Elsevier

Clinical Radiology

Volume 68, Issue 12, December 2013, Pages e659-e668
Clinical Radiology

Additional value of adenosine-stress dynamic CT myocardial perfusion imaging in the reclassification of severity of coronary artery stenosis at coronary CT angiography

https://doi.org/10.1016/j.crad.2013.07.015Get rights and content

Aim

To assess the additional value of adenosine-stress dynamic computed tomography (CT) perfusion (ASDCTP) imaging compared with coronary CT angiography (CCTA) alone to detect significant coronary artery stenosis for each threshold of 50% and 70% diameter stenosis.

Materials and methods

The study included 34 patients (65 ± 11 years, 79% men) with suspected coronary artery diseases who underwent ASDCTP imaging using a 128-section dual-source CT (DSCT) and invasive coronary angiography (ICA). Two investigators classified coronary artery stenosis on CCTA as severe or not. If appropriate image quality could not be acquired due to artefacts, the segment was classified as a lesion with significant stenosis. After the interpretation of ASDCTP imaging, the degree of stenosis was reclassified. All parameters of diagnostic accuracy were calculated before and after ASDCTP analysis for detection of significant coronary artery stenosis with ICA as the reference standard.

Results

The diagnostic accuracy parameters per vessel for the detection of ≥50% stenosis before and after ASDCTP analysis changed as follows: sensitivity, from 80% to 83%; specificity, from 83% to 98%; positive predictive value (PPV), from 87% to 98%; and negative predictive value (NPV), from 75% to 80%. The addition of ASDCTP resulted in reclassification from one class of stenosis severity to another in a significant number of vessels with threshold of 50% stenosis [net reclassification improvement (NRI), 0.176; p < 0.01]. Conversely, the addition of ASDCTP did not result in significant reclassification of stenosis severity in vessels with threshold of 70% stenosis (NRI, 0.034; p = 0.51).

Conclusions

ASDCTP imaging provides incremental value in the detection of significant coronary artery stenosis using a threshold of 50%.

Introduction

Multidetector computed tomography (MDCT) has high sensitivity for the detection of coronary artery disease, with good negative predictive values.1, 2, 3, 4, 5 However, it is limited for evaluating the physiological significance of particular stenotic lesions. Currently, invasive techniques, such as fractional flow reserve (FFR), as well as non-invasive examinations, such as single photon-emission computed tomography (SPECT) and positron-emission tomography (PET) are used for this task. However, although PET is capable of quantitatively measuring myocardial blood flow (MBF) and coronary flow reserve, neither SPECT nor PET are able to provide anatomical assessment of coronary arteries. Invasive coronary angiography (ICA) with FFR provides information on the degree of arterial stenosis and its haemodynamic significance, not visualizing myocardial perfusion directly. Cardiac magnetic resonance imaging (MRI) is also used for myocardial perfusion imaging (MPI). However, cardiac MRI is expensive and time-consuming compared to cardiac CT. Furthermore, the number of sections in myocardial perfusion MRI is limited and dark-rim artefacts decrease its diagnostic accuracy.6

In most myocardial CT perfusion (CTP) research to date, a “snapshot” protocol has been used with the acquisition of a CTP dataset in a single phase both at rest and during stress.7, 8, 9, 10, 11, 12, 13 After the introduction of “shuttle mode” of 128-section dual-source CT (DSCT), adenosine-stress dynamic-stress myocardial perfusion CT (ASDCTP) and quantitative analysis of MBF14, 15, 16, 17, 18, 19, 20 have recently been adopted. The purpose of the present study was to evaluate the additional value of ASDCTP using a second-generation DSCT for the detection of significant coronary artery stenosis compared to coronary CT angiography (CCTA).

Section snippets

Subjects

This study included 34 consecutive patients (65 ± 11 years, 79% men) who underwent ASDCTP using a 128-section DSCT with subsequent ICA. They were referred to radiology department for the evaluation of clinically suspected CAD. All patients were examined with ICA within 3 months of the CTP examination (22 ± 18 days; range 0–75 days). In our institution, adenosine-induced CTP or MR perfusion have routinely replaced SPECT. Patients were screened for contraindications to adenosine administration.

Patient characteristics

Patient characteristics are listed in Table 1. Of the 34 patients (mean 65 ± 11 years old), 79% were men, 94% had a body mass index (BMI) below 30, 65% had experienced angina pectoris previously, 41% were former or current smokers, and 50% had diabetes mellitus. The pretest probability of coronary artery disease of those patients was classified as follows: low, 12 patients (35%); intermediate, 16 patients (47%); high, six patients (18%). In patients with low pretest probability of coronary

Discussion

In the present study, the diagnostic performances of CCTA for the detection of significant stenosis were compared at thresholds of 50% and 70% diameter stenosis before and after perfusion analysis, using ICA as the reference standard. After ASDCTP interpretation with a cut-off value of 50% luminal stenosis, the addition of ASDCTP showed significant improvement in diagnostic estimates on a vessel-based analysis after reclassification (p < 0.01). However, at a cut-off value of 70% stenosis,

Acknowledgement

The authors appreciate the contribution of Ms Sang Eun Lee for the illustration in Fig. 2.

This study was supported by a grant of Korea Health Technology R&D Project, Ministry for Health, Welfare & Family Affairs, Republic of Korea (A102065-26).

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