Skip to main content


Log in

Accuracy of coronary artery stenosis detection with CT versus conventional coronary angiography compared with composite findings from both tests as an enhanced reference standard

  • Cardiac
  • Published:
European Radiology Aims and scope Submit manuscript



To prospectively compare the accuracy of coronary CT angiography (CCTA) and conventional coronary angiography (CCA) for stenosis detection using composite findings from both tests as an enhanced reference standard.


One hundred thirteen patients underwent CCTA and CCA. Per-segment and per-patient accuracy of CCTA compared with initial CCA interpretation were determined. Angiographers were then unblinded to the CCTA results and re-evaluation of the CCA studies was performed with knowledge of CCTA findings, which was used as an enhanced reference standard to compare the diagnostic accuracy of CCTA versus CCA.


When using the enhanced reference standard instead of initial CCA interpretation, CCTA accuracy for identifying segments (patients) with ≥50% stenosis increased from 97.7% (96.5%) to 98.1% (98.2%), sensitivity from 90.5% (100%) to 90.8% (100%), and specificity from 98.4% (94.3%) to 98.9% (97.1%). CCTA identified six segments and two patients with stenoses ≥50% missed on initial CCA interpretation. Compared with the enhanced reference standard the accuracies of CCTA and of initial CCA interpretation were not different (p = 0.87).


CCTA compares favourably with CCA for stenosis detection. Use of a composite reference standard combining findings from both tests can control for the effect of false-negative CCA results when evaluating the accuracy of CCTA.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others


  1. Budoff MJ, Dowe D, Jollis JG et al (2008) Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive coronary angiography) trial. J Am Coll Cardiol 52:1724–1732

    Article  PubMed  Google Scholar 

  2. Miller JM, Rochitte CE, Dewey M et al (2008) Diagnostic performance of coronary angiography by 64-row CT. N Engl J Med 359:2324–2336

    Article  PubMed  CAS  Google Scholar 

  3. Becker CR, Knez A, Leber A et al (2002) Detection of coronary artery stenoses with multislice helical CT angiography. J Comput Assist Tomogr 26:750–755

    Article  PubMed  Google Scholar 

  4. Hoffmann MH, Shi H, Schmitz BL et al (2005) Noninvasive coronary angiography with multislice computed tomography. JAMA 293:2471–2478

    Article  PubMed  CAS  Google Scholar 

  5. Nieman K, Cademartiri F, Lemos PA, Raaijmakers R, Pattynama PM, de Feyter PJ (2002) Reliable noninvasive coronary angiography with fast submillimeter multislice spiral computed tomography. Circulation 106:2051–2054

    Article  PubMed  Google Scholar 

  6. Stein PD, Yaekoub AY, Matta F, Sostman HD (2008) 64-slice CT for diagnosis of coronary artery disease: a systematic review. Am J Med 121:715–725

    Article  PubMed  Google Scholar 

  7. Mowatt G, Cook JA, Hillis GS et al (2008) 64-slice computed tomography angiography in the diagnosis and assessment of coronary artery disease: systematic review and meta-analysis. Heart 94:1386–1393

    Article  PubMed  CAS  Google Scholar 

  8. De Scheerder I, De Man F, Herregods MC et al (1994) Intravascular ultrasound versus angiography for measurement of luminal diameters in normal and diseased coronary arteries. Am Heart J 127:243–251

    Article  PubMed  Google Scholar 

  9. Grondin CM, Dyrda I, Pasternac A, Campeau L, Bourassa MG, Lesperance J (1974) Discrepancies between cineangiographic and postmortem findings in patients with coronary artery disease and recent myocardial revascularization. Circulation 49:703–708

    PubMed  CAS  Google Scholar 

  10. Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA (2009) ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization: a report by the American College of Cardiology Foundation Appropriateness Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, and the American Society of Nuclear Cardiology Endorsed by the American Society of Echocardiography, the Heart Failure Society of America, and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol 53:530–553

    Article  PubMed  Google Scholar 

  11. Diamond GA, Forrester JS (1979) Analysis of probability as an aid in the clinical diagnosis of coronary artery disease. N Engl J Med 300:1350–1358

    Article  PubMed  CAS  Google Scholar 

  12. Schoepf UJ, Zwerner PL, Savino G, Herzog C, Kerl JM, Costello P (2007) Coronary CT Angiography. Radiology 244:48–63

    Article  PubMed  Google Scholar 

  13. American College of Cardiology/American Heart Association Ad Hoc Task Force on Cardiac Catheterization (1991) American College of Cardiology/American Heart Association. Guidelines for cardiac catheterization and cardiac catheterization laboratories. J Am Coll Cardiol 84:1149–1182

    Google Scholar 

  14. Bowker A (1948) A test for symmetry in contingency tables. J Am Stat Assoc 43:572–574

    Article  PubMed  CAS  Google Scholar 

  15. Boden WE, O'Rourke RA, Teo KK et al (2007) Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 356:1503–1516

    Article  PubMed  CAS  Google Scholar 

  16. Mühlenbruch G, Seyfarth T, Soo CS, Pregalathan N, Mahnken AH (2007) Eur Radiol 17:603–609

    Article  PubMed  Google Scholar 

  17. Marano R, De Cobelli F, Floriani I et al (2009) Italian multicenter, prospective study to evaluate the negative predictive value of 16- and 64-slice MDCT imaging in patients scheduled for coronary angiography (NIMISCAD-Non Invasive Multicenter Italian Study for Coronary Artery Disease). Eur Radiol 19:1114–1123

    Article  PubMed  Google Scholar 

  18. Pugliese F, Mollet NR, Runza G et al (2006) Diagnostic accuracy of non-invasive 64-slice CT coronary angiography in patients with stable angina pectoris. Eur Radiol 16:575–582

    Article  PubMed  Google Scholar 

  19. Husmann L, Herzog BA, Gaemperli O et al (2009) Diagnostic accuracy of computed tomography coronary angiography and evaluation of stress-only single-photon emission computed tomography/computed tomography hybrid imaging: comparison of prospective electrocardiogram triggering vs. retrospective gating. Eur Heart J 30:600–607

    Article  PubMed  Google Scholar 

  20. Flohr TG, McCollough CH, Bruder H et al (2006) First performance evaluation of a dual-source CT (DSCT) system. Eur Radiol 16:256–268

    Article  PubMed  Google Scholar 

  21. Johnson TR, Nikolaou K, Busch S et al (2007) Diagnostic accuracy of dual-source computed tomography in the diagnosis of coronary artery disease. Invest Radiol 42:684–691

    Article  PubMed  Google Scholar 

  22. Ropers U, Ropers D, Pflederer T et al (2007) Influence of heart rate on the diagnostic accuracy of dual-source computed tomography coronary angiography. J Am Coll Cardiol 50:2393–2398

    Article  PubMed  Google Scholar 

  23. Alkadhi H, Scheffel H, Desbiolles L et al (2008) Dual-source computed tomography coronary angiography: influence of obesity, calcium load, and heart rate on diagnostic accuracy. Eur Heart J 29:766–776

    Article  PubMed  Google Scholar 

  24. Husmann L, Schepis T, Scheffel H et al (2008) Comparison of diagnostic accuracy of 64-slice computed tomography coronary angiography in patients with low, intermediate, and high cardiovascular risk. Acad Radiol 15:452–461

    Article  PubMed  Google Scholar 

  25. Pickhardt PJ, Choi JR, Hwang I et al (2003) Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. N Engl J Med 349:2191–2200

    Article  PubMed  CAS  Google Scholar 

  26. Topol E, Nissen S (1995) Our preoccupation with coronary luminology. The dissociation between clinical and angiographic findings in ischemic heart disease. Circulation 92:2333–2342

    PubMed  CAS  Google Scholar 

  27. Sones FM Jr (1958) Cine-cardio-angiography. Pediatr Clin N Am 5:945–979

    Google Scholar 

  28. Leber AW, Becker A, Knez A et al (2006) Accuracy of 64-slice computed tomography to classify and quantify plaque volumes in the proximal coronary system: a comparative study using intravascular ultrasound. J Am Coll Cardiol 47:672–677

    Article  PubMed  Google Scholar 

  29. Zir LM, Miller SW, Dinsmore RE, Gilbert JP, Harthorne JW (1976) Interobserver variability in coronary angiography. Circulation 53:627–632

    PubMed  CAS  Google Scholar 

  30. Zir LM (1983) Observer variability in coronary angiography. Int J Cardiol 3:171–173

    Article  PubMed  CAS  Google Scholar 

Download references


U. Joseph Schoepf is a medical consultant for and receives research support from Bayer-Schering, Bracco, General Electric Healthcare, Medrad, and Siemens. Peter L. Zwerner receives research support from Boehringer-Ingelheim, Bristol Myers Squib, Bracco, and Siemens.

Author information

Authors and Affiliations


Corresponding author

Correspondence to U. Joseph Schoepf.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Kerl, J.M., Schoepf, U.J., Zwerner, P.L. et al. Accuracy of coronary artery stenosis detection with CT versus conventional coronary angiography compared with composite findings from both tests as an enhanced reference standard. Eur Radiol 21, 1895–1903 (2011).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: