Writing Committee Members Daniel B.Mark,MD,MPH,FACC,FAHA,
Chair*
Daniel S.Berman,MD,FACC†‡
Matthew J.Budoff,MD,FACC,FAHA§
J.Jeffrey Carr,MD,FACC,FAHAʈ
Thomas C.Gerber,MD,FACC,FAHA¶#
Harvey S.Hecht,MD,FACC§
Mark A.Hlatky,MD,FACC,FAHA
John McB.Hodgson,MD,FSCAI,FACC**
Michael S.Lauer,MD,FACC,FAHA*
Julie M.Miller,MD,FACC*
Richard L.Morin,P H Dʈ
Debabrata Mukherjee,MD,FACC洛克沙胂
Michael Poon,MD,FACC‡
Geoffrey D.Rubin,MD,FAHA¶#
Robert S.Schwartz,MD,FACC**
*American College of Cardiology Foundation Representative;†Amer-
ican Society of Nuclear Cardiology Representative;‡Society of Cardio-
vascular Computed Tomography Representative;§Society of Athero-
sclerosis Imaging and Prevention Representative;ʈAmerican College of
Radiology Representative;¶American Heart Association Representa-
tive;#North American Society for Cardiovascular Imaging Represen-
tative;**Society for Cardiovascular Angiography and Interventions
Representative
ACCF
Task Force Members Robert A.Harrington,MD,FACC,FAHA,
Chair
Eric R.Bates,MD,FACC
Charles R.Bridges,MD,MPH,FACC,
FAHA
Mark J.Eisenberg,MD,MPH,FACC,
FAHA
Victor A.Ferrari,MD,FACC,FAHA
Mark A.Hlatky,MD,FACC,FAHA
Alice K.Jacobs,MD,FACC,FAHA
Sanjay Kaul,MD,MBBS,FACC
David J.Moliterno,MD,FACC
Debabrata Mukherjee,MD,FACC
Robert S.Rosenson,MD,FACC,FAHA
James H.Stein,MD,FACC,FAHA††
Howard H.Weitz,MD,FACC
Deborah J.Wesley,RN,BSN,CCA
††Former Task Force member during this writing effort
This document was approved by the American College of Cardiology Foundation Board of Trustees in November2009,the American College of Radiology in January 2010,the American Heart Association Science Advisory and Coordinating Commit-tee in January2010,the North American Society for Cardiovascular Imaging in January2010,the Society of Atherosclerosis Imaging and Prevention in January2010, the Society for Cardiovascular Angiography and Interventions in January2010,and the Society of Cardiovascular Computed Tomography in January2010.
The American College of Cardiology Foundation requests that this document be cited as follows:Mark DB,Berman DS,Budoff MJ,Carr JJ,Gerber TC,Hecht HS, Hlatky MA,Hodgson JM,Lauer MS,Miller JM,Morin RL,Mukherjee D,Poon M, Rubin GD,Schwartz RS.ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT2010 expert consensus document on coronary compu连续供墨
系统 ted tomographic angiography:a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents.J Am Coll Cardiol2010;55:2663–99.
This article has been copublished in the June8,2010,issue of Circulation and e-published in Catheterization and Cardiovascular Interventions.
Copies:This document is available on the World Wide Web sites of the American College of Cardiology()and the American Heart Association(my. ).For copies of this document,please contact Elsevier Inc.Reprint Department,fax(212)633-3820.e-mail
Permissions:Modification,alteration,enhancement,and/or distribution of this document are not permitted without the express permission of the American College of Cardiology Foundation.Please contact Elsevier’s permission department at
Preamble (2664)
1.Introduction (2665)
1.1.Writing Committee Organization (2665)
1.2.Document Development Process (2665)
1.2.1.Relationships With Industry and Other Entities (2665)
1.2.2.Consensus Development (2665)
1.2.3.External Peer Review (2665)
1.2.4.Final Writing Committee and Task Force
Sign-Off on the Document (2665)
1.2.5.Document Approval (2666)
1.3.Purpose of This Expert Consensus Document (2666)
酚醛模塑料2.Executive Summary (2666)
3.Perspective and Scope of This Document (2668)
4.Coronary CT Angiography:Brief Overview of
the Technology (2668)
4.1.Patient Selection and Preparation (2668)
4.2.Coronary CT Image Acquisition (2669)
4.2.1.Temporal Resolution of a CT Scan (2669)
4.2.2.Spatial Resolution of a CT Scan (2669)
4.3.Image Reconstruction and Interpretation (2670)
5.Diagnostic Imaging of Coronary Arteries:
Important Concepts (2671)
6.Assessment of Left Ventricular Function:
Important Concepts (2672)
7.General Issues in Clinical Test Evaluation (2673)
7.1.Key Clinical Questions (2673)
7.1.1.Assessing Diagnostic Accuracy (2673)
7.1.2.Likelihood Ratios and Receiver-Operator
Characteristic Curves (2673)
7.1.3.Assessing Prognostic Value (2674)
7.1.4.Assessing Therapeutic Value (2674)
8.Current Coronary CT Angiography Applications..2674
8.1.Diagnostic Accuracy of Coronary CT Angiography
in Stable Patients With Suspected CAD (2674)
8.1.1.Coronary Anatomic Subgroup Data (2676)
8.1.2.Comparison of Coronary CT Angiography With
Stress Perfusion Imaging (2677)
8.1.3.Comparison of Coronary CT Angiography With
Fractional Flow Reserve (2678)
防撞钢梁
8.2.Prognostic Evaluation of Coronary
CT Angiography in Stable Patients With
Suspected Coronary Disease (2678)
8.3.Use of Coronary CT Angiography in the
磁卡电表Assessment of Patients With Acute Chest Pain (2679)
8.4.Use of Coronary CT Angiography in Preoperative
Evaluation of Patients Before Noncoronary
Cardiac Surgery (2680)
8.5.Use of Coronary CT Angiography in the
Follow-Up of Cardiac Transplant Patients (2680)
8.6.Use of Coronary CT Angiography in Patients
With Prior Coronary Bypass Surgery (2680)
8.7.Use of Coronary CT Angiography in Patients
With Prior Coronary Stenting (2681)
8.8.Other Patient Subgroup Data (2682)
8.9.Assessment of Global and Regional Left
Ventricular Function (2682)
9.Emerging Applications (2683)
9.1.Noncalcified Coronary Plaque Imaging and
Its Potential Clinical Uses (2683)
9.2.Assessing Atherosclerotic Burden (2683)
9.3.Identification of Vulnerable Plaques (2684)
9.4.Left Ventricular Enhancement Patterns (2684)
10.Areas Without Consensus (2684)
10.1.Incidental Extracardiac Findings (2684)
10.2.Use of Coronary CT Angiography in
Asymptomatic High-Risk Individuals (2686)
10.3.The“Triple Rule-Out”in the Emergency
Department (2686)
11.Safety Considerations (2687)
11.1.Patient Radiation Dose (2687)
11.2.Intravenous Contrast (2689)
12.Cost-Effectiveness Considerations (2690)
13.Quality Considerations (2691)
References (2692)
Appendix1.Author Relationships With Industry
and Other Entities (2697)
Appendix2.Peer Reviewer Relationships With
Industry and Other Entities (2698)
Preamble
This document was developed by the American College of Cardiology Foundation(ACCF)Task Force on Clinical Expert Consensus Documents(ECDs)and cosponsored by the American College of Radiology(ACR),American Heart Association(AHA),American Society of Nuclear Cardiology(ASNC),North American Society for Cardio-vascular Imaging(NASCI),Society of Atherosclerosis Im-aging and Prevention(SAIP),Society for Cardiovascular Angiography and Interventions(SCAI),and Society of Cardiovascular Computed Tomography(SCCT)to provide
2664Mark et al.JACC Vol.55,No.23,2010 Expert Consensus on CT Angiography June8,2010:2663–99
a perspective on the current state of computed tomographic angiography(CTA).ECDs are intended to inform practi-tioners and other interested parties of the opinion of the ACCF and document cosponsors concerning evolving areas of clinical practice and/or technologies that are widely available or new to the practice community.Topics are chosen for coverage because the evidence base,the experi-ence with technology,and/or the clinical practice are not considered sufficiently well developed to be evaluated by the formal ACCF/AHA practice guidelines process.Often the topic is the subject of ongoing investigation.Thus,the reader should view the ECD as the best attempt of the ACCF and document cosponsors to inform and guide clinical practice in areas where rigorous evide
nce may not be available or the evidence to date is not widely accepted. When feasible,ECDs include indications or contraindica-tions.Some topics covered by ECDs will be addressed subsequently by the ACCF/AHA Practice Guidelines Committee.
The task force makes every effort to avoid any actual or potential conflicts of interest that might arise as a result of an outside relationship or personal interest of a member of the writing panel.Specifically,all members of the writing panel are asked to provide disclosure statements of all such relationships that might be perceived as real or potential conflicts of interest to inform the writing effort.These statements are reviewed by the parent task force,reported orally to all members of the writing panel at thefirst meeting,and updated as changes occur.The relationships and industry information for writing committee members and peer reviewers are published in Appendix1and Ap-pendix2of the document,respectively.
Robert A.Harrington,MD,FACC,FAHA
Chair,ACCF Task Force on
Clinical Expert Consensus Documents 1.Introduction
1.1.Writing Committee Organization
The writing committee consisted of acknowledged experts in thefield of CTA,as well as a liaison from the ACCF Task Force on Clinical ECDs,the oversight group for this document.In addition to2ACCF members,the writing committee included2representatives from the ACR and AHA and1representative from ASNC,NASCI,SAIP, SCAI,and SCCT.Representation by an outside organiza-tion does not necessarily imply endorsement.
1.2.Document Development Process
1.2.1.Relationships With Industry and Other Entities At itsfirst meeting,each member of the writing committee reported all relationships with industry and other entities relevant to this document topic.This information was updated,if applicable,at the beginning of all subsequent meetings and full committee conference calls.As noted in the Preamble,relevant relationships with industry and other entities of writing committee members are published in Appendix1.
1.2.2.Consensus Development
During thefirst meeting,the writing committee discussed the topics to be covered in the document and assigned lead authors for each section.Authors conducted literature searches and drafted their sections of the document outline. Over a series of meetings and conference calls,the writing committ
ee reviewed each section,discussed document con-tent,and ultimately arrived at consensus on a document that was sent for external peer review.Following peer review,the writing committee chair engaged authors to address re-viewer comments andfinalize the document for document approval by participating organizations.Of note,telecon-ferences were scheduled between the writing committee chair and members who were not present at the meetings to ensure consensus on the document.
1.2.3.External Peer Review
This document was reviewed by15official representatives from the ACCF(2representatives),ACR(2representa-tives),AHA(2representatives),ASNC(1representative), NASCI(2representatives),SAIP(2representatives),SCAI (2representatives),and SCCT(2representatives),as well as 10content reviewers,resulting in518peer review com-ments.See list of peer reviewers,affiliations for the review process,and corresponding relationships with industry and other entities in Appendix2.Peer review comments were entered into a table and reviewed in detail by the writing committee chair.The chair engaged writing committee members to respond to the comments,and the document was revised to incorporate reviewer comments where deemed appropriate by the writing committee.
In addition,a member of the ACCF Task Force on Clinical ECDs served as lead reviewer for this document. This person conducted an independent review of the doc-ument at the time of peer review.Once the writing committee documented its response to reviewer comments and updated the manuscript,the lead reviewer assessed whether all peer review issues were handled adequately or whether there were gaps that required additional review. The lead reviewer reported to the task force chair that all comments were handled appropriately and recommended that the document go forward to the task force forfinal review and sign-off.
1.2.4.Final Writing Committee and Task Force
Sign-Off on the Document
The writing committee formally signed off on thefinal document,as well as the relationships with industry that would be published with the document.The ACCF Task Force on Clinical ECDs also reviewed and formally ap-proved the document to be sent for organizational approval.
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1.2.5.Document Approval
Thefinal version of the document,along with the peer review comments and responses to comments were circu-lated to the ACCF Board of Trustees for review and approval.The document was approved in November2009. The document was then sent to the governing boards of the ACR,AHA,ASNC,NASCI,SAIP,SCAI,and SCCT for endorsement consideration,along with the peer review comments/responses for their respective official peer review-ers.ACCF,ACR,AHA,NASCI,SAIP,SCAI,and SCCT formally endorsed this document.This document will be considered current until the ACCF Task Force on Clinical ECDs revises or withdraws it from publication.
牙箱
1.3.Purpose of This Expert Consensus Document This document presents an expert consensus overview of the current and emerging clinical uses of coronary CTA in patients with suspected or known coronary artery disease (CAD).Since the evidence base for this technology is not felt to be sufficiently mature to support a clinical practice guideline at present,this ECD offers an alternative vehicle in which the state of the art of coronary CTA can be described without the requirement to provide explicit rec-ommendations accompanied by formal ratings of the quality of available evidence.
The intention of this document is to summarize the strengths and weaknesses of current clinical uses of coronary CTA as reflected in the published peer-reviewed literature and as interpreted by the writing committee.The document is not intended primarily as either a comprehensive litera-ture review or as an instruction guide for those interested in performing or interpreting coronary computed tomography (CT)angiograms.The document also does not offer specific statements rating the appropriateness of various potential clinical uses of coronary CTA,as this has been dealt with in the ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/ SIR2006Appropriateness Criteria for Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging (1).Finally,this document does not address the evaluation of coronary calcium using CT,except as it pertains to CTA studies in patients with suspected or known CAD,since this topic has also been covered in the ACCF/AHA2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring by Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Pa-tients With Chest Pain(1a).
2.Executive Summary
Advances in CT imaging technology,including the intro-duction of multidetector row systems with electrocardio-graphic gating,have made imaging of the heart and the coronary arteries feasible.The
potential to obtain informa-tion noninvasively comparable to that provided by invasive coronary angiography has been the major driving force behind the rapid growth and dissemination of cardiac CT imaging.In the future,the ability of CTA to provide information not currently available from invasive angiogra-phy may provide the basis for a major shift in how patients with atherosclerotic cardiovascular disease are classified and managed.Currently,cardiac CTA can provide information about coronary anatomy and left ventricular(LV)function that can be used in the evaluation of patients with suspected or known CAD.
The technology for performing coronary CT angiograms is evolving at a rate that often outpaces research evaluating its incremental benefits.Multidetector CT technology prior to64-channel or“slice”systems should now be considered inadequate for cardiac imaging(except for studies limited to assessing coronary calcium).The incremental value of re-cently introduced CT hardware with128-,256-,and 320-channel systems over64-channel systems has not yet been determined.As with any diagnostic technology,cor-onary CTA has technical limitations with which users should be familiar,and proper patient selection and prepa-ration are important to maximize the diagnostic accuracy of the test.Most cardiac CTA examinations result in a large 4-dimensional(4D)dataset of the heart obtained over the entire cardiac cycle.Physicians who interpret these exami-nations must b
e able to analyze the image data interactively on a dedicated workstation and combine knowledge of the patient with expertise in coronary anatomy,coronary patho-physiology,and CT image analysis techniques and limita-tions.In addition,integration of coronary CTA data into clinical practice requires that the results be evaluated in terms of what was known diagnostically and prognostically before the test was performed and,thus,what incremental information the test provides.The ability of a test such as coronary CTA to provide incremental diagnostic informa-tion that alters management(as contrasted with increasing diagnostic certainty alone)is heavily dependent both on the pretest probability and on the alternative diagnostic strate-gies considered.
The published literature on the diagnostic accuracy of 64-channel coronary CTA compared with invasive coronary angiography as of June2009consists of3multicenter cohort studies along with over45single-center studies,many of the latter involving fewer than100patients.This literature reflects careful selection of study subjects and test interpre-tation by expert readers,typically with exclusion of patients who would be expected to have lower quality studies,such as those with irregular heart ,atrialfibrillation), obesity,or inability to comply with instructions for breath holding.In addition,because the cohorts for these studies were assembled from patients referred for invasive coronary angiography,they do not necessarily reflect,in terms of obstructive CAD prevalence or clinic
al presentation,the population to which coronary CTA is most likely to be applied in clinical practice.Accepting these caveats,some consistent conclusions emerge from this literature that may be useful in clinical decision making.In these studies,
2666Mark et al.JACC Vol.55,No.23,2010 Expert Consensus on CT Angiography June8,2010:2663–99
overall sensitivity and specificity on a per-patient basis are both high,and the number of indeterminate studies due to inability to image important coronary segments in the select cohorts represented is less than5%.In most circumstances, a negative coronary CT angiogram rules out significant obstructive coronary disease with a very high degree of confidence,based on the post-test probabilities obtained in cohorts with a wide range of pretest probabilities.However, post-test probabilities following a positive coronary CT angiogram are more variable,due in part to the tendency to overestimate disease severity,particularly in smaller and more distal coronary segments or in segments with artifacts caused by calcification in the arterial walls.At present,data on the prognostic value of coronary CTA using64-channel or greater systems remain quite limited.Furthermore,no large-scale studies have yet made a direct comparison of long-term outcomes following conventional diagnostic im-aging strategies versus strategies involving coronary
CTA. As with invasive coronary angiography,the results of coronary CTA are often not concordant with stress single-photon emission computed tomography(SPECT)myocar-dial perfusion imaging(MPI).The differences in the pa-rameters measured by MPI(“function”or“physiology”)and CTA(“anatomy”)must be considered when making patient management decisions with these studies.Of note,a normal MPI does not exclude the presence of coronary atheroscle-rosis although it does signify a very low risk of future major adverse events over the short to intermediate term.Con-versely,coronary CTA allows detection of some coronary atherosclerotic plaques that are not hemodynamically sig-nificant.The optimal management of such disease has not been established.Neither test can presently identify with any reasonable clinical probability nonobstructive coronary plaques that might rupture in the future and cause acute myocardial infarction(MI).Invasive coronary angiography has a similar limitation.
Studies comparing coronary CTA with fractionalflow reserve(FFR)measured as part of invasive coronary angio-graphic studies complement the MPI comparisons de-scribed in the preceding text by showing that coronary CTA anatomic data do not provide very accurate insights into the probability that specific lesions will produce clinically sig-nificant ischemia.Similar observations have been made about the relationship of FFR data and the anatomic information provided by invasive coronary angiography.
In the context of the emergency department evaluation of patients with acute chest discomfort,currently available data suggest that coronary CTA may be useful in the evaluation of patients presenting with an acute coronary syndrome (ACS)who do not have either acute electrocardiogram (ECG)changes or positive cardiac markers.However, existing data are limited,and large multicenter trials com-paring CTA with conventional evaluation strategies are needed to help define the role of this technology in this category of patients.
Coronary CTA imaging of patients with prior coronary bypass surgery yields very accurate information about the state of the bypass grafts but less accurate information about the native arteries distal to the bypasses and the ungrafted arteries.Because chest pain after bypass surgery might be associated with disease progression in either a graft or a native coronary artery,the difficulty of accurately assessing the native vessels is an important limitation for the clinical use of coronary CTA in the post-bypass patient. Coronary stents pose some significant technical chal-lenges for coronary CTA,since the metal in the stents may create several types of artifacts in the images.Special algorithms are now routinely used that may reduce some of these artifacts during image reconstruction.The literature suggests that in patients who have large diameter stents, good image quality,and whose clinical presentation suggests low-to-intermediate probability for restenosis,
64-channel coronary CTA can be used to rule out severe in-stent restenosis.There are no studies that directly compare a coronary CTA strategy with an invasive coronary angiog-raphy strategy in patients with coronary stents,and such data will be required to understand the efficiencies and tradeoffs of these2strategies in this population.
The literature on the assessment of LV function using cardiac CTA in patients with suspected or known CAD is much smaller than that for diagnostic coronary imaging. One likely reason is that echocardiography already provides a readily available,noninvasive means of assessing ventric-ular function and wall motion and does so without exposing patients to ionizing radiation or iodinated contrast agents. Available comparisons with cardiovascular magnetic res-onance(CMR)suggest that CTA estimation of LV ejection fraction is accurate over a wide range of values.Accuracy may,however,be reduced at higher heart rates due to difficulties in capturing end-systolic and end-diastolic phases accurately.Use of some newer strategies to reduce the radiation dose of coronary CTA studies,such as sequential scanning,will eliminate the ability to assess LV function with the same study.
The writing committee considered several emerging ap-plications where empirical data were deemed insufficient to support development of a consensus.Imaging of noncalci-fied coronary plaqu
es may in the future become a useful application for coronary CTA,but it has no role in current practice since there are insufficient data to assess its clinical utility.CTA assessment of total atherosclerotic burden and potential plaque vulnerability similarly will require substan-tial additional technical development and clinical investiga-tion to define their potential value in patient management. The writing committee identified3areas without con-sensus:the interpretation of incidental noncardiacfindings on the CT examination,the use of coronary CTA in asymptomatic subjects,and the“triple rule-out”examina-tion of patients with acute chest pain in the emergency department.
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JACC Vol.55,No.23,2010Mark et al. June8,2010:2663–99Expert Consensus on CT Angiography
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