determined the net reclassification improvement of the risk of cardiac death or nonfatal myocardial infarction (major adverse cardiac events) incremental to clinical risk models, using guideline-based low (<1%), moderate (1% to 3%), and high (>3%) annual risk categories. In the whole cohort, inducible ischemia demonstrated a strong association with major adverse cardiac events (hazard ratio=14.66; P<0.0001) with low negative event rates of major adverse cardiac events and cardiac death (0.6% and 0.4%, respectively). This prognostic robustness was maintained in patients with previous coronary artery disease (hazard ratio=8.17; P<0.0001; 1.3% and 0.6%, respectively). Adding inducible ischemia to the multivariable clinical risk model (adjusted for age and previous coronary artery disease) improved discrimination of major adverse cardiac events (C statistic, 0.81-0.86; P=0.04; adjusted hazard ratio=7.37; P<0.0001) and reclassified 91.5% of patients at moderate pretest risk (65.7% to low risk; 25.8% to high risk) with corresponding changes in the observed event rates (0.3%/y and 4.9%/y for low and high risk posttest, respectively). Categorical net reclassification index was 0.229 (95% confidence interval, 0.063-0.391). Continuous net reclassification improvement was 1.11 (95% confidence interval, 0.81-1.39). |
3 |
| 49. Gargiulo P, Dellegrottaglie S, Bruzzese D, et al. The prognostic value of normal stress cardiac magnetic resonance in patients with known or suspected coronary artery disease: a meta-analysis. Circ Cardiovasc Imaging 2013;6:574-82. |
Meta-analysis |
14 studies |
To define the prognostic value of stress cardiac magnetic resonance (CMR) for prediction of adverse cardiac events in patients with known or suspected coronary artery disease. |
Studies published between January 1985 and April 2012 were identified by database search. We included studies using stress CMR to evaluate subjects with known or suspected coronary artery disease and providing primary data on clinical outcomes of nonfatal myocardial infarction or cardiac death with a follow-up time =3 months. Total of 14 studies were finally included, recruiting 12 178 patients. The negative predictive value for nonfatal myocardial infarction and cardiac death of normal CMR was 98.12% (95% confidence interval, 97.26-98.83) during a weighted mean follow-up of 25.3 months, resulting in estimated event rate after a negative test equal to 1.88% (95% confidence interval, 1.17-2.74). The corresponding annualized event rate after a negative test was 1.03%. Comparable negative predictive values for major coronary events were obtained in studies considering the absence of inducible perfusion defect compared with those evaluating the absence of inducible wall motion abnormality (98.39% versus 97.31%, respectively; P=0.227 by meta-regression analysis). |
Good |
| 50. Nagel E, Greenwood JP, McCann GP, et al. Magnetic Resonance Perfusion or Fractional Flow Reserve in Coronary Disease. N Engl J Med 2019;380:2418-28. |
Observational-Dx |
918 patients |
To determine if an initial management strategy based on myocardial-perfusion cardiovascular magnetic resonance imaging (MRI) would be noninferior to a strategy guided by invasive angiography and fractional flow reserve (FFR) in terms of major adverse cardiac events. |
A total of 184 of 454 patients (40.5%) in the cardiovascular-MRI group and 213 of 464 patients (45.9%) in the FFR group met criteria to recommend revascularization (P = 0.11). Fewer patients in the cardiovascular-MRI group than in the FFR group underwent index revascularization (162 [35.7%] vs. 209 [45.0%], P = 0.005). The primary outcome occurred in 15 of 421 patients (3.6%) in the cardiovascular-MRI group and 16 of 430 patients (3.7%) in the FFR group (risk difference, -0.2 percentage points; 95% confidence interval, -2.7 to 2.4), findings that met the noninferiority threshold. The percentage of patients free from angina at 12 months did not differ significantly between the two groups (49.2% in the cardiovascular-MRI group and 43.8% in the FFR group, P = 0.21). |
3 |
| 51. Nandalur KR, Dwamena BA, Choudhri AF, Nandalur MR, Carlos RC. Diagnostic performance of stress cardiac magnetic resonance imaging in the detection of coronary artery disease: a meta-analysis. J Am Coll Cardiol 2007;50:1343-53. |
Meta-analysis |
37 studies |
To conduct an evidence-based evaluation of stress cardiac magnetic resonance imaging (MRI) in the diagnosis of coronary artery disease (CAD). |
Thirty-seven studies (2,191 patients) met the inclusion criteria, with 14 datasets (754 patients) using stress-induced wall motion abnormalities imaging and 24 datasets (1,516 patients) using perfusion imaging. Stress-induced wall motion abnormalities imaging demonstrated a sensitivity of 0.83 (95% confidence interval [CI] 0.79 to 0.88) and specificity of 0.86 (95% CI 0.81 to 0.91) on a patient level (disease prevalence = 70.5%). Perfusion imaging demonstrated a sensitivity of 0.91 (95% CI 0.88 to 0.94) and specificity of 0.81 (95% CI 0.77 to 0.85) on a patient level (disease prevalence = 57.4%). |
Good |
| 52. Hamon M, Fau G, Nee G, Ehtisham J, Morello R. Meta-analysis of the diagnostic performance of stress perfusion cardiovascular magnetic resonance for detection of coronary artery disease. J Cardiovasc Magn Reson 2010;12:29. |
Meta-analysis |
35 studies |
To provide a comprehensive and contemporary meta-analysis of its diagnostic accuracy compared with an invasive coronary angiography (CA) used as a reference standard. |
From the 263 citations identified, 55 relevant original articles were selected. Only 35 fulfilled all of the inclusion criteria, and of these 26 presented data on patient-based analysis. The overall patient-based analysis demonstrated a sensitivity of 89% (95% CI: 88-91%), and a specificity of 80% (95% CI: 78-83%). Adenosine stress perfusion CMR had better sensitivity than with dipyridamole (90% (88-92%) versus 86% (80-90%), P = 0.022), and a tendency to a better specificity (81% (78-84%) versus 77% (71-82%), P = 0.065). |
M |
| 53. Nagel E, Lehmkuhl HB, Bocksch W, et al. Noninvasive diagnosis of ischemia-induced wall motion abnormalities with the use of high-dose dobutamine stress MRI: comparison with dobutamine stress echocardiography. Circulation 1999;99:763-70. |
Observational-Dx |
208 patients |
To compare echocardiography and MR for the detection of stress-induced wall motion abnormalities in patients with suspected coronary artery disease. |
Eighteen patients could not be examined by DSMR (claustrophobia 11 and adipositas 6) and 18 patients by DSE (poor image quality). Four patients did not reach target heart rate. In 107 patients, coronary artery disease was found. With DSMR, sensitivity was increased from 74.3% to 86.2% and specificity from 69.8% to 85.7% (both P<0.05) compared with DSE. Analysis for women yielded similar results. |
1 |
| 54. Hundley WG, Hamilton CA, Thomas MS, et al. Utility of fast cine magnetic resonance imaging and display for the detection of myocardial ischemia in patients not well suited for second harmonic stress echocardiography. Circulation 1999;100:1697-702. |
Experimental-Dx |
153 patients |
To assess the safety and clinical utility of fast cine MRI stress testing for the determination of inducible ischemia in patients not suitable for stress echocardiography. |
No patients experienced myocardial infarction, ventricular fibrillation, exacerbation of congestive heart failure, or death. In patients who underwent computer-assisted quantitative coronary angiography, the sensitivity and specificity for detecting a >50% luminal diameter narrowing were 83% and 83%, respectively. In the 103 patients with a negative MRI examination, the cardiovascular occurrence-free survival rate was 97%. |
2 |
| 55. Bengel FM, Higuchi T, Javadi MS, Lautamaki R. Cardiac positron emission tomography. J Am Coll Cardiol 2009;54:1-15. |
Review/Other-Dx |
N/A |
To summarize the state-of-the-art in current imaging methodology and clinical application, and outlines novel developments and future directions. |
No results available. |
4 |
| 56. Tsukamoto T, Morita K, Naya M, et al. Myocardial flow reserve is influenced by both coronary artery stenosis severity and coronary risk factors in patients with suspected coronary artery disease. Eur J Nucl Med Mol Imaging 2006;33:1150-6. |
Observational-Dx |
74 patients |
To investigate the influence of coronary artery stenosis severity and risk factors on myocardial flow reserve (MFR). |
In stenotic regions, MFR correlated inversely with coronary artery stenosis severity (r=-0.50, p<0.01). Univariate analysis did not show any significant differencein MFR between the patients with and the patients without each risk factor. In remote regions, however, MFR was significantly decreased in the diabetes and smoking groups (each p<0.05). By multivariate analysis, diabetes and smoking were independent predictors of MFR (each p<0.05). In the group with more than one risk factor, MFR was significantly lower (2.78±0.79) than in the other group (3.40±1.22, p<0.05). |
2 |
| 57. Dorbala S, Vangala D, Sampson U, Limaye A, Kwong R, Di Carli MF. Value of vasodilator left ventricular ejection fraction reserve in evaluating the magnitude of myocardium at risk and the extent of angiographic coronary artery disease: a 82Rb PET/CT study. J Nucl Med 2007;48:349-58. |
Observational-Dx |
510 patients |
To determine the value of vasodilator left ventricular ejection fraction (LVEF) reserve (stress ejection fraction - rest ejection fraction) in evaluating the magnitude of myocardium at risk and the anatomic extent of underlying severe coronary artery disease (CAD). |
Patients without coronary risk factors who comprised our control group as well as patients with coronary risk factors and normal perfusion demonstrated a high LVEF reserve (7% +/- 7% and 5% +/- 6%, respectively). The mean LVEF reserve was negative (-0.2% +/- 8%) in patients with severe reversible defects and in patients with 3-vessel (-6% +/- 8%) and left main (-8% +/- 5%) disease. Among the clinical and scintigraphic variables studied, male sex, rest ejection fraction, and increasing magnitude of myocardium at risk predicted a lower LVEF reserve, whereas LVEF reserve was the only independent predictor of left main/3-vessel disease (P = 0.008). An LVEF reserve of more than +5% had a positive predictive value of only 41% but a negative predictive value of 97% for excluding severe left main/3-vessel CAD. |
2 |
| 58. Mc Ardle BA, Dowsley TF, deKemp RA, Wells GA, Beanlands RS. Does rubidium-82 PET have superior accuracy to SPECT perfusion imaging for the diagnosis of obstructive coronary disease?: A systematic review and meta-analysis. J Am Coll Cardiol 2012;60:1828-37. |
Meta-analysis |
23 studies |
To evaluate the accuracy of rubidium (Rb)-82 positron emission tomography (PET) for the diagnosis of obstructive coronary artery disease (CAD) in comparison to single-photon emission tomography (SPECT). |
Fifteen PET and 8 SPECT studies (1,344 and 1,755 patients, respectively) met inclusion criteria and pooled accuracy using weighted averages according to the size of the patient population was determined for PET and SPECT with sensitivities of 90% (confidence interval [CI]: 0.88 to 0.92) and 85% (CI: 0.82 to 0.87) and specificities of 88% (CI: 0.85 to 0.91) and 85% (CI: 0.82 to 0.87), respectively. Summary receiver-operating characteristic curves were computed: area under the curve was 0.95 and 0.90 for PET and SPECT, respectively (p < 0.0001). There was heterogeneity among study populations and some studies were limited by referral bias. |
Good |
| 59. Dorbala S, Hachamovitch R, Curillova Z, et al. Incremental prognostic value of gated Rb-82 positron emission tomography myocardial perfusion imaging over clinical variables and rest LVEF. JACC Cardiovasc Imaging 2009;2:846-54. |
Observational-Dx |
1,432 patients |
To study the incremental value of gated rubidium (Rb)-82 positron emission tomography (PET) myocardial perfusion imaging (MPI) over clinical variables for predicting survival and future cardiac events. |
Over a mean follow-up of 1.7 ± 0.7 years, 83 (5.8%) CE and 140 (9.7%) all-cause death were observed. There was an increase in risk for both end points with an increasing percentage of abnormal and ischemic myocardium. With normal, mild, moderate, or severely ischemic scans, the observed annualized rates of CE were 0.7%, 5.5%, 5%, and 11% and of all-cause death were 3.3%, 7.2%, 6.9%, and 12.5%, respectively. In 985 patients with peak stress gated data, the observed annualized rates of CE (2.1% vs. 5.3%, p < 0.001) and all-cause death (4.3% vs. 9.2%, p < 0.001) were higher in patients with an LVEF reserve <0% compared with those with an LVEF reserve =0%. On Cox proportional hazards analysis, after consideration of clinical, historical, and rest LVEF information, stress PET results and LVEF reserve yielded incremental prognostic value with respect to both CE and all-cause death. |
3 |
| 60. Dorbala S, Di Carli MF, Beanlands RS, et al. Prognostic value of stress myocardial perfusion positron emission tomography: results from a multicenter observational registry. J Am Coll Cardiol 2013;61:176-84. |
Observational-Dx |
7,061 patients |
To study the prognostic value of positron emission tomography myocardial perfusion imaging (PET MPI) and the improved classification of risk in a large cohort of patients with suspected or known coronary artery disease (CAD). |
Risk-adjusted hazard of cardiac-death increased with each 10% abnormal myocardium with mildly, moderately or severely abnormal stress PET [hazard ratio 2.3 (95% CI 1.4–3.8, P=0.001), 4.2 (95% CI 2.3–7.5, P<0.001), and 4.9 (95% CI 2.5–9.6, P <0.0001), respectively, normal MPI: referent]. Addition of %myocardium ischemic and scarred to clinical information (age, female sex, body mass index, history of hypertension, diabetes, dyslipidemia, smoking, angina, betablocker use, prior revascularization and rest heart rate) improved the model performance [C-statistic 0.805 (95% CI, 0.772–0.838) to 0.839 (95% CI, 0.809–0.869)] and risk reclassification for cardiac-death [NRI 0.116 (95% CI 0.021–0.210)] with smaller improvements in risk assessment for all-cause death. |
3 |
| 61. Di Carli MF, Dorbala S, Curillova Z, et al. Relationship between CT coronary angiography and stress perfusion imaging in patients with suspected ischemic heart disease assessed by integrated PET-CT imaging. J Nucl Cardiol. 2007;14(6):799-809. |
Observational-Dx |
110 patients |
To examine the value of CTA to identify the presence of ischemia, as determined by stress perfusion imaging, using integrated positron emission tomography (PET)-CT imaging. |
Increasing degrees of CTA-detected luminal narrowing (<50%, 50%-70%, and >70%) were associated with reduced sensitivity with commensurate improvements in specificity for identifying myocardial ischemia both on a per-vessel basis and on a per-patient basis. Consequently, with increasing degrees of CTA-detected stenosis severity, the positive predictive value increased (14%, 26%, and 53%, respectively, on a per-vessel basis [P < .001] and 29%, 44%, and 77%, respectively, on a per-patient basis [P = .005]), whereas the negative predictive value was unchanged (97%, 97%, and 96%, respectively, on a per-vessel basis [P = not significant (NS)] and 92%, 91%, and 88%, respectively, on a per-patient basis [P = NS]). Receiver operating characteristic analysis revealed no differences between these 3 anatomic criteria (receiver operating characteristic areas of 0.66 +/- 0.07, 0.73 +/- 0.06, and 0.71 +/- 0.07, respectively [P = NS]) for identifying ischemia. Nearly half of significant angiographic stenoses (47%) occurred without evidence of myocardial ischemia, whereas 50% of normal PET studies were associated with some CTA abnormality. |
2 |
| 62. Giri S, Shaw LJ, Murthy DR, et al. Impact of diabetes on the risk stratification using stress single-photon emission computed tomography myocardial perfusion imaging in patients with symptoms suggestive of coronary artery disease. Circulation 2002;105:32-40. |
Observational-Dx |
4,755 patients |
To evaluate the incremental role of stress single-photon emission computed tomography (SPECT) imaging in diabetic patients in the prediction of cardiac events. |
Of 4755 patients, 929 (19.5%) were diabetic. Patients with diabetes, despite an increased revascularization rate, had 80 cardiac events (8.6%; 39 deaths and 41 MIs) compared with 172 cardiac events (4.5%; 69 deaths and 103 MIs) in the nondiabetic cohort (P<0.0001). Abnormal stress MPI was an independent predictor of cardiac death and MI in both populations. Diabetics with ischemic defects had an increased number of cardiac events (P<0.001), with the highest MI rates (17.1%) observed with 3-vessel ischemia. Similarly, a multivessel fixed defect was associated with the highest rate of cardiac death (13.6%) among diabetics. The unadjusted cardiac survival rate was lower for diabetic patients (91% versus 97%, P<0.001), but it became comparable once adjusted for the pretest clinical risk and stress MPI results. In multivariable Cox analysis, both ischemic and fixed MPI defects independently predicted cardiac death alone or cardiac death/MI. Diabetic women had the worst outcome for any given extent of myocardial ischemia. |
2 |
| 63. Soman P, Taillefer R, DePuey EG, Udelson JE, Lahiri A. Enhanced detection of reversible perfusion defects by Tc-99m sestamibi compared to Tc-99m tetrofosmin during vasodilator stress SPECT imaging in mild-to-moderate coronary artery disease. J Am Coll Cardiol 2001;37:458-62. |
Observational-Dx |
88 patients |
To compare dipyridamole single-photon emission computed tomography (SPECT) imaging with Tc-99m sestamibi and Tc-99m tetrofosmin for the detection of reversible perfusion defects in patients with mild-to-moderate coronary artery disease. |
Tc-99m sestamibi detected reversible perfusion defects in a greater number of segments (total 363 and 285, p < 0.001, and mean +/- SD, 2.2 +/- 3.0 and 1.8 +/- 2.5 per patient, p = 0.008, for Tc-99m sestamibi and Tc-99m tetrofosmin, respectively), demonstrated a larger extent of perfusion defect (mean +/- SD, 15.8% +/- 12.3% and 12.0% +/- 11.4%, p < 0.03, for Tc-99m sestamibi and Tc-99m tetrofosmin, respectively) and more often correctly identified patients with disease in more than one coronary artery (p = 0.02). There was better defect contrast with Tc-99m sestamibi (defect/normal wall count ratios were 0.60 +/- 0.15 vs. 0.73 +/- 0.14 for Tc-99m sestamibi and Tc99m tetrofosmin, respectively, p = 0.01, for reversible defects seen in identical segments with both agents; and 0.73 +/- 0.16 vs 0.79 +/- 0.17, respectively, p <0.01, for reversible defects detected with either agent alone). There was no significant difference in diagnostic sensitivity or image quality. |
2 |
| 64. Emmett L, Iwanochko RM, Freeman MR, Barolet A, Lee DS, Husain M. Reversible regional wall motion abnormalities on exercise technetium-99m-gated cardiac single photon emission computed tomography predict high-grade angiographic stenoses. J Am Coll Cardiol 2002;39:991-8. |
Observational-Dx |
100 patients |
To determine the level of angiographic stenosis at which reversible regional wall motion abnormalities (RWMA) are present on exercise stress technetium-99m (Tc-99m)-gated single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), and whether assessments of stress and rest RWMA add incremental diagnostic information. |
The sensitivity of reversible RWMA for angiographic stenoses >70% was 53%, with a specificity of 100%. The presence of reversible RWMA was able to stratify patients with angiographic stenoses of 50% to 79% and 80% to 99% with a high positive predictive value. A good correlation was noted between the presence of reversible RWMA and the coronary artery jeopardy score (R = 0.49, p < 0.0001). Multivariate analysis showed that the post-stress RWMA, Duke treadmill and reversible RWMA scores were significant predictors of angiographic severity. |
2 |
| 65. Baghdasarian SB, Noble GL, Ahlberg AW, Katten D, Heller GV. Risk stratification with attenuation corrected stress Tc-99m sestamibi SPECT myocardial perfusion imaging in the absence of ECG-gating due to arrhythmias. J Nucl Cardiol 2009;16:533-9. |
Observational-Dx |
419 patients |
To define the role of AC in the risk stratification of patients with SPECT myocardial perfusion imaging studies in patients unable to undergo ECG-gating. |
The 419 patients had a mean age of 71.5 +/- 11.7 years and most (70.6%) underwent pharmacologic stress. In follow-up, 35 (8.4%) patients suffered an adverse cardiac event. Patients with AC-SSS 1-3 and AC-SSS 4-8 had similar cardiac event rates (11.4% vs 10.5%, P = NS). Accordingly, AC-SSS cutoffs of 0, 1-8, and >8 were selected to classify perfusion as normal, mildly abnormal, and moderately to severely abnormal with annualized event rates of 2.1%, 10.8%, and 18.7%, respectively (P < .001). In multivariable analysis, AC-SSS >8 was the most powerful predictor of cardiac events followed by AC-SSS 1-8, history of CAD, age >75 and pharmacologic stress. |
3 |
| 66. Jaarsma C, Leiner T, Bekkers SC, et al. Diagnostic performance of noninvasive myocardial perfusion imaging using single-photon emission computed tomography, cardiac magnetic resonance, and positron emission tomography imaging for the detection of obstructive coronary artery disease: a meta-analysis. J Am Coll Cardiol. 2012;59(19):1719-1728. |
Meta-analysis |
166 articles |
To determine the diagnostic accuracy of the 3 most commonly used noninvasive myocardial perfusion imaging modalities, single-photon emission computed tomography (SPECT), cardiac magnetic resonance (CMR), and positron emission tomography (PET) perfusion imaging for the diagnosis of obstructive coronary artery disease (CAD). |
Of the 3,635 citations, 166 articles (n = 17,901) met the inclusion criteria: 114 SPECT, 37 CMR, and 15 PET articles. There were not enough publications on other perfusion techniques such as perfusion echocardiography and computed tomography to include these modalities into the study. The patient-based analysis per imaging modality demonstrated a pooled sensitivity of 88% (95% confidence interval [CI]: 88% to 89%), 89% (95% CI: 88% to 91%), and 84% (95% CI: 81% to 87%) for SPECT, CMR, and PET, respectively; with a pooled specificity of 61% (95% CI: 59% to 62%), 76% (95% CI: 73% to 78%), and 81% (95% CI: 74% to 87%). This resulted in a pooled diagnostic odds ratio (DOR) of 15.31 (95% CI: 12.66 to 18.52; I(2) 63.6%), 26.42 (95% CI: 17.69 to 39.47; I(2) 58.3%), and 36.47 (95% CI: 21.48 to 61.92; I(2) 0%). Most of the evaluated test and study characteristics did not affect the ranking of diagnostic performances. |
M |
| 67. Hachamovitch R, Rozanski A, Hayes SW, et al. Predicting therapeutic benefit from myocardial revascularization procedures: are measurements of both resting left ventricular ejection fraction and stress-induced myocardial ischemia necessary? J Nucl Cardiol 2006;13:768-78. |
Observational-Dx |
5,366 patients |
To determine whether gated MPS measures of stress perfusion and poststress LV EF predicted which patients would accrue a survival benefit with revascularization versus medical therapy after stress MPS in an observational series of patients who underwent stress MPS. |
The percent of myocardium that was ischemic was the most important predictor of revascularization. The overall model (multivariate chi2 = 728, c index = 0.89, P < 10(-5)) was used as a propensity score. Cox proportional hazards analysis, assessing the relationship between MPS results, non-MPS covariates, and cardiac death, revealed that EF was superior to percent ischemic myocardium in the prediction of cardiac death after adjustment for pre-MPS data and the propensity score. However, an interaction between percent ischemic myocardium and revascularization was present such that, irrespective of EF, patients with little or no ischemia had an improved survival rate with medical therapy, whereas with increasing ischemia, progressive improvements in survival rate were noted with revascularization. |
3 |
| 68. Schaap J, Kauling RM, Boekholdt SM, et al. Incremental diagnostic accuracy of hybrid SPECT/CT coronary angiography in a population with an intermediate to high pre-test likelihood of coronary artery disease. Eur Heart J Cardiovasc Imaging 2013;14:642-9. |
Observational-Dx |
98 patients |
To evaluate the performance of hybrid SPECT/CCTA vs. standalone SPECT and CCTA for the diagnosis of significant coronary artery disease (CAD) in patients with an intermediate to high pre-test likelihood of CAD. |
Hybrid SPECT/CCTA was performed prior to conventional coronary angiography (CA) including fractional flow reserve (FFR) measurements. Hybrid analysis was performed by combined interpretation of SPECT and CCTA images. The sensitivity, specificity, positive (PPV), and negative (NPV) predictive values were calculated for standalone SPECT, CCTA, and hybrid SPECT/CCTA on per patient level, using an FFR <0.80 as a reference for significant CAD. Significant CAD was demonstrated in 56 patients (57.9%). Non-conclusive SPECT or CCTA results were found in 32 (32.7%) patients. SPECT had a sensitivity of 93%, specificity 79%, PPV 85%, and NPV 89%. CCTA had a sensitivity of 98%, specificity 62%, PPV 77%, and NPV 96%. Hybrid analysis of SPECT and CCTA improved the overall performance: sensitivity, specificity, PPV, and NPV for the presence of significant CAD to 96, 95, 96, and 95%, respectively. |
2 |
| 69. Schaap J, de Groot JA, Nieman K, et al. Hybrid myocardial perfusion SPECT/CT coronary angiography and invasive coronary angiography in patients with stable angina pectoris lead to similar treatment decisions. Heart 2013;99:188-94. |
Observational-Dx |
107 patients |
To evaluate to what extent treatment decisions for patients with stable angina pectoris can be made based on hybrid myocardial perfusion single-photon emission CT (SPECT) and CT coronary angiography (CCTA). It has been shown that hybrid SPECT/CCTA has good performance in the diagnosis of significant coronary artery disease (CAD). |
Revascularisation (PCI or CABG) was indicated in 54 (50%) patients based on SPECT and CA. Percentage agreement of treatment decisions in all patients based on hybrid SPECT/CCTA versus SPECT and CA on the necessity of revascularisation was 92%. Percentage agreement of treatment decisions in patients with matched, unmatched and normal hybrid SPECT/CCTA findings was 95%, 84% and 100%, respectively. |
2 |
| 70. Smart SC, Bhatia A, Hellman R, et al. Dobutamine-atropine stress echocardiography and dipyridamole sestamibi scintigraphy for the detection of coronary artery disease: limitations and concordance. J Am Coll Cardiol 2000;36:1265-73. |
Observational-Dx |
83 patients |
To compare dobutamine-atropine stress echocardiography (DASE) and dipyridamole Technetium 99-m (Tc-99m) sestamibi single photon emission computed tomography (SPECT) scintigraphy (DMIBI) for detecting coronary artery disease (CAD). |
The 183 patients (mean age: 60 +/- 11 years, including 50 women) consisted of 64 patients with no coronary disease and 61 with single-, 40 with two- and 18 with three-vessel coronary disease. Dobutamine-atropine stress echocardiography and DMIBI were similarly sensitive (87%, 104/119 and 80%, 95/119, respectively) for the detection of CAD, but DASE was more specific (91%, 58/64 vs. 73%, 47/64, p < 0.01). Sensitivity was similar for the detection of CAD in patients with single-vessel disease (84%, 51/61 vs. 74%, 45/61, respectively) and multivessel disease (91%, 53/58 vs. 86%, 50/58, respectively). Multiple wall motion abnormalities and perfusion defects were similarly sensitive for multivessel disease (72%, 42/58 vs. 66%, 38/53, respectively), but, again, DASE was more specific than DMIBI (95%, 119/125 vs. 76%, 95/125, respectively, p < 0.01). Dobutamine-atropine stress echocardiography and DMIBI were moderately concordant for the detection and extent of CAD (Kappa 0.47, p < 0.0001) but were only fairly (Kappa 0.35, p < 0.001) concordant for the type of abnormalities (normal, fixed, ischemia or mixed). |
3 |
| 71. Picano E, Molinaro S, Pasanisi E. The diagnostic accuracy of pharmacological stress echocardiography for the assessment of coronary artery disease: a meta-analysis. Cardiovasc Ultrasound 2008;6:30. |
Meta-analysis |
5 studies; 435 patients |
To evaluate the diagnostic accuracy of dobutamine versus dipyridamole stress echocardiography through an evidence-based approach. |
The 5 analyzed papers recruited 435 patients, 299 with and 136 without angiographically assessed coronary artery disease (quantitatively assessed stenosis > 50%). Dipyridamole and dobutamine showed similar accuracy (87%, 95% confidence intervals, CI, 83-90, vs. 84%, CI, 80-88, p = 0.48), sensitivity (85%, CI 80-89, vs. 86%, CI 78-91, p = 0.81) and specificity (89%, CI 82-94 vs. 86%, CI 75-89, p = 0.15). |
M |
| 72. Schinkel AF, Bax JJ, Geleijnse ML, et al. Noninvasive evaluation of ischaemic heart disease: myocardial perfusion imaging or stress echocardiography? Eur Heart J. 2003;24(9):789-800. |
Meta-analysis |
17 studies including 1405 patients |
To evaluate the value of stress echocardiography and myocardial perfusion imaging in: (1) the detection of coronary artery disease, (2) the prognosis of coronary artery disease in patients with known or suspected coronary artery disease, (3) prediction of functional recovery following acute myocardial infarction and (4) prediction of functional recovery after revascularisation in patients with chronic ischaemic LV dysfunction. |
Pooling of the data showed a slightly higher overall sensitivity for myocardial perfusion imaging as compared to stress echocardiography (84 vs 80%, P<0.05). This finding is in line with the ischaemic cascade (Fig. 1), since perfusion abnormalities (detected by perfusion imaging) proceed systolic dysfunction (detected by stress echocardiography). On the other hand, stress echocardiography was more specific compared to perfusion imaging (86 vs 77%, P=0.001). |
M |
| 73. Salame G, Juselius WE, Burden M, et al. Contrast-Enhanced Stress Echocardiography and Myocardial Perfusion Imaging in Patients Hospitalized With Chest Pain: A Randomized Study. Crit. pathw. cardiol.. 17(2):98-104, 2018 06. |
Experimental-Dx |
240 patients |
To compare the clinical utility of ultrasound contrast-enhanced stress echocardiography and stress myocardial perfusion imaging (MPI) in patients hospitalized with chest pain. |
A total of 240 patients were randomized, and 229 completed testing. Diagnostic test rates were similar for stress echocardiography versus MPI {89.4% [95% confidence interval (CI), 82.2–94.4] vs. 94.8% [95% CI, 89.1–98.1], P = 0.13} and did not differ with multivariable adjustment. Modalities requiring a diagnostic heart rate criteria were more frequently ordered with stress echocardiography (100% vs. 26%; P < 0.001). Therefore, an imaging-based analysis without the 12 individuals who failed to achieve target heart rate (n = 217) was evaluated with diagnostic test rates of 100% versus 94.8% (95% CI, 89.1%–98.1%; P = 0.03) for stress echocardiography and MPI, respectively. Median length of stay did not differ. Median (interquartile range) test-related charges were lower with stress echocardiography: $2,424 ($2400–$2508) versus $3619 ($3584–$3728), P < 0.0001. |
2 |
| 74. Plana JC, Mikati IA, Dokainish H, et al. A randomized cross-over study for evaluation of the effect of image optimization with contrast on the diagnostic accuracy of dobutamine echocardiography in coronary artery disease The OPTIMIZE Trial. JACC Cardiovasc Imaging 2008;1:145-52. |
Experimental-Dx |
101 patients |
To evaluate whether the addition of a contrast agent to dobutamine stress echocardiography (DSE) improves its diagnostic accuracy for coronary artery disease (CAD) and to determine the effect of image quality on the diagnostic impact of contrast agent use in this setting. |
A total of 101 patients underwent both DSE studies. Similar hemodynamics were achieved during the 2 stress testing sessions. The use of a contrast agent improved the percentage of segments adequately visualized at baseline (from 72 +/- 24% to 95 +/- 8%) and more so at peak stress (67 +/- 28% to 96 +/- 7%); both p < 0.001. Interpretation of wall motion with high confidence also increased with contrast agent use from 36% to 74% (p < 0.001). Segment visualization with the use of a contrast agent improved in all views, but was more pronounced in the apical views. In unenhanced DSE, 36% of studies were normal, 51% had ischemia, and 8% were uninterpretable-all of which became interpretable with the use of a contrast agent. When compared with angiography (n = 92; 55 patients with CAD), accurate detection of ischemia was higher with contrast-enhanced studies versus nonenhanced studies (p = 0.02). As endocardial visualization and confidence of interpretation decreased in unenhanced studies, a greater impact of the use of a contrast agent on DSE accuracy was observed (p < 0.01). |
2 |
| 75. De Bruyne B, Pijls NH, Kalesan B, et al. Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease. N Engl J Med 2012;367:991-1001. |
Experimental-Tx |
1220 patients |
The aim of this trial was to determine whether FFR-guided PCI with drug-eluting stents plus the best available medical therapy is superior to the best available medical therapy alone in reducing the rate of death, myocardial infarction, or unplanned hospitalization leading to urgent revascularization among patients with stable coronary artery disease. |
Recruitment was halted prematurely after enrollment of 1220 patients (888 who underwent randomization and 332 enrolled in the registry) because of a significant between-group difference in the percentage of patients who had a primary end-point event: 4.3% in the PCI group and 12.7% in the medical-therapy group (hazard ratio with PCI, 0.32; 95% confidence interval [CI], 0.19 to 0.53; P<0.001). The difference was driven by a lower rate of urgent revascularization in the PCI group than in the medical-therapy group (1.6% vs. 11.1%; hazard ratio, 0.13; 95% CI, 0.06 to 0.30; P<0.001); in particular, in the PCI group, fewer urgent revascularizations were triggered by a myocardial infarction or evidence of ischemia on electrocardiography (hazard ratio, 0.13; 95% CI, 0.04 to 0.43; P<0.001). Among patients in the registry, 3.0% had a primary end-point event. |
1 |
| 76. Fearon WF, Shilane D, Pijls NH, et al. Cost-effectiveness of percutaneous coronary intervention in patients with stable coronary artery disease and abnormal fractional flow reserve. Circulation 2013;128:1335-40. |
Observational-Tx |
888 patients |
To evaluate the economic and quality-of-life outcomes in the FAME 2 trial. |
Initial costs were significantly higher for PCI in the setting of an abnormal fractional flow reserve than with medical therapy ($9927 versus $3900, P<0.001), but the $6027 difference narrowed over 1-year follow-up to $2883 (P<0.001), mostly because of the cost of subsequent revascularization procedures. Patient utility was improved more at 1 month with PCI than with medical therapy (0.054 versus 0.001 units, P<0.001). The incremental cost-effectiveness ratio of PCI was $36 000 per quality-adjusted life-year, which was robust in bootstrap replications and in sensitivity analyses. |
1 |
| 77. Tonino PA, De Bruyne B, Pijls NH, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med 2009;360:213-24. |
Experimental-Tx |
1,005 patients |
To compare treatment based on the measurement of FFR in addition to angiography with the current practice of treatment guided solely by angiography in patients with multivessel coronary artery disease for whom PCI is the appropriate treatment. |
The mean (+/-SD) number of indicated lesions per patient was 2.7+/-0.9 in the angiography group and 2.8+/-1.0 in the FFR group (P=0.34). The number of stents used per patient was 2.7+/-1.2 and 1.9+/-1.3, respectively (P<0.001). The 1-year event rate was 18.3% (91 patients) in the angiography group and 13.2% (67 patients) in the FFR group (P=0.02). Seventy-eight percent of the patients in the angiography group were free from angina at 1 year, as compared with 81% of patients in the FFR group (P=0.20). |
1 |
| 78. Maron DJ, Hochman JS, Reynolds HR, et al. Initial Invasive or Conservative Strategy for Stable Coronary Disease. N Engl J Med 2020;382:1395-407. |
Observational-Tx |
5,179 patients |
To discuss whether clinical outcomes are better in those who receive an invasive intervention plus medical therapy than in those who receive medical therapy alone is uncertain in patients with stable coronary disease and moderate or severe ischemia, |
Over a median of 3.2 years, 318 primary outcome events occurred in the invasive-strategy group and 352 occurred in the conservative-strategy group. At 6 months, the cumulative event rate was 5.3% in the invasive-strategy group and 3.4% in the conservative-strategy group (difference, 1.9 percentage points; 95% confidence interval [CI], 0.8 to 3.0); at 5 years, the cumulative event rate was 16.4% and 18.2%, respectively (difference, -1.8 percentage points; 95% CI, -4.7 to 1.0). Results were similar with respect to the key secondary outcome. The incidence of the primary outcome was sensitive to the definition of myocardial infarction; a secondary analysis yielded more procedural myocardial infarctions of uncertain clinical importance. There were 145 deaths in the invasive-strategy group and 144 deaths in the conservative-strategy group (hazard ratio, 1.05; 95% CI, 0.83 to 1.32). |
1 |
| 79. Spertus JA, Jones PG, Maron DJ, et al. Health-Status Outcomes with Invasive or Conservative Care in Coronary Disease. N Engl J Med 2020;382:1408-19. |
Observational-Tx |
4,617 patients |
To document the health-status outcomes of these two treatment strategies in high-risk patients with stable ischemic heart disease, a key secondary outcome of the ISCHEMIA trial. |
At baseline, 35% of patients reported having no angina in the previous month. SAQ summary scores increased in both treatment groups, with increases at 3, 12, and 36 months that were 4.1 points (95% credible interval, 3.2 to 5.0), 4.2 points (95% credible interval, 3.3 to 5.1), and 2.9 points (95% credible interval, 2.2 to 3.7) higher with the invasive strategy than with the conservative strategy. Differences were larger among participants who had more frequent angina at baseline (8.5 vs. 0.1 points at 3 months and 5.3 vs. 1.2 points at 36 months among participants with daily or weekly angina as compared with no angina). |
1 |
| 80. Rochitte CE, George RT, Chen MY, et al. Computed tomography angiography and perfusion to assess coronary artery stenosis causing perfusion defects by single photon emission computed tomography: the CORE320 study. Eur Heart J 2014;35:1120-30. |
Experimental-Dx |
381 patients |
To evaluate the diagnostic power of integrating the results of computed tomography angiography (CTA) and CT myocardial perfusion (CTP) to identify coronary artery disease (CAD) defined as a flow limiting coronary artery stenosis causing a perfusion defect by single photon emission computed tomography (SPECT). |
The prevalence of obstructive CAD defined by combined ICA-SPECT/MPI and ICA alone was 38 and 59%, respectively. The patient-based diagnostic accuracy defined by the area under the receiver operating characteristic curve (AUC) of integrated CTA-CTP for detecting or excluding flow-limiting CAD was 0.87 [95% confidence interval (CI): 0.84-0.91]. In patients without prior myocardial infarction, the AUC was 0.90 (95% CI: 0.87-0.94) and in patients without prior CAD the AUC for combined CTA-CTP was 0.93 (95% CI: 0.89-0.97). For the combination of a CTA stenosis >/=50% stenosis and a CTP perfusion deficit, the sensitivity, specificity, positive predictive, and negative predicative values (95% CI) were 80% (72-86), 74% (68-80), 65% (58-72), and 86% (80-90), respectively. For flow-limiting disease defined by ICA-SPECT/MPI, the accuracy of CTA was significantly increased by the addition of CTP at both the patient and vessel levels. |
1 |
| 81. Nieman K, Cury RC, Ferencik M, et al. Differentiation of recent and chronic myocardial infarction by cardiac computed tomography. Am J Cardiol 2006;98:303-8. |
Observational-Dx |
42 patients |
To determine the degree of myocardial attenuation on a contrast-enhanced computed tomogram would facilitate differentiation of recent from long-standing myocardial infarction (MI). |
Contrast-enhanced coronary computed tomographic (CT) scans (Siemens Sensation 64) of patients with a recent MI (<7 days, n = 16), long-standing MI (>12 months, n = 13), and no MI (n = 13) were retrospectively evaluated. To anticipate transmural variation of myocardial perfusion and to neutralize image noise, a series of thin, overlapping slices was created in parallel alignment to the myocardial wall. Within each of these slices, a small region of interest was placed at a constant in-plane position to measure the CT attenuation (Hounsfield units [HU]) at consecutive transmural locations of injured and normal remote myocardium. In addition, wall thickness and the myocardial cavity were measured. Significantly lower CT attenuation values were found in patients with long-standing MI (-13 ± 37 HU) than in those with acute MI (26 ± 26HU) and normal controls (73 ± 14 HU, p <0.001). The attenuation difference between infarcted and remote myocardia was larger in patients with long-standing MI than in patients with recent MI (89 ± 41 and 55 ± 33 HU, respectively, p <0.001). In addition, long-standing MI was associated with wall thinning (p <0.01), and ventricular dilation (p <0.05), whereas recent MI was not (p >0.05). |
3 |
| 82. Achenbach S. Coronary CT Angiography: Moving Up on the Risk Scale. J Am Coll Cardiol 2020;75:464-66. |
Review/Other-Dx |
N/A |
To report the diagnostic accuracy of coronary computed tomography angiography (CTA) in patients with non–ST-segment elevation acute coronary syndrome in comparison to invasive angiography. |
No abstract available. |
4 |
| 83. Min JK, Dunning A, Lin FY, et al. Age- and sex-related differences in all-cause mortality risk based on coronary computed tomography angiography findings results from the International Multicenter CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry) of 23,854 patients without known coronary artery disease. J Am Coll Cardiol 2011;58:849-60. |
Observational-Dx |
27,125 patients |
To examine the predictive value of nonobstructive and obstructive coronary artery disease (CAD) from a large cohort of 23,854 patients without known CAD for intermediate-term mortality risk and further investigated the relationship of mortality risk to CAD as stratified by age and sex. |
At a 2.3 ± 1.1-year follow-up, 404 deaths had occurred. In risk-adjusted analysis, both per-patient obstructive (hazard ratio [HR]: 2.60; 95% confidence interval [CI]: 1.94 to 3.49; p < 0.0001) and nonobstructive (HR: 1.60; 95% CI: 1.18 to 2.16; p = 0.002) CAD conferred increased risk of mortality compared with patients without evident CAD. Incident mortality was associated with a dose-response relationship to the number of coronary vessels exhibiting obstructive CAD, with increasing risk observed for nonobstructive (HR: 1.62; 95% CI: 1.20 to 2.19; p = 0.002), obstructive 1-vessel (HR: 2.00; 95% CI: 1.43 to 2.82; p < 0.0001), 2-vessel (HR: 2.92; 95% CI: 2.00 to 4.25; p < 0.0001), or 3-vessel or left main (HR: 3.70; 95% CI: 2.58 to 5.29; p < 0.0001) CAD. Importantly, the absence of CAD by CCTA was associated with a low rate of incident death (annualized death rate: 0.28%). When stratified by age <65 years versus =65 years, younger patients experienced higher hazards for death for 2-vessel (HR: 4.00; 95% CI: 2.16 to 7.40; p < 0.0001 vs. HR: 2.46; 95% CI: 1.51 to 4.02; p = 0.0003) and 3-vessel (HR: 6.19; 95% CI: 3.43 to 11.2; p < 0.0001 vs. HR: 3.10; 95% CI: 1.95 to 4.92; p < 0.0001) CAD. The relative hazard for 3-vessel CAD (HR: 4.21; 95% CI: 2.47 to 7.18; p < 0.0001 vs. HR: 3.27; 95% CI: 1.96 to 5.45; p < 0.0001) was higher for women as compared with men. |
2 |
| 84. Bittencourt MS, Hulten EA, Murthy VL, et al. Clinical Outcomes After Evaluation of Stable Chest Pain by Coronary Computed Tomographic Angiography Versus Usual Care: A Meta-Analysis. Circ Cardiovasc Imaging. 9(4):e004419, 2016 Apr. |
Meta-analysis |
14 817 pts(4 RCTs) - 7403 were eval by coronary CTA and 7414 were evaluated by UC
Promise (n=10,003)
Sco heart(n=4146)
CAPP(n=488)
Min et al(n=180) |
To discuss the a meta-analysis of randomized controlled trials comparing the use of coronary computed tomographic angiography (CTA) with usual care. |
We systematically searched databases for randomized clinical trials comparing coronary CTA with usual care for the evaluation of stable chest pain with follow-up for cardiovascular outcomes. The primary outcomes were myocardial infarction and all-cause mortality. We identified 4 randomized clinical trials, including a total of 7403 patients undergoing coronary CTA and 7414 patients undergoing usual care with various functional testing approaches. When compared with usual care, the use of coronary CTA was associated with a significant reduction in the annual rate of myocardial infarction (rate ratio, 0.69; 95% confidence interval, 0.49-0.98; P=0.038), but no difference was found in all-cause mortality. There was a trend toward more invasive coronary angiographies among patients undergoing coronary CTA (odds ratio, 1.33; 95% confidence interval, 0.95-1.84; P=0.09) and higher use of coronary revascularizations (odds ratio, 1.77; 95% confidence interval, 1.14-2.75). Significant heterogeneity for invasive coronary angiography and revascularization was noted, which was attributable to the Scottish Computed Tomography of the HEART (SCOT-HEART) study. We found no difference in the rate of admission for cardiac chest pain (rate ratio, 1.21; 95% confidence interval, 0.95-1.54). |
M |
| 85. Ferencik M, Mayrhofer T, Bittner DO, et al. Use of High-Risk Coronary Atherosclerotic Plaque Detection for Risk Stratification of Patients With Stable Chest Pain: A Secondary Analysis of the PROMISE Randomized Clinical Trial. JAMA Cardiol. 3(2):144-152, 2018 02 01. |
Experimental-Dx |
4415 patients |
To determine whether high-risk plaque detected by coronary computed tomographic angiography (coronary CTA) was associated with incident major adverse cardiovascular events (MACE) independently of significant stenosis (SS) and cardiovascular risk factors. |
The study included 4415 patients, of whom 2296 (52%) were women, with a mean age of 60.5 years, a median atherosclerotic cardiovascular disease (ASCVD) risk score of 11, and a MACE rate of 3% (131 events). A total of 676 patients (15.3%) had high-risk plaques, and 276 (6.3%) had SS. The presence of high-risk plaque was associated with a higher MACE rate (6.4% vs 2.4%; hazard ratio, 2.73; 95% CI, 1.89-3.93). This association persisted after adjustment for ASCVD risk score and SS (adjusted hazard ratio [aHR], 1.72; 95% CI, 1.13-2.62). Adding high-risk plaque to the ASCVD risk score and SS assessment led to a significant continuous net reclassification improvement (0.34; 95% CI, 0.02-0.51). Presence of high-risk plaque increased MACE risk among patients with nonobstructive coronary artery disease relative to patients without high-risk plaque (aHR, 4.31 vs 2.64; 95% CI, 2.25-8.26 vs 1.49-4.69). There were no significant differences in MACE in patients with SS and high-risk plaque as opposed to those with SS but not high-risk plaque (aHR, 8.68 vs. 9.31; 95% CI, 4.25-17.73 vs 4.21-20.61). High-risk plaque was a stronger predictor of MACE in women (aHR, 2.41; 95% CI, 1.25-4.64) vs men (aHR, 1.40; 95% CI, 0.81-2.39) and younger patients (aHR, 2.33; 95% CI, 1.20-4.51) vs older ones (aHR, 1.36; 95% CI, 0.77-2.39). |
2 |
| 86. Nerlekar N, Ha FJ, Cheshire C, et al. Computed Tomographic Coronary Angiography-Derived Plaque Characteristics Predict Major Adverse Cardiovascular Events: A Systematic Review and Meta-Analysis. Circ Cardiovasc Imaging 2018;11:e006973. |
Meta-analysis |
13 studies |
To conduct a systematic review and meta-analysis to assess the association between baseline computed tomographic coronary angiography (CTCA)-defined plaque characteristics and subsequent major adverse cardiovascular events (MACE) in patients undergoing imaging for suspected stable coronary artery disease (CAD) . |
Electronic databases were searched for studies reporting computed tomographic coronary angiography plaque characterization and MACE. Data were gathered on plaque morphology (noncalcified, partially calcified, and calcified) and high-risk plaque (HRP) features, including low-attenuation plaque, napkin-ring sign, spotty calcification, and positive remodeling. Of 5496 citations, 13 studies met inclusion criteria. Five hundred fifty-two (3.9%) MACE occurred in 13?977 patients with mean follow-up ranging between 1.3 and 8.2 years. In terms of plaque morphology, the strongest association was observed for noncalcified plaque (hazard ratio [HR], 1.45; 95% confidence interval [CI], 1.24–1.70; P<0.001), with weaker associations found for partially calcified (HR, 1.37; 95% CI, 1.18–1.60; P<0.001) and calcified plaques (HR, 1.23; 95% CI, 1.16–1.30; P<0.001). All HRP features were strongly associated with MACE, including napkin-ring sign (HR, 5.06; 95% CI, 3.23–7.94; P<0.001), low-attenuation plaque (HR, 2.95; 95% CI, 2.03–4.29; P<0.001), positive remodeling (HR, 2.58; 95% CI, 1.84–3.61; P<0.001), and spotty calcification (HR, 2.25; 95% CI, 1.26–4.04; P=0.006). The presence of =2 HRP features had highest risk of MACE (HR, 9.17; 95% CI, 4.10–20.50; P<0.001). |
Good |
| 87. Motoyama S, Ito H, Sarai M, et al. Plaque Characterization by Coronary Computed Tomography Angiography and the Likelihood of Acute Coronary Events in Mid-Term Follow-Up. J Am Coll Cardiol 2015;66:337-46. |
Observational-Dx |
4,423 patients |
This study evaluated whether plaque characteristics by coronary computed tomography angiography (CTA) predict mid-term likelihood of acute coronary syndrome (ACS). |
ACS occurred in 88 (2.8%) patients: 48 (16.3%) of 294 HRP(+) and 40 (1.4%) of 2,864 HRP(-) patients. ACS was also significantly more frequent in SS(+) (36 of 659; 5.5%) than SS(-) patients (52 of 2,499; 2.1%). HRP(+)/SS(+) (19%) and HRP(+)/SS(-) (15%) had higher rates of ACS compared with no-plaque patients (0.6%). Although ACS incidence was relatively low in HRP(-) patients, the cumulative number of patients with ACS developing from HRP(-) lesions (n = 43) was similar to ACS patients with HRP(+) lesions (n = 45). In patients with serial CTA, PP also was an independent predictor of ACS, with HRP (27%; p < 0.0001) and without HRP (10%) compared with HRP(-)/PP(-) patients (0.3%). |
2 |
| 88. Andreini D, Modolo R, Katagiri Y, et al. Impact of Fractional Flow Reserve Derived From Coronary Computed Tomography Angiography on Heart Team Treatment Decision-Making in Patients With Multivessel Coronary Artery Disease: Insights From the SYNTAX III REVOLUTION Trial. Circ Cardiovasc Interv 2019;12:e007607. |
Observational-Dx |
223 patients |
To determine the impact of FFR computed tomography (CT) derived (FFRCT) on heart team's treatment decision-making and selection of vessels for revascularization in patients with 3-vessel coronary artery disease. |
Overall, 223 patients were included. Coronary computed tomography angiography assessment was feasible in 99% of the patients and FFRCT analysis in 88%. FFRCT was available for 1030 lesions (mean FFRCT value 0.64±13). A treatment recommendation of coronary artery bypass grafting was made in 24% of the patients with coronary computed tomography angiography with FFRCT. The addition of FFRCT changed the treatment decision in 7% of the patients and modified selection of vessels for revascularization in 12%. With conventional angiography as reference, FFRCT assessment resulted in reclassification of 14% of patients from intermediate and high to low SYNTAX score tertile. |
2 |
| 89. Kumbhani DJ, Ingelmo CP, Schoenhagen P, Curtin RJ, Flamm SD, Desai MY. Meta-analysis of diagnostic efficacy of 64-slice computed tomography in the evaluation of coronary in-stent restenosis. Am J Cardiol 2009;103:1675-81. |
Meta-analysis |
14 studies |
To perfrm a meta-analysis to determine the diagnostic efficacy of 64-slice computer tomography (CT) in the evaluation of coronary instent restonosis (ISR) compared with invasive angiography. |
. We included studies that used 64-slice CT for evaluation of coronary ISR. We pooled efficacy estimates across studies using random-effects models. We identified 14 studies, which included 895 patients (1,447 stents, mean diameter 3.1 mm). Of these, 1,231 (91.4%) stents were adequately assessed by 64-slice CT. Overall sensitivity was 91% (95% confidence interval [CI] 86 to 94), specificity was 91% (95% CI 89 to 92), positive predictive value (PPV) was 68% (95% CI 63 to 73), and negative predictive value (NPV) was 98% (95% CI 97 to 99). The summary receiver operating characteristic curves graph showed a symmetric area under the curve of 0.96. When nonassessable segments were included, overall sensitivity and specificity decreased to 87% (95% CI 81 to 92) and 84% (95% CI 82 to 87), with a PPV of 53% (95% CI 47 to 59) and an NPV of 97% (95% CI 96 to 98), respectively. In conclusion, 64-slice CT detects (high sensitivity and specificity) or excludes ISR (high NPV) with a high degree of confidence; however, precise quantification of ISR is not accurate (low PPV). Efficacy estimates are even lower when nonassessable segments are included. |
Inadequate |
| 90. Bello D, Shah DJ, Farah GM, et al. Gadolinium cardiovascular magnetic resonance predicts reversible myocardial dysfunction and remodeling in patients with heart failure undergoing beta-blocker therapy. Circulation. 2003; 108(16):1945-1953. |
Observational-Dx |
45 patients |
To obtain high-resolution spatial maps of myocardial scarring and viability in patients with chronic heart failure in whom coronary revascularization was not anticipated at baseline and, with the addition of cine CMR, to precisely assess changes in LV function and remodeling after 6 months of beta-blocker therapy. |
Gadolinium CMR demonstrated scarring in 30 of 45 patients (67%). Scarring was found in 100% of patients with ischemic cardiomyopathy (28 of 28) but in only 12% with nonischemic cardiomyopathy (2 of 17). In the 35 patients who were maintained on beta-blockers and had a second study, there was an inverse relation between the extent of scarring at baseline and the likelihood of contractile improvement 6 months later (P<0.001). For instance, contractility improved in 56% (674 of 1207) of regions with no scarring but in only 3% with >75% scarring (8 of 232). Multivariate analysis showed that the amount of dysfunctional but viable myocardium by CMR was an independent predictor of the change in ejection fraction (P=0.01), mean wall motion score (P=0.0007), LV end-diastolic volume index (P=0.007), and LV end-systolic volume index (P< or =0.0001). |
3 |
| 91. Bogaert J, Kalantzi M, Rademakers FE, Dymarkowski S, Janssens S. Determinants and impact of microvascular obstruction in successfully reperfused ST-segment elevation myocardial infarction. Assessment by magnetic resonance imaging. Eur Radiol 2007;17:2572-80. |
Observational-Dx |
52 patients |
To evaluate the underlying determinants of microvascular obstruction (MVO) using serial magnetic resonance imaging (MRI) in patients in the early phase (i.e., within 1 week and at 4 months after a successful revascularization of an ST-elevation acute MI. |
On early (i.e., 2-5 min) post-contrast MRI, MVO was detected in 32 patients with an MVO to infarct ratio of 36.3 +/- 24.9%. On late (i.e., 10-25 min) post-contrast MRI, MVO was detected in only 27 patients, with an MVO to infarct ratio of 15.9 +/- 13.9%. MVO infarcts (n = 32) were associated with higher cardiac enzymes (troponin I, P = 0.016), and lower pre-revascularization thrombolysis in myocardial infarction (TIMI) flow (P = 0.018) than non-MVO infarcts (n = 20). Infarct size was larger in MVO infarcts (25.0 +/- 14.3 g) than non-MVO infarcts (12.5 +/- 7.9 g), P = 0.0007. Systolic wall thickening in the infarct and peri-infarct area, and left ventricular (LV) ejection fraction (EF) were worse in MVO (46.1 +/- 7.2%) than non-MVO infarcts (50.5 +/- 6.6%, P = 0.038). At 4 months, MVO infarcts showed more adverse remodeling and lack of functional improvement, whereas non-MVO infarcts improved significantly (LV EF at 4 months, MVO, 47.5 +/- 7.8%, P = 0.31; non-MVO, 55.2 +/- 10.3%, P = 0.0028). |
3 |
| 92. Ganame J, Messalli G, Masci PG, et al. Time course of infarct healing and left ventricular remodelling in patients with reperfused ST segment elevation myocardial infarction using comprehensive magnetic resonance imaging. Eur Radiol 2011;21:693-701. |
Observational-Dx |
58 patients |
To describe the time course of myocardial infarct (MI) healing and left ventricular (LV) remodelling and to assess factors predicting LV remodelling using cardiac magnetic resonance imaging (MRI). |
Infarct size decreased between baseline and 4M (p<0.001), but not at 1Y; i.e. 18±11%, 12±8%, 11±6% of LV mass respectively; this was associated with LV mass reduction. Infarct and adjacent wall thinning was found at 4M, whereas significant remote wall thinning was measured at 1Y. LVend-diastolic and end-systolic volumes significantly increased at 1Y, p<0.05 at 1Y vs. baseline and vs. 4M; this was associated with increased LV sphericity index. No regional or global LV functional improvement was found atfollow-up. Baseline infarct size was the strongest predictor of adverse LV remodelling. |
2 |
| 93. Grover S, Bell G, Lincoff M, et al. Utility of CMR Markers of Myocardial Injury in Predicting LV Functional Recovery: Results from PROTECTION AMI CMR Sub-study. Heart Lung Circ 2015;24:891-7. |
Observational-Dx |
96 patients |
To predict 90-day left ventricular (LV) function following acute ST-segment elevation myocardial infarction (STEMI) using variables from clinical presentation, biomarkers, and cardiovascular magnetic resonance imaging (CMR). |
Ninety-six patients were enrolled in the CMR sub study and 85 completed the 90-day follow-up, across 24 centres worldwide. LV ejection fraction (EF) was 56% (46-63%) at baseline and 60% (49-67%) at 90 days (p<0.001). Infarct size had moderate inverse correlation with 90-day EF (Spearman's rho = -0.7, p < 0.001) and had the strongest correlation when compared to myocardial salvage index (Spearman's rho = 0.5, p = 0.001), infarct heterogeneity (Spearman's rho = -0.4, p = 0.02 or microvascular obstruction (Spearman's rho = -0.4, p < 0.001). All biochemical markers had similar moderate relationship to LVEF at 90 days (Spearman's rho -0.6 to -0.8, p=0.001). In a multivariable model, only baseline LVEF, CMR infarct size and infarct heterogeneity independently predicted 90-day LVEF. |
3 |
| 94. Ingkanisorn WP, Rhoads KL, Aletras AH, Kellman P, Arai AE. Gadolinium delayed enhancement cardiovascular magnetic resonance correlates with clinical measures of myocardial infarction. J Am Coll Cardiol 2004;43:2253-9. |
Observational-Dx |
33 patients |
To test the hypothesis that gadolinium delayed enhancement assessment of infarct size correlates with clinical indices of myocardial infarction (MI) in humans. |
In patients with acute percutaneous coronary intervention, acute MI mass correlated with peak troponin I (r = 0.83, p < 0.001, n = 23). In the 20 acute infarct patients with follow-up CMR scans, the acute infarct size correlated well with the follow-up LV ejection fraction (r = 0.86, p < 0.001). The transmural extent of delayed enhancement imaged acutely correlated inversely with wall thickening measured acutely (p < 0.001) and at follow-up (p < 0.001). Although chronic infarct size was reproducible (11 +/- 4% vs. 12 +/- 7%, p = NS), acute infarct size decreased from 16 +/- 12% to 11 +/- 9% (p < 0.003). |
3 |
| 95. Kim RJ, Albert TS, Wible JH, et al. Performance of delayed-enhancement magnetic resonance imaging with gadoversetamide contrast for the detection and assessment of myocardial infarction: an international, multicenter, double-blinded, randomized trial. Circulation 2008;117:629-37. |
Experimental-Dx |
566 patient |
To prospectively test the performance of delayed-enhancement magnetic resonance imaging (MRI) with gadolinium-based contrast for the detection of myocardial infarction (MI) in an international, multicenter trial. |
Patients with their first MI were enrolled in an acute (< or = 16 days after MI; n=282) or chronic (17 days to 6 months; n=284) arm and then randomized to 1 of 4 doses of gadoversetamide: 0.05, 0.1, 0.2, or 0.3 mmol/kg. Standard delayed-enhancement MRI was performed before contrast (control) and 10 and 30 minutes after gadoversetamide. For blinded analysis, precontrast and postcontrast MRIs were randomized and then scored for enhanced regions by 3 independent readers not associated with the study. The infarct-related artery perfusion territory was scored from x-ray angiograms separately. In total, 566 scans were performed in 26 centers using commercially available scanners from all major US/European vendors. All scans were included in the analysis. The sensitivity of MRI for detecting MI increased with rising dose of gadoversetamide (P<0.0001), reaching 99% (acute) and 94% (chronic) after contrast compared with 11% before contrast. Likewise, the accuracy of MRI for identifying MI location (compared with infarct-related artery perfusion territory) increased with rising dose of gadoversetamide (P<0.0001), reaching 99% (acute) and 91% (chronic) after contrast compared with 9% before contrast. For gadoversetamide doses > or = 0.2 mmol/kg, 10- and 30-minute images provided equal performance, and peak creatine kinase-MB levels correlated with MRI infarct size (P<0.0001). |
2 |
| 96. Kim RJ, Wu E, Rafael A, et al. The use of contrast-enhanced magnetic resonance imaging to identify reversible myocardial dysfunction. N Engl J Med 2000;343:1445-53. |
Observational-Dx |
50 patients (44 men, 6 women) |
To test the hypothesis if this new magnetic resonance imaging (MRI) technique can be used to predict whether or not regions of myocardial dysfunction will improve after revascularization. |
Contrast-enhanced MRI showed hyperenhancement of myocardial tissue in 40 of 50 patients before revascularization. In all patients with hyperenhancement the difference in image intensity between hyperenhanced regions and regions without hyperenhancement was more than 6 SD. Before revascularization, 804 of the 2093 myocardial segments analyzed (38 percent) had abnormal contractility, and 694 segments (33 percent) had some areas of hyperenhancement. In an analysis of all 804 dysfunctional segments, the likelihood of improvement in regional contractility after revascularization decreased progressively as the transmural extent of hyperenhancement before revascularization increased (P<0.001). For instance, contractility increased in 256 of 329 segments (78 percent) with no hyperenhancement before revascularization, but in only 1 of 58 segments with hyperenhancement of more than 75 percent of tissue. The percentage of the left ventricle that was both dysfunctional and not hyperenhanced before revascularization was strongly related to the degree of improvement in the global mean wall-motion score (P<0.001) and the ejection fraction (P<0.001) after revascularization. |
3 |
| 97. Orn S, Manhenke C, Anand IS, et al. Effect of left ventricular scar size, location, and transmurality on left ventricular remodeling with healed myocardial infarction. Am J Cardiol 2007;99:1109-14. |
Observational-Dx |
57 patients |
To assess the long-term relations among myocardial scar size, localization, transmurality, and left ventricular (LV) remodeling in survivors after myocardial infarction (MI). |
Cardiac magnetic resonance imaging was used to explore the relation between myocardial scar size, localization, transmurality, and degree of long-term LV remodeling in patients with healed MI. Subjects were recruited from a registry of patients with healed MI who participated in the OPTIMAAL trial. Cardiac magnetic resonance imaging was performed to assess LV mass, volumes, LV ejection fraction, and myocardial scarring, adjusting for myocardial ischemia. Fifty-seven patients (mean age 69 +/- 10 years mean ejection fraction 49 +/- 13%) were studied 4.4 +/- 0.4 years after MI. Anterior scar was found in 19 patients and nonanterior scar in 33, whereas 5 patients did not show myocardial scar. Transmural scar was evident in 36 patients. In the 52 patients with scar, average total scar size was 13 +/- 8% of total LV mass. There was a strong linear relation between scar size and LV end-diastolic volume index (r = 0.81, p <0.0001), end-systolic volume index (r = 0.86, p <0.0001), and LV ejection fraction (r = -0.74, p <0.0001). In multivariate analysis, scar size was the strongest independent predictor of ejection fraction and LV volumes independently of scar localization and transmurality. |
3 |
| 98. Wellnhofer E, Olariu A, Klein C, et al. Magnetic resonance low-dose dobutamine test is superior to SCAR quantification for the prediction of functional recovery. Circulation 2004;109:2172-4. |
Observational-Dx |
29 patients |
To compare low-dose dobutamine challenge (DSMR) by magnetic resonance imaging (MRI) with delayed enhancement imaging with Gd-DTPA (SCAR) as a predictor of improvement of wall motion after revascularization (RECOVERY). |
In 29 patients with coronary artery disease (68+/-7 years of age, 2 women, 32+/-8% ejection fraction), wall motion was evaluated semiquantitatively by MRI before and 3 months after revascularization. SCAR and DSMR were performed before revascularization. The transmural extent of scar was assessed semiquantitatively. Binary prediction of RECOVERY was performed by logistic regression in 288 segments with wall motion abnormalities at rest. Receiver operating characteristic-area under curve (AUC) statistics were used to compare different models. Low-dose DSMR (AUC 0.838) was superior to SCAR (AUC 0.728) in predicting RECOVERY. SCAR did not improve accuracy of prediction by DSMR. Subgroup analysis showed superiority of DSMR for 1% to 74% transmural extent of infarction. |
2 |
| 99. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. |
Review/Other-Dx |
N/A |
To provide evidence-based guidelines on exposure of patients to ionizing radiation. |
No abstract available. |
4 |
