Download Diagnostic value of 64-slice CT angiography in coronary artery

European Journal of Radiology 67 (2008) 78–84
Review
Diagnostic value of 64-slice CT angiography in
coronary artery disease: A systematic review
Zhonghua Sun a,∗ , ChengHsun Lin b , Robert Davidson c ,
Chiauhuei Dong b , Yunchan Liao b
a
Discipline of Medical Imaging, Department of Imaging and Applied Physics,
Curtin University of Technology, Perth, Western Australia, Australia
b Department of Radiological Technology, Central Taiwan University of
Science and Technology, Taichung, Taiwan, ROC
c Discipline of Medical Radiations, RMIT University,
Victoria 3083, Australia
Received 7 April 2007; received in revised form 4 July 2007; accepted 4 July 2007
Abstract
Purpose: To perform a systematic review of the diagnostic value of 64-multislice CT (MSCT) angiography in the detection of coronary artery
disease (CAD) when compared to conventional coronary angiography.
Materials and methods: A search of PUBMED and MEDLINE databases for English literature was performed. Only studies with at least 10
patients comparing 64-slice MSCT angiography with conventional coronary angiography in the detection of CAD were included. Diagnostic value
of MSCT angiography compared to coronary angiography was compared and analysed at segment-, vessel- and patient-based assessment.
Results: Fifteen studies met selection criteria and were included for analysis. Pooled sensitivity, specificity, positive predictive value and negative
predictive value as well as 95% confidence interval (CI) were 97% (94 and 99%), 88% (79 and 97%), 94% (91 and 97%), and 95% (90 and 99%)
for patient-based assessment; 92% (85 and 99%), 92% (85 and 99%), 78% (66 and 91%) and 98% (96 and 99%) for vessel-based assessment; 90%
(85 and 94%), 96% (95 and 97%), 75%(68 and 82%) and 98% (98 and 99%) for segment-based assessment, respectively. No significant difference
was found in the diagnostic accuracy of 64-slice CT in the detection of CAD when comparison was performed either among four main coronary
arteries, or between proximal and middle or distal segments (p > 0.05).
Conclusion: Our results showed that 64-slice CT angiography has a high-diagnostic value in the detection of CAD. Severe coronary artery
calcification seems to be the major factor affecting the visualisation and assessment.
© 2007 Elsevier Ireland Ltd. All rights reserved.
Keywords: Multislice CT; Coronary artery disease; Diagnostic value; Systematic review
Contents
1.
2.
3.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1. Criteria for data selection and literature screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.2. Data extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.3. Definition of coronary artery segments and stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.4. Statistical analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1. General information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.2. Prevalence of CAD and corresponding diagnostic value of MSCT in CAD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
∗
Corresponding author at: Discipline of Medical Imaging, Department of Imaging and Applied Physics, Curtin University of Technology, GPO Box U1987,
Perth, Western Australia 6845, Australia. Tel.: +61 8 9266 7509; fax: +61 8 9266 4344.
E-mail address: [email protected] (Z. Sun).
0720-048X/$ – see front matter © 2007 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ejrad.2007.07.014
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Z. Sun et al. / European Journal of Radiology 67 (2008) 78–84
4.
3.3. Patient-based, vessel-based and segment-based analysis of MSCT in CAD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.4. Evaluation of four main coronary arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.5. Evaluation of proximal, middle and distal segments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.6. Factors affecting the diagnostic value of MSCT in CAD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Introduction
Coronary artery disease (CAD) is the leading cause of death
in Western countries [1]. The standard of reference for diagnosis of CAD is still conventional coronary angiography, with
the advantage of high-spatial resolution and temporal resolution. However, its diagnostic value has been challenged due
to its invasiveness and high expenditure by the introduction of
multislice CT imaging (MSCT). Previous reports showed that
MSCT angiography is a promising technique with the increase
of detector rows from 4-slice to 16-slice and 64-slice scanners
[2–10]. With the increase of number of detectors, more coronary
segments were evaluable, and the sensitivity for a significant
coronary stenosis in evaluable segment was reported to increase
[8–10]. However, diagnostic value of MSCT angiography with
4-slice and 16-slice was still limited and has not reached the
accuracy as that of conventional coronary angiography. Preliminary data showed that 64-slice CT is more sensitive and specific
than earlier 4-slice and 16-slice CT in the diagnosis of coronary
artery disease [11]. Currently there exists a lack of data for a
systematic analysis of the diagnostic value of 64-slice CT in
coronary artery disease. Therefore, the aim of this study was
to perform a systematic review of 64-slice CT angiography in
the detection of CAD with regard to the diagnostic value in
comparison to conventional coronary angiography, based on the
available studies.
2. Materials and methods
2.1. Criteria for data selection and literature screening
A search of PUBMED and MEDLINE databases for English
literature was performed by three reviewers (CD, YL, and
ZS) for articles describing the diagnostic value of 64-slice CT
angiography in CAD when compared to conventional coronary
angiography. The articles must be peer-reviewed and published
in English language. The key words used in describing 64-slice
CT angiography in coronary artery disease were; 64-slice CT
and coronary artery stenosis or disease; MSCT and coronary
arteries and MSCT and coronary angiography. The search was
limited to reports on human subjects and excluded case reports,
conference abstracts, review articles, in vitro studies and articles investigating the coronary stent or bypass graft treatment.
Exclusions were also included investigations limited to reports
of 64-slice CT techniques or methods, electron beam CT. The
search of literature ranged from 1998 to 2007 (March 2007), as
MSCT was first introduced into clinical practice in 1998 [12]. In
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addition, the reference lists of identified articles were checked to
obtain additional relevant articles. Prospective and retrospective
studies were included if they met all of the following criteria:
(a) patients undergoing both 64-slice CT angiography and coronary angiography examinations; (b) studies included at least 10
patients; (c) assessment or comparison of 64-slice CT angiography with coronary angiography was focused on the visualization
of coronary arteries and detection or exclusion of coronary artery
stenosis; (d) diagnostic value of 64-slice CT angiography was
addressed when compared to coronary angiography in terms of
sensitivity, specificity, positive predictive value (PPV), negative
predictive value (NPV), either segment-based, vessel-based or
patient-based assessment.
2.2. Data extraction
Data were extracted repeatedly by three reviewers (CD,
YL, and ZS) based on study design and procedure techniques. The reviewers looked for the following characteristics
in each study: year of publication; origin of the study performed; number of participants in the study; mean age; mean
heart rate; number of patients receiving ␤-blockers; prevalence
of suspected or known CAD; type of imaging unit used for
MSCT scanning; scanning protocols; time interval between
MSCT and conventional coronary angiography; assessable coronary segments in each study; diagnostic accuracy of 64-slice
CT when compared to coronary angiography in terms of the
sensitivity, specificity, PPV, NPV and main factors affecting
the visualization of coronary artery or lesions. All diagnostic accuracy estimates referred to segment/vessel/patient-based
assessment.
2.3. Definition of coronary artery segments and stenosis
Significant stenosis was defined as more than 50% stenosis of the coronary artery lumen which is haemodynamically
significant. High-grade stenosis was defined as more than 75%
stenosis. In our review, we analysed the diagnostic value of
64-slice MSCT in CAD with more than 50 and 75% stenosis. Coronary artery segments were numbered as defined by
the American Heart Association [13]. Assessment of coronary
artery was based on variable description as some investigators
listed the segments, while others described the portion of the
arteries evaluated in terms of numbered segments. The 15/17segment assessment is commonly used by investigators in these
studies comparing 64-slice CT angiography with conventional
coronary angiography.
330
330
370
330
330
370
330
330
400
330
330
330
330
330
330
NS
NS
0.5
0.4
0.4
0.8
0.4
0.5
0.3
0.5
NS
NS
0.5
NS
0.5
NS
NS
0.75
0.75
0.75
1.0
0.75
0.75
0.5
0.75
NS
NS
0.75
NS
0.75
64 × 0.6
64 × 0.6
64 × 0.6
64 × 0.6
64 × 0.6
64 × 0.6
64 × 0.6
64 × 0.6
64 × 0.5
64 × 0.6
64 × 0.6
64 × 0.6
64 × 0.6
64 × 0.6
64 × 0.6
100
36
60
77
NS
60
74
NS
72
NS
22
NS
0
63
54
HR: heart rate; ST: section thickness; RI: reconstruction interval; GRT: gantry rotation time; NS: not stated.
a Two groups were included in the study based on Agatston score (<142 or >142).
17
80
31
49
58
88
72
40
50
68
65
62
66
58
NS
65
59
62
60
61
72
61
70
NS
58
54
17
70
NS
83
NS
100
83
NS
NS
51
42
NS
28
60
50
32
100
59
64
60
61
62
66
58
53/57a
60
59
67
64
63
58/59a
56
2005
2005
2005
2005
2006
2006
2006
2006
2006
2006
2006
2006
2006
2007
2007
Raff et al. [10]/USA
Leber et al. [14]/Germany
Leschka et al. [15]/Switzerland
Pugliese et al. [16]/Italy
Fine et al. [17]/USA
Plass et al. [18]/Switzerland
Ropers et al. [19]/Germany
Ong et al. [21]/Malaysia
Schuijf et al. [22]/Netherlands
Muhlenbruch et al. [23]/Germany
Ehara et al. [24]/Japan
Nilolaou et al. [25]/Germany
Scheffel et al. [26]/Switzerland
Meijboom et al. [27]/Netherlands
Oncel et al. [28]/Turkey
70
59
67
35
66
50
84
134
60
51
69
68
30
104
80
Mean
HR
Known
CAD (%)
Suspected
CAD (%)
Mean
age
No. of
patients
Year of
publication
Table 1
Study characteristics of 64-slice CT angiography in CAD
16 studies met criteria and 15 were included for analysis
[10,14–28]. Two studies were reported from the same institution
and one of them was excluded because of cumulative addition of
previous cases [16,20]. There were two studies involving separate comparisons in different groups, either dealing with the
diagnostic value of 64-slice CT in CAD based on degree of calcification [10], on calcium scores [10,21], or based on body mass
index [10]. Another two studies were reported with the cumulative addition of previous cases from the same institution [14,25],
however, we treated them as separate studies as they dealt with
different pathological situations (patients with known/without
history of CAD in Ref. [25]; while in Ref. [14], the study was
focused on the atherosclerotic lesions). Table 1 shows the general information in each study reviewed. The number of patients
enrolled in these studies ranged from 30 to 134. There were
only two studies involving more than 100 cases [21,27]. Of 15
studies retrieved, all were performed on 64-slice scanners with
spatial resolution of 165–200 ms except in one study, in which
scans were performed on a dual source CT scanner with spatial resolution of 83 ms [26]. All MSCT scans were performed
with Siemens scanners, except in one study which was done on
a Toshiba scanner [22].
Of all studies reviewed, it was found that the male patients
were most commonly affected with CAD, with pooled estimate
and 95% confidence interval (CI) being 72% (66 and 77%).
␤-blocking agent was used in most of the studies (80%) and
pooled estimate and 95% CI was 56% (37 and 75%). Diagnostic value of 64-slice CT angiography in the evaluation of
assessable segment was reported in 14 studies with pooled estimate and 95% CI being 96% (94 and 98%). Table 2 lists the
detailed information regarding classification of coronary segments as well as the segments included for analysis in each
study.
In three studies, diagnostic value of 64-slice CT in CAD was
investigated for stenosis >50 and 75%, respectively [14,23,25].
However, comparison could not be performed due to limited
data and different method of analysis (patient-based or segmentbased), although the sensitivity of 64-slice in the evaluation of
>75% stenosis showed slightly higher than that in >50% stenosis
(78% versus 84%).
No. of cases
␤-blocker (%)
3.1. General information
ST
(mm)
3. Results
No. of
detectors
Pitch
RI
(mm)
GRT
(ms)
All of the data were entered into SPSS (version 14.0) for
analysis. Sensitivity, specificity, PPV, and NPV estimates for
each study were combined across studies using one sample
test. Comparison was performed by Chi-Square test using n − 1
degree of freedom to test if there is any significant difference
regarding the diagnostic value of MSCT angiography in CAD,
between segment-based assessment, vessel-based assessment or
patient-based assessment; proximal and middle, distal coronary
segment. Statistical hypotheses (2-tailed) were tested at the 5%
level of significance.
0.2
NS
0.24
0.20
0.2
0.24
0.2
NS
NS
0.2
0.2
0.2
0.2–0.43
0.2
0.2
Types of
Scanner
2.4. Statistical analysis
Siemens
Siemens
Siemens
Siemens
Siemens
Siemens
Siemens
Siemens
Toshiba
Siemens
Siemens
Siemens
Siemens
Siemens
Siemens
Z. Sun et al. / European Journal of Radiology 67 (2008) 78–84
Reference/country of origin
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Z. Sun et al. / European Journal of Radiology 67 (2008) 78–84
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Table 2
Coronary artery segments included for analysis by 64-slice CT angiography in CAD
Studies
Segment classification
used in the study
Number of segments
included in the studies
Diameter of segments included for
analysis (mm)
Assessable
segments (%)
Raff et al. [10]/USA
Leber et al. [14]/Germany
Leschka et al. [15]/Switzerland
Pugliese et al. [16]/Italy
Fine et al. [17]/USA
Plass et al. [18]/Switzerland
Ropers et al. [19]/Germany
Ong et al. [21]/Malaysia
Schuijf et al. [22]/Netherlands
Muhlenbruch et al. [23]/Germany
Ehara et al. [24]/Japan
Nilolaou et al. [25]/Germany
Scheffel et al. [26]/Switzerland
Meijboom et al. [27]/Netherlands
Oncel et al. [28]/Turkey
15
15
15
17
NS
11
17
11
15
15
14
15
16
17
15
1065
798
1005
494
NS
550
1128
748
854
765
966
1020
420
1525
1200
NS
NS
>1.5
All segments
>1.5
>1.5
>1.5
>1.5
NS
NS
All segments
NS
>1.5
NS
All segments
88
100
100
100
94
97
96
93.6
99
95
92
90
98.6
NS
100
NS: not stated.
Conventional coronary angiography was used as the standard
of reference in all studies, however, the method of assessment of the degree of coronary artery stenosis or occlusion
by coronary angiography was variable among these studies.
In six of the studies, quantitative coronary angiography was
used which involved quantitative assessment of the coronary
artery disease using the QuantCor software to determine the
severity stenosis, while in the remaining studies, visual or
subjective assessment was utilised in the coronary angiography. The time interval between MSCT angiography and
coronary angiography examinations was available in 11 studies and all patients underwent these two procedures within
2 weeks except in one study, in which the average interval between MSCT and conventional angiography was 49
days [22]. Comparisons were performed regarding the diagnostic value of 64-slice CT in CAD between studies utilizing
quantitative coronary angiography and those utilizing visual
assessment, and our analysis showed that there is no significant difference (p > 0.05) in terms of the sensitivity and
specificity, whether the analysis was patient-based, vessel-based
or segment-based.
3.2. Prevalence of CAD and corresponding diagnostic
value of MSCT in CAD
Prevalence of CAD in these studies was variable according to our review, and we categorised it into suspected and
known CAD. Patients suspected of CAD indicate that the
patients presented with clinical symptoms such as typical or
atypical chest pain, elevated ST, and they were recommended
for coronary angiography for confirmation of presence of the
lesion (stenosis/occlusion). Pooled estimates and 95% CI of suspected CAD was 63% (44 and 82%). In contrast, known CAD
refers to these patients which were confirmed to suffer from
coronary artery disease (presence of stenosis or occlusion) by
coronary angiography. Our analysis showed that high-risk or
known CAD ranged from 17 to 88%, with pooled estimates
and 95% CI being 53% (40 and 67%). No significant difference was found when compared the prevalence of low-risk
CAD or suspected CAD with that of high risk or known CAD
(p > 0.05).
3.3. Patient-based, vessel-based and segment-based
analysis of MSCT in CAD
Of 15 studies, evaluation of 64-slice CT in CAD on
patient-based, vessel-based and segment-based assessment was
available in 12, 6, and 12 studies, respectively. Pooled estimates
and 95% CI of the sensitivity, specificity, PPV and NPV were
97% (94 and 99%), 88% (79 and 97%), 94% (91 and 97%),
and 95% (90 and 99%) for patient-based assessment; 92% (85
and 99%), 92% (85 and 99%), 78% (66 and 91%) and 98% (96
and 99%) for vessel-based assessment; 90% (85 and 94%), 96%
(95 and 97%), 75%(68 and 82%) and 98% (98 and 99%) for
segment-based assessment, respectively.
3.4. Evaluation of four main coronary arteries
Assessment of the diagnostic value of 64-slice CT angiography in the four main coronary arteries including left main
(LM), left anterior descending (LAD), right coronary artery
(RCA) and left circumflex (LCX) were available in six studies. Pooled estimates and 95% CI of sensitivity, specificity,
PPV and NPV were 100 and 99% (97 and 100%), 90% (69
and 100%) and 100% for LM; 93% (84 and 99%), 93% (89
and 97%), 80% (65 and 94%) and 98% (96 and 99%) for
LAD; 93% (89 and 98%), 92% (82 and 99%), 82% (75 and
89%) and 97% (95 and 99%) for RCA; 83% (82 and 99%),
91% (81 and 99%), 79% (71 and 86%) and 97% (95 and
100%) for LCX, respectively. A significant difference was
only reached in the sensitivity of 64-slice CT in CAD when
comparing LM with RCA and LM with LCX (p < 0.05), and
no significant different was found among other comparisons
(p > 0.05).
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Z. Sun et al. / European Journal of Radiology 67 (2008) 78–84
3.5. Evaluation of proximal, middle and distal segments
Evaluation of 64-slice CT angiography in the detection
of CAD in proximal, middle and distal coronary artery segments was only available in five studies with six comparisons.
Although diagnostic accuracy of MSCT in CAD showed
decreased tendency when looking at the middle and distal artery
branches compared to proximal branches, no significant difference was reached between comparisons of these segments
(p > 0.05), except in the comparison of proximal with distal RCA
segment, which demonstrated significant difference in sensitivity (p < 0.05).
3.6. Factors affecting the diagnostic value of MSCT in CAD
Diagnostic accuracy of 64-slice CT in CAD was influenced
by the presence of calcification and its relationship to the degree
of calcium score was investigated in three studies [9,21,26],
and analysis of the effect of coronary calcification on diagnostic accuracy of MSCT could not be performed due to variable
criteria applied in these studies (calcium score based on 142 or
400). Diagnostic accuracy of MSCT in CAD was affected in the
presence of extensive calcification, even with dual source CT
scanning as shown in the study reviewed [26].
Relationship between body mass index (BMI) and the
diagnostic accuracy of 64-slice angiography in CAD was investigated in one study and the results showed that sensitivity,
specificity, PPV and NPV were the highest at normal BMI
patients (less than 25 kg/m2 ) with all 100%, remaining still
high accurate at overweight patients (more than 25 kg/m2 ) and
reduced to a lower level of diagnostic accuracy at obese patients
[10].
4. Discussion
This systematic review showed that 64-slice CT angiography has high diagnostic accuracy in the detection of CAD. In
comparison to earlier scanners such as 4-slice and 16-slice CT,
64-slice CT angiography has demonstrated significant improvement in the assessment of coronary artery branches, including
distal segments. Studies performed on the 16-slice CT scanners in the detection of CAD showed that the sensitivity of
MSCT angiography decreased when assessing the distal coronary segments due to limited spatial and temporal resolution
[11]. However, this was not observed in this study since no significant difference was found when comparing proximal with
middle or distal segments. In comparison to 16-slice MSCT
scanners, the current 64-slice scanner has increased slices per
gantry rotation and fast gantry speed (330 ms/rotation versus
375), which translate into superior spatial resolution (0.4 mm
versus 0.75) and temporal resolution (83 or 165 versus 188 ms).
The reduction in voxel size allows acquisition of isotropic volume data and makes distinction between hypointense soft plaque
and contrast enhanced blood more evident. Moreover, more
coronary segments can be assessed with 64-slice CT angiography with the percentage of assessable segments being higher
than that from 16-slice scanners. Percentage of assessable seg-
ments was significantly higher than that of 16- and 4-slice
scanners as shown in our results (96% versus 92% and 74%)
[29].
Recent studies have reported that two major limitations for
affecting the MSCT evaluation of coronary artery segments are
motion artifacts and severe coronary calcifications. In order to
reduce motion artifacts, ␤-blockers were commonly used prior
to CT examination, even if in the 64-slice scanners, as shown
in the results. Consistent use of ␤-blocking agents before the
scan to keep patients’ heart rates below 60 bpm could produce
better results in some studies. The latest development of dual
source CT has been reported to improve temporal resolution
when compared to early 64-slice scanners, and coronary arteries were visualised without motion artifacts at any heart rate
and beta-blocker utilization could be discarded [30,31]. Initial
experience on dual source CT showed the advantages of imaging patients with high heart rates and reduction of occurrence
of motion artifacts in comparison to earlier 64-slice scanners
[31], although further studies need to be performed to establish
the diagnostic accuracy of dual source CT in the diagnosis of
CAD. Only one study performed on a dual source MSCT was
included in our analysis, therefore, a comparison between dual
source CT and earlier 64-slice scanners cannot be performed,
although dual source demonstrated improved results even if in
patients with higher high rate.
Another common factor that affects evaluation of coronary
artery lumen is the presence of extensive calcification. Similar
to 4-slice and 16-slice CT, extensive artery calcifications are
a frequent source for impairing vessel assessment, even with
64-slice CT, although the degree of artifacts due to partial volume effects seem to be less severe. Severe calcification obscures
coronary lumen and can lead to overestimation of the severity of
the lesions due to blooming artifacts, making quantification of
the degree of coronary artery stenosis difficult. The interference
of calcification with assessment of coronary artery lumen was
reported in three studies, and results showed that the specificity
was decreased with the increase of the calcium score, indicating
the relatively high false positive cases in the presence of extensive calcification. Thus, caution should be taken into account in
imaging patients with severe calcification.
Body mass index (BMI) seems to be another factor that may
affect the diagnostic accuracy of 64-slice CT in the detection of
CAD. This was investigated in one study which demonstrated
the relationship between BMI and diagnostic value of 64-slice
CT [10]. Relevant research has been performed to investigate
the relationship between body weight/BMI and image noise
for reduction of radiation exposure without loss of diagnostic information in CT scanning protocols [32,33]. Yoshimura
et al recently reported that image noise correlated well with
body weight in coronary MSCT angiography [32]. Therefore,
relationship between radiation dose, image noise and diagnostic accuracy should be investigated to minimise radiation dose
while maintaining adequate diagnostic information for clinical
investigation of coronary artery disease.
It must be noted that in practice, MSCT angiography is more
likely to be applied to patients who have low to intermediate probability of CAD. While the negative predictive value
Z. Sun et al. / European Journal of Radiology 67 (2008) 78–84
of MSCT coronary angiography remains relatively high with
16- and 64-slice scanners, the positive predictive value will be
low in a population with a lower prevalence of CAD. However this was not found in our current results. We analysed
the diagnostic value of 64-slice CT based on the prevalence of
CAD in different patient groups, and our results did not show
significant difference between patients suspected of CAD and
those confirmed with CAD, although the prevalence of suspected
CAD was slightly higher than that of confirmed CAD. With the
current MSCT scanners, we can conclude that 64-slice CT is
able to diagnose patients suspected of CAD with relatively high
diagnostic accuracy when compared to conventional coronary
angiography.
There are some limitations in the study which will be
addressed. First, publication bias may have affected the results
as non-English references were excluded. Second, lack of uniform criteria of assessment is another limitation inherent in most
of the studies analysed. Inclusion of variable number of coronary segments makes the analysis and comparison of MSCT
performance difficult. Not all of the studies provided detailed
information about the diagnostic value of 64-slice CT. Assessment of four main coronary branches was only reported in about
one third of the studies, while evaluation of distal coronary artery
segments was available in only five studies. Finally, radiation
dose was only addressed in five studies. The increase in dose
estimates with 64-slice CT when compared to 4- and 16-slice
scanners is due to the higher spatial and temporal resolution
achieved with the current CT scanner technology and therefore,
radiation dose related to 64-slice CT in cardiac imaging deserves
to be investigated.
In conclusion, this systematic review demonstrated that 64slice CT has a high diagnostic accuracy in the detection of
coronary artery disease. More coronary artery segments including distal branches were assessed by 64-slice CT angiography.
Dual source CT could be an alternative method in patients with
higher heart rate. For patients with extensive calcifications in the
coronary lumen or coronary artery stenoses defined by MSCT
angiography are of uncertain significance, myocardial perfusion
SPECT should be performed for purposes of risk stratification
and guiding patient management.
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