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Role of coronary angiography MDCT in the clinical setting: changes in diagnostic workup in the real world

Ruolo dell’angiografia coronarica TCMS nel setting clinico: modifiche del percorso diagnostico nel mondo reale

  • Cardiac Radiology / Cardioradiologia
  • Published:
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Abstract

Purpose

The authors sought to evaluate the incremental value of introducing coronary angiography with multidetector computed tomography (MDCT-CA) compared with the conventional diagnostic workup in managing patients with suspected coronary artery disease (CAD) workup.

Materials and methods

A total of 531 consecutive patients underwent MDCT-CA between April 2008 and August 2010. For each patient the pretest probability of CAD was obtained by using the Morise score as well as the diagnostic performance of the exercise test and of MDCT-CA, considering conventional coronary angiography (CCA) as the gold standard. Based on these results, we calculated the posttest likelihood of CAD after stress testing, comparing the incremental diagnostic value for each category of cardiovascular risk with data obtained with MDCT-CA. The conventional diagnostic workup (without MDCT-CA) was then compared with the modified workup (including MDCT-CA).

Results

The diagnostic performance of the exercise test for identifying patients with significant lesions had a sensitivity and specificity of 20% and 88%, respectively, with positive (PPV) and negative (NPV) predictive value of 41% and 72%, respectively. Taking CA as the gold standard, MDCT-CA had 93% sensitivity, 89% specificity, 88% PPV and 93% NPV compared with CCA in evaluating significant stenoses in the per-patient analysis. The overall diagnostic accuracy of MDCT-CA was 91%. The exercise tests provided no significant incremental diagnostic value compared with cardiovascular history in patients with a low to intermediate risk. Comparison of the diagnostic accuracy of these protocols showed improved performance results for the modified protocol.

Conclusions

MDCT-CA is the reference modality for the noninvasive exclusion of critical CAD. It provides a very high incremental diagnostic value compared with exercise testing in patients with a low to intermediate risk of CAD. The use of diagnostic protocols based on MDCT-CA ensures improved diagnostic performance compared with those involving conventional exercise electrocardiograms.

Riassunto

Obiettivo

Scopo del nostro lavoro è valutare il valore incrementale dell’introduzione della angiografia coronarica mediante tomografia assiale multistrato (AC-TCMS) nella gestione diagnostica del paziente con sospetta malattia coronarica (CAD) rispetto al tradizionale workup diagnostico.

Materiali e metodi

Sono stati presi in considerazione 531 pazienti consecutivi sottoposti ad AC-TCMS tra marzo 2008 e agosto 2010. Per ogni paziente è stato calcolata la probabilità pre-test di CAD mediante Morise score e la performance diagnostica del cicloergometro e della ACTCMS considerando l’AC come standard di riferimento; Sulla base dei risultati è stata calcolata la probabilità post-test di CAD dopo stress test, confrontandone il valore diagnostico incrementale per ogni categoria di rischio cardiovascolare con i dati ottenuti dalla AC-TCMS. è stato confrontato il percorso diagnostico tradizionale senza ACTCMS, con quello modificato dall’introduzione dell’ACTCMS.

Risultati

La performance diagnostica dello stress test nella individuazione dei pazienti con lesioni significative ha dimostrato una sensibilità e specificità del 20% e 88% con valore predittivo positivo (VPP) e valore predittivo negativo (VPN) di 41% e 72%. Considerando come standard di riferimento la AC il confronto tra AC e ACTCMS nella valutazione di stenosi significative mediante analisi per paziente ha rilevato una sensibilità pari a 93%, una specificità pari a 89%, un VPP e VPN pari a 88 % e 93%. L’accuratezza diagnostica globale della metodica è risultata essere pari a 91%. Lo stress test ha dimostrato di non fornire un significativo valore diagnostico incrementale rispetto all’anamnesi cardiovascolare nei pazienti a basso-medio rischio. Il confronto tra l’accuratezza diagnostica dei protocolli ha dimostrato una migliore performance del protocollo che prevede l’introduzione dell’ACTCMS nei confronti del protocollo tradizionale.

Conclusioni

La AC-TCMS è una metodica di riferimento non invasiva per l’esclusione di coronaropatia critica. Fornisce un valore diagnostico incrementale molto elevato rispetto allo stress test nei pazienti a basso-medio rischio. L’utilizzazione del protocollo diagnostico che prevede l’utilizzo dell’AC-TCMS garantisce una migliore perfomance diagnostica rispetto al protocollo tradizionale.

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Authors and Affiliations

  1. Istituto di Radiologia, Azienda Ospedaliero Universitaria Integrata di Verona Policlinico G.B. Rossi, P.le L.A. Scuro 10, 37134, Verona, Italy

    R. Malagò, A. Pezzato, C. Barbiani, U. Alfonsi, M. D’Onofrio & R. Pozzi Mucelli

  2. U.O. Cardiologia, Azienda Ospedaliero Universitaria Integrata di Verona, Policlinico G.B. Rossi, Verona, Italy

    D. Tavella & P. Benussi

Authors
  1. R. Malagò
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  2. A. Pezzato
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  3. C. Barbiani
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  4. U. Alfonsi
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  5. M. D’Onofrio
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  6. D. Tavella
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  7. P. Benussi
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  8. R. Pozzi Mucelli
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Correspondence to R. Malagò.

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Malagò, R., Pezzato, A., Barbiani, C. et al. Role of coronary angiography MDCT in the clinical setting: changes in diagnostic workup in the real world. Radiol med 117, 939–952 (2012). https://doi.org/10.1007/s11547-012-0842-6

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  • DOI: https://doi.org/10.1007/s11547-012-0842-6

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