A systematic review on diagnostic accuracy of CT-based detection of significant coronary artery disease

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Abstract

Objectives

Systematic review of diagnostic accuracy of contrast enhanced coronary computed tomography (CE-CCT).

Background

Noninvasive detection of coronary artery stenosis (CAS) by CE-CCT as an alternative to catheter-based coronary angiography (CCA) may improve patient management.

Methods

Forty-one articles published between 1997 and 2006 were included that evaluated native coronary arteries for significant stenosis and used CE-CCT as diagnostic test and CCA as reference standard. Study group characteristics, study methodology and diagnostic outcomes were extracted. Pooled summary sensitivity and specificity of CE-CCT were calculated using a random effects model (1) for all coronary segments, (2) assessable segments, and (3) per patient.

Results

The 41 studies totaled 2515 patients (75% males; mean age: 59 years, CAS prevalence: 59%). Analysis of all coronary segments yielded a sensitivity of 95% (80%, 89%, 86%, 98% for electron beam CT, 4/8-slice, 16-slice and 64-slice MDCT, respectively) for a specificity of 85% (77%, 84%, 95%, 91%). Analysis limited to segments deemed assessable by CT showed sensitivity of 96% (86%, 85%, 98%, 97%) for a specificity of 95% (90%, 96%, 96%, 96%). Per patient, sensitivity was 99% (90%, 97%, 99%, 98%) and specificity was 76% (59%, 81%, 83%, 92%). Heterogeneity was quantitatively important but not explainable by patient group characteristics or study methodology.

Conclusions

Current diagnostic accuracy of CE-CCT is high. Advances in CT technology have resulted in increases in diagnostic accuracy and proportion of assessable coronary segments. However, per patient, accuracy may be lower and CT may have more limited clinical utility in populations at high risk for CAD.

Introduction

Catheter-based coronary angiography (CCA) is currently the standard for the diagnosis of obstructive coronary artery disease (CAD) in symptomatic patients. However, about 30–40% of all invasive coronary angiograms in the United States are performed for diagnostic purposes only. This is of concern especially as diagnostic CCA poses serious risks yielding an overall mortality of 0.13%—nearly twofold higher than that for multidetector computed tomography (CT) angiography (0.07%) [1], [2], [3], [4], [5].

The temporal and spatial resolution of cardiac multidetector CT (MDCT) has improved considerably over the last 7 years from 330 ms and 1.25 mm slice thickness to 165 ms and 0.5 mm slice thickness. Despite reports indicating that motion artifacts are reduced at lower heart rates (<65 beats/min) permitting excellent visualization of both coronary artery lumen and wall, sub-optimal signal to noise ratio in obese patients and severe calcification remain challenges to accurately determine the presence of significant stenosis.

Although many publications suggested high sensitivities and specificities for the detection of significant coronary stenosis, CT has not been widely adopted in clinical practice yet. Thus, the present review analyzed 41 single center feasibility studies conducted between 1997 and 2006 to determine the diagnostic accuracy of coronary CT angiography for the detection of significant CAD and the progress that has been made through technology improvements. The specific goals of our study were (1) to systematically characterize study population and methodology, (2) to synthesize the available evidence into summary estimates of sensitivity and specificity and (3) to determine differences between segment and patient based analyses as well as between CT scanner types (electron beam CT (EBCT), 4- or 8-slice multidetector CT (MDCT), 16-slice MDCT, and 64-slice MDCT).

Section snippets

Data sources and study selection

A computerized literature search was performed in Medline and Embase to identify all articles published in peer-reviewed literature from 1 January 1990, through 1 March 2006. We used the keywords (1) coronary computed tomography and contrast, (2) coronary multi-slice or multi-detector computed tomography and contrast, and (3) coronary electron beam computed tomography and contrast. In addition, we scanned references in retrieved articles and contacted first authors from original articles and

Study population and methodology

Out of 1181 articles identified in our electronic literature search, we included 41 individual studies performed in 21 academic hospitals with a total of 2515 patients (21,821 coronary segments) published between 1997 and 2004 (EBCT) and between 2001 and 2006 (MDCT). Sample size of individual studies ranged from 20 to 133 patients (Fig. 1). Table 1 summarizes characteristics and methodology of these 41 studies. Thirteen studies with 847 patients were performed using EBCT [9], [14], [16], [20],

Discussion

This systematic review of the diagnostic accuracy of CT-based detection of significant CAD summarizes the findings of 41 studies performed with EBCT, 4/8-slice, 16-slice and 64-slice MDCT. Beyond the published sensitivity and specificity results of individual studies we gathered raw data (i.e., number of true and false positive and negative findings) that permitted a standardized analysis of the diagnostic accuracy of coronary CT for the detection of significant CAD including all 17 coronary

Acknowledgments

We greatly appreciate the enthusiastic help from the following authors who kindly provided access to data from their original study: Y. Sato, C. Becker, T. Nakanishi, K. Nieman, M. Budoff, G. Morgan-Hughes, K. Nikolaou, and P. Carrascosa.

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