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Incremental improvement of diagnostic performance of coronary CT angiography for the assessment of coronary stenosis in the presence of calcium using a dual-layer spectral detector CT: validation by invasive coronary angiography

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Abstract

To investigate value of spectral reconstructions for the quantification of coronary stenosis in the presence of calcified or partially calcified plaques using a dual-layer spectral detector CT (SDCT). Seventy-two consecutive patients were retrospectively enrolled. Conventional 120 kVp images, eight virtual monoenergetic images (VMI) (70 to 140 keV), the effective atomic number (Z effective) and iodine no water images were reconstructed. Invasive coronary angiography was used as the reference standard. Parallel and serial testing were used to assess the incremental diagnostic value of Z effective and iodine no water images to the best VMI series. 122 coronary lesions of 72 patients (49 men and 23 women; 63.7 ± 10.2 years) were enrolled in analysis. Reconstruction at 100 keV yielded optimal diagnostic performance, the sensitivity, specificity, PPV, NPV and diagnostic accuracy to identify stenosis ≥ 50% or ≥ 70% were 84%, 70%, 80%, 76%, 79% and 78%, 98%, 93%, 91%, 92%, respectively. A serial combination (100 keV VMI followed by Z effective images) resulted in an improved specificity (from 70 to 80%) with a moderate loss of sensitivity (81% from 84%) in identifying ≥ 50% stenosis (P = 0.021). For patients with high Agatston score, this combination could further reduce false positive cases and improve diagnostic accuracy. 100 keV VMI provide optimal diagnostic performance for the detection of coronary stenosis in the presence of calcified or partially calcified plaques using a dual-layer SDCT, with further improvements obtained with the combined use of Z effective images.

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Data availability

Datasets are available upon request.

Abbreviations

CTA:

Computed tomography angiography

CAD:

Coronary artery disease

HU:

Hounsfield-Unit

VMI:

Virtual monoenergetic images

SDCT:

Spectral detector CT

ICA:

Invasive coronary angiography

CTDIvol:

Volume of CT dose index

DLP:

Dose length product

SBI:

Spectral based images

SNR:

Signal-to-noise ratio

CNR:

Contrast-to-noise ratio

WL:

Window level

WW:

Window width

PPV:

Positive predictive value

NPV:

Negative predictive value

LR+:

Positive likelihood ratio

LR−:

Negative likelihood ratio

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Funding

This work was supported by the National Natural Science Foundation of China (Grant No. 81873891, 2019), the “13th Five-Year Plan” National key R & D projects of China (Grant No. 2016YFC1300402; 2016YFC1300400, 2016), CAMS Innovation Fund for Medical Sciences (CIFMS) (Grant NO. 2020-I2M-C-T-B-034, 2020), the Non-profit Central Research Institute Fund of Chinese Academy of Medical Sciences (Grant No. 2018RC320004, 2018).

Author information

Author notes

  1. Cheng Xu and Yan Yi contributed equally to this work.

Authors and Affiliations

  1. Department of Radiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College , No.1, Shuaifuyuan, Dongcheng District, Beijing, 100730, China

    Cheng Xu, Yan Yi, Zhengyu Jin & Yining Wang

  2. Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China

    Yechen Han & Hongzhi Xie

  3. Clinical Science, Philips Healthcare, Beijing, China

    Xiaomei Lu

  4. CT Clinical Science, Philips Healthcare, Cleveland, OH, USA

    Mani Vembar

  5. Department of Radiology, University Medical Center of Utrecht, Utrecht, The Netherlands

    Tim Leiner

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  1. Cheng Xu
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Contributions

Guarantor of integrity of the entire study: ZJ, YW. Study concepts and design: YW. Literature research: CX, YY. Clinical studies: N/A. Experimental studies/data analysis: YH, HX. Statistical analysis: CX, WH. Manuscript preparation: CX, YY. Manuscript editing: YW, XL, MV, TL.

Corresponding author

Correspondence to Yining Wang.

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Xu, C., Yi, Y., Han, Y. et al. Incremental improvement of diagnostic performance of coronary CT angiography for the assessment of coronary stenosis in the presence of calcium using a dual-layer spectral detector CT: validation by invasive coronary angiography. Int J Cardiovasc Imaging 37, 2561–2572 (2021). https://doi.org/10.1007/s10554-021-02205-3

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