Skip to main content

Diagnostic performance of computed tomography coronary angiography to detect and exclude left main and/or three-vessel coronary artery disease

European Radiology volume 23, pages 2934–2943 (2013)Cite this article

Abstract

Objectives

To determine the diagnostic performance of CT coronary angiography (CTCA) in detecting and excluding left main (LM) and/or three-vessel CAD (“high-risk” CAD) in symptomatic patients and to compare its discriminatory value with the Duke risk score and calcium score.

Materials and methods

Between 2004 and 2011, a total of 1,159 symptomatic patients (61 ± 11 years, 31 % women) with stable angina, without prior revascularisation underwent both invasive coronary angiography (ICA) and CTCA. All patients gave written informed consent for the additional CTCA. High-risk CAD was defined as LM and/or three-vessel obstructive CAD (≥50 % diameter stenosis).

Results

A total of 197 (17 %) patients had high-risk CAD as determined by ICA. The sensitivity, specificity, positive predictive value, negative predictive value, positive and negative likelihood ratios of CTCA were 95 % (95 % CI 91–97 %), 83 % (80–85 %), 53 % (48–58 %), 99 % (98–99 %), 5.47 and 0.06, respectively. CTCA provided incremental value (AUC 0.90, P < 0.001) in the discrimination of high-risk CAD compared with the Duke risk score and calcium score.

Conclusions

CTCA accurately excludes high-risk CAD in symptomatic patients. The detection of high-risk CAD is suboptimal owing to the high percentage (47 %) of overestimation of high-risk CAD. CTCA provides incremental value in the discrimination of high-risk CAD compared with the Duke risk score and calcium score.

Key Points

• Computed tomography coronary angiography (CTCA) accurately excludes high-risk coronary artery disease.

• CTCA overestimates high-risk coronary artery disease in 47 %.

• CTCA discriminates high-risk CAD better than clinical evaluation and coronary calcification.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

Fig. 1

Abbreviations

1VD:

One-vessel CAD

2VD:

Two-vessel CAD

3VD:

Three-vessel CAD

AUC:

Area under the receiver operating characteristic curve

CAD:

Coronary artery disease

CTCA:

Computed tomography coronary angiography

CX:

Circumflex

DSCT:

Dual-source CT

ECG:

Electrocardiogram

HR:

Heart rate

ICA:

Invasive coronary angiography

LAD:

Left anterior descending artery

LM:

Left main

NS:

Not significant

PPV:

Positive predictive value

NPV:

Negative predictive value

RCA:

Right coronary artery

SN:

Sensitivity

SP:

Specificity

SSCT:

Single-source CT

QCA:

Quantitative coronary angiography

References

  1. Mosca L, Benjamin EJ, Berra K et al (2011) Effectiveness-based guidelines for the prevention of cardiovascular disease in women–2011 update a guideline from the american heart association. J Am Coll Cardiol 57:1404–1423

    PubMed  Article  Google Scholar 

  2. Thom T, Haase N, Rosamond W et al (2006) Heart disease and stroke statistics—2006 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 113:e85–e151

    PubMed  Article  Google Scholar 

  3. Roger VL, Go AS, Lloyd-Jones DM et al (2012) Heart disease and stroke statistics—2012 update: a report from the american heart association. Circulation 125:e2–e220

    PubMed  Article  Google Scholar 

  4. Yusuf S, Zucker D, Peduzzi P et al (1994) Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet 344:563–570

    PubMed  Article  CAS  Google Scholar 

  5. Jeremias A, Kaul S, Rosengart TK, Gruberg L, Brown DL (2009) The impact of revascularization on mortality in patients with nonacute coronary artery disease. Am J Med 122:152–161

    PubMed  Article  Google Scholar 

  6. Wijns W, Kolh P, Danchin N et al (2010) Guidelines on myocardial revascularization. Eur Heart J 31:2501–2555

    PubMed  Article  Google Scholar 

  7. Weiner DA, Ryan TJ, McCabe CH et al (1987) Value of exercise testing in determining the risk classification and the response to coronary artery bypass grafting in three-vessel coronary artery disease: a report from the Coronary Artery Surgery Study (CASS) registry. Am J Cardiol 60:262–266

    PubMed  Article  CAS  Google Scholar 

  8. Campos CT, Chu HW, D'Agostino HJ Jr, Jones RH (1983) Comparison of rest and exercise radionuclide angiocardiography and exercise treadmill testing for diagnosis of anatomically extensive coronary artery disease. Circulation 67:1204–1210

    PubMed  Article  CAS  Google Scholar 

  9. Fox K, Garcia MA, Ardissino D et al (2006) Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. Eur Heart J 27:1341–1381

    PubMed  Article  Google Scholar 

  10. Mahajan N, Polavaram L, Vankayala H et al (2010) Diagnostic accuracy of myocardial perfusion imaging and stress echocardiography for the diagnosis of left main and triple vessel coronary artery disease: a comparative meta-analysis. Heart 96:956–966

    PubMed  Article  CAS  Google Scholar 

  11. 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

    PubMed  Article  Google Scholar 

  12. Taylor AJ, Cerqueira M, Hodgson JM et al (2010) ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol 56:1864–1894

    PubMed  Article  Google Scholar 

  13. Pryor DB, Shaw L, McCants CB et al (1993) Value of the history and physical in identifying patients at increased risk for coronary artery disease. Ann Intern Med 118:81–90

    PubMed  Article  CAS  Google Scholar 

  14. Meijboom WB, Van Mieghem CA, van Pelt N et al (2008) Comprehensive assessment of coronary artery stenoses: computed tomography coronary angiography versus conventional coronary angiography and correlation with fractional flow reserve in patients with stable angina. J Am Coll Cardiol 52:636–643

    PubMed  Article  Google Scholar 

  15. Weustink AC, Mollet NR, Neefjes LA et al (2009) Preserved diagnostic performance of dual-source CT coronary angiography with reduced radiation exposure and cancer risk. Radiology 252:53–60

    PubMed  Article  Google Scholar 

  16. Weustink AC, Mollet NR, Neefjes LA et al (2010) Diagnostic accuracy and clinical utility of noninvasive testing for coronary artery disease. Ann Intern Med 152:630–639

    PubMed  Article  Google Scholar 

  17. Dharampal AS, Rossi A, Papadopoulou SL et al (2011) Is there a difference in the diagnostic accuracy of computed tomography coronary angiography between women and men? Coron Artery Dis 22:421–427

    PubMed  Article  Google Scholar 

  18. Dharampal AS, Papadopoulou SL, Rossi A et al (2012) Computed tomography coronary angiography accuracy in women and men at low to intermediate risk of coronary artery disease. Eur Radiol 22:2415–2423

    PubMed  Article  Google Scholar 

  19. Weustink AC, Mollet NR, Pugliese F et al (2008) Optimal electrocardiographic pulsing windows and heart rate: effect on image quality and radiation exposure at dual-source coronary CT angiography. Radiology 248:792–798

    PubMed  Article  Google Scholar 

  20. Neefjes LA, Dharampal AS, Rossi A et al (2011) Image quality and radiation exposure using different low-dose scan protocols in dual-source ct coronary angiography: randomized study. Radiology 261:779–786

    PubMed  Article  Google Scholar 

  21. Agatston AS, Janowitz WR, Hildner FJ, Zusmer NR, Viamonte M Jr, Detrano R (1990) Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol 15:827–832

    PubMed  Article  CAS  Google Scholar 

  22. Wilson EB (1927) Probable inference, law of succession, and statistical inference. J Am Stat Assoc 22:209–212

    Article  Google Scholar 

  23. Diamond GA (1991) Affirmative actions: can the discriminant accuracy of a test be determined in the face of selection bias? Med Decis Making 11:48–56

    PubMed  Article  CAS  Google Scholar 

  24. Fischer JE, Bachmann LM, Jaeschke R (2003) A readers' guide to the interpretation of diagnostic test properties: clinical example of sepsis. Intensive Care Med 29:1043–1051

    PubMed  Article  Google Scholar 

  25. DeLong ER, DeLong DM, Clarke-Pearson DL (1988) Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics 44:837–845

    PubMed  Article  CAS  Google Scholar 

  26. Bossuyt PM, Reitsma JB, Bruns DE et al (2003) Towards complete and accurate reporting of studies of diagnostic accuracy: the STARD initiative. Clin Radiol 58:575–580

    PubMed  Article  CAS  Google Scholar 

  27. Bruschke AV, Proudfit WL, Sones FM Jr (1973) Progress study of 590 consecutive nonsurgical cases of coronary disease followed 5–9 years. I. Arterographic correlations. Circulation 47:1147–1153

    PubMed  Article  CAS  Google Scholar 

  28. Platia EV, Grunwald L, Mellits ED, Humphries JO, Griffith LS (1980) Clinical and arteriographic variables predictive of survival in coronary artery disease. Am J Cardiol 46:543–552

    PubMed  Article  CAS  Google Scholar 

  29. Chaitman BR, Davis K, Fisher LD et al (1983) A life table and Cox regression analysis of patients with combined proximal left anterior descending and proximal left circumflex coronary artery disease: non-left main equivalent lesions (CASS). Circulation 68:1163–1170

    PubMed  Article  CAS  Google Scholar 

  30. Proudfit WJ, Bruschke AV, MacMillan JP, Williams GW, Sones FM Jr (1983) Fifteen year survival study of patients with obstructive coronary artery disease. Circulation 68:986–997

    PubMed  Article  CAS  Google Scholar 

  31. Ostrom MP, Gopal A, Ahmadi N et al (2008) Mortality incidence and the severity of coronary atherosclerosis assessed by computed tomography angiography. J Am Coll Cardiol 52:1335–1343

    PubMed  Article  Google Scholar 

  32. Min JK, Shaw LJ, Devereux RB et al (2007) Prognostic value of multidetector coronary computed tomographic angiography for prediction of all-cause mortality. J Am Coll Cardiol 50:1161–1170

    PubMed  Article  Google Scholar 

  33. Min JK, Dunning A, Lin FY et al (2011) Age- and sex-related differences in all-cause mortality risk based on coronary computed tomography angiography findings results from the International Multicenter CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry) of 23,854 patients without known coronary artery disease. J Am Coll Cardiol 58:849–860

    PubMed  Article  Google Scholar 

  34. Shaw LJ, Mieres JH, Hendel RH et al (2011) Comparative effectiveness of exercise electrocardiography with or without myocardial perfusion single photon emission computed tomography in women with suspected coronary artery disease: results from the What Is the Optimal Method for Ischemia Evaluation in Women (WOMEN) trial. Circulation 124:1239–1249

    PubMed  Article  Google Scholar 

  35. Christian TF, Miller TD, Bailey KR, Gibbons RJ (1994) Exercise tomographic thallium-201 imaging in patients with severe coronary artery disease and normal electrocardiograms. Ann Intern Med 121:825–832

    PubMed  Article  CAS  Google Scholar 

  36. McNeer JF, Margolis JR, Lee KL et al (1978) The role of the exercise test in the evaluation of patients for ischemic heart disease. Circulation 57:64–70

    PubMed  Article  CAS  Google Scholar 

  37. Uthamalingam S, Zheng H, Leavitt M et al (2011) Exercise-induced ST-segment elevation in ECG lead aVR is a useful indicator of significant left main or ostial LAD coronary artery stenosis. JACC Cardiovasc Imaging 4:176–186

    PubMed  Article  Google Scholar 

  38. Daou D, Delahaye N, Vilain D, Lebtahi R, Faraggi M, Le Guludec D (2002) Identification of extensive coronary artery disease: incremental value of exercise Tl-201 SPECT to clinical and stress test variables. J Nucl Cardiol 9:161–168

    PubMed  Article  Google Scholar 

  39. Lima RS, Watson DD, Goode AR et al (2003) Incremental value of combined perfusion and function over perfusion alone by gated SPECT myocardial perfusion imaging for detection of severe three-vessel coronary artery disease. J Am Coll Cardiol 42:64–70

    PubMed  Article  Google Scholar 

  40. Berman DS, Kang X, Slomka PJ et al (2007) Underestimation of extent of ischemia by gated SPECT myocardial perfusion imaging in patients with left main coronary artery disease. J Nucl Cardiol 14:521–528

    PubMed  Article  Google Scholar 

  41. Ragosta M, Bishop AH, Lipson LC et al (2007) Comparison between angiography and fractional flow reserve versus single-photon emission computed tomographic myocardial perfusion imaging for determining lesion significance in patients with multivessel coronary disease. Am J Cardiol 99:896–902

    PubMed  Article  Google Scholar 

  42. Pellikka PA, Nagueh SF, Elhendy AA, Kuehl CA, Sawada SG (2007) American Society of Echocardiography recommendations for performance, interpretation, and application of stress echocardiography. J Am Soc Echocardiogr 20:1021–1041

    PubMed  Article  Google Scholar 

  43. Hoffmann R, Lethen H, Marwick T et al (1996) Analysis of interinstitutional observer agreement in interpretation of dobutamine stress echocardiograms. J Am Coll Cardiol 27:330–336

    PubMed  Article  CAS  Google Scholar 

  44. Sarno G, Decraemer I, Vanhoenacker PK et al (2009) On the inappropriateness of noninvasive multidetector computed tomography coronary angiography to trigger coronary revascularization: a comparison with invasive angiography. JACC Cardiovasc Interv 2:550–557

    PubMed  Article  Google Scholar 

  45. Tonino PA, De Bruyne B, Pijls NH et al (2009) Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med 360:213–224

    PubMed  Article  CAS  Google Scholar 

  46. Koo BK, Erglis A, Doh JH et al (2011) Diagnosis of ischemia-causing coronary stenoses by noninvasive fractional flow reserve computed from coronary computed tomographic angiograms. Results from the prospective multicenter DISCOVER-FLOW (Diagnosis of Ischemia-Causing Stenoses Obtained Via Noninvasive Fractional Flow Reserve) study. J Am Coll Cardiol 58:1989–1997

    PubMed  Article  Google Scholar 

  47. Bastarrika G, Ramos-Duran L, Rosenblum MA, Kang DK, Rowe GW, Schoepf UJ (2010) Adenosine-stress dynamic myocardial CT perfusion imaging: initial clinical experience. Invest Radiol 45:306–313

    PubMed  Article  CAS  Google Scholar 

  48. Bamberg F, Becker A, Schwarz F et al (2011) Detection of hemodynamically significant coronary artery stenosis: incremental diagnostic value of dynamic CT-based myocardial perfusion imaging. Radiology 260:689–698

    PubMed  Article  Google Scholar 

  49. Meijboom WB, Meijs MF, Schuijf JD et al (2008) Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study. J Am Coll Cardiol 52:2135–2144

    PubMed  Article  Google Scholar 

  50. Halliburton SS, Abbara S, Chen MY et al (2011) SCCT guidelines on radiation dose and dose-optimization strategies in cardiovascular CT. J Cardiovasc Comput Tomogr 5:198–224

    PubMed  Article  Google Scholar 

  51. Diamond GA (1983) A clinically relevant classification of chest discomfort. J Am Coll Cardiol 1:574–575

    PubMed  Article  CAS  Google Scholar 

Download references

Acknowledgements

Parts of this single-centre cardiac database have been used in previous studies [14–18].

Author information

Affiliations

  1. Department of Radiology, Erasmus MC, Room Ca207a, s-Gravendijkwal 230, PO Box 2040, 3015 CE, Rotterdam, The Netherlands

    Anoeshka S. Dharampal, Stella L. Papadopoulou, Alexia Rossi, W. Bob Meijboom, Annick Weustink, Marcel Dijkshoorn, Koen Nieman, Pim J. de Feijter & Gabriel P. Krestin

  2. Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands

    Anoeshka S. Dharampal, Stella L. Papadopoulou, Alexia Rossi, W. Bob Meijboom, Annick Weustink, Koen Nieman, Eric H. Boersma & Pim J. de Feijter

Authors
  1. Anoeshka S. Dharampal
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Stella L. Papadopoulou
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Alexia Rossi
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. W. Bob Meijboom
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Annick Weustink
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Marcel Dijkshoorn
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Koen Nieman
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Eric H. Boersma
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Pim J. de Feijter
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Gabriel P. Krestin
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Anoeshka S. Dharampal.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Dharampal, A.S., Papadopoulou, S.L., Rossi, A. et al. Diagnostic performance of computed tomography coronary angiography to detect and exclude left main and/or three-vessel coronary artery disease. Eur Radiol 23, 2934–2943 (2013). https://doi.org/10.1007/s00330-013-2935-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00330-013-2935-6

Keywords

  • Computed tomography coronary angiography
  • Diagnostic performance
  • Left main and/or three-vessel CAD
  • “High-risk” CAD
  • Calcium score, coronary calcification
  • Duke risk score, clinical evaluation