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Computed tomography (CT) coronary angiography has become a highly accurate noninvasive approach for delineation of the presence and severity of coronary atherosclerosis [1–9]. Cardiac CT is optimally suited for the evaluation of patients with a low or intermediate risk of coronary disease, allowing the non-invasive rule-out of coronary disease at relatively low cost and risk [10–18]. However, the appropriate radiation dose remains an important issue in cardiac CT. On one hand, a too low radiation dose may result in a high level of image noise and therefore in non-diagnostic images. On the other hand, using higher radiation exposure levels may put patients at unnecessary risk of radiation damage [19–26]. Effective strategies to reduce radiation dose, such as prospective gating, heart rate control, ECG-correlated modulation of the tube current, and tube voltage below 100 kV, are becoming more and more applied in the clinical situation [27–31].
Recently, Buechel et al. [32] evaluated a large group of 612 patients referred for CT coronary angiography by 64-slice computed tomography. Intravenous metoprolol (2 to 30 mg) was administered if necessary to achieve a target heart rate below 65 beats/min. Using prospective ECG-triggering a mean effective radiation dose of 1.8 ± 0.6 mSv was obtained with a diagnostic image quality in 96.2% of segments. The authors concluded that low-dose CT coronary angiography by prospective ECG-triggering is feasible in the vast majority of an every-day population, whereby a heart rate below 62 beats/min favors diagnostic image quality. Blankstein et al. [33] investigated the effective radiation dose and image quality of 100 kV versus 120 kV tube voltage among patients referred for cardiac dual source CT imaging in 294 consecutive patients. They convincingly demonstrated that use of low kV resulted in a substantial reduction of radiation dose without compromising image quality. The effective radiation dose for the 100 and 120 kV scans was 8.5 and 15.4 mSv, respectively. In the recently published PROTECTION II trial, Hausleiter et al. [34] studied 400 non-obese patients undergoing CT angiography with either 100 or 120 kV CT coronary angiography. The study specifically examined the impact of a reduction in tube voltage to 100 kV using 64-slice CT angiography systems from three different manufacturers. It was demonstrated that a further 31% reduction in radiation exposure could be obtained with 100 kV tube voltage settings while image quality was preserved. Zhang et al. [35] prospectively evaluated image quality parameters, contrast volume and radiation dose at the 100 kV tube voltage setting during CT coronary angiography using a 320-row computed tomography scanner. The effective radiation dose was 2.12 ± 0.19 mSv for 100 kV, being a reduction of 54% compared to 4.61 ± 0.82 mSv for 120 kV. Diagnostic image quality was achieved in 98.2% of coronary segments with 100 kV and 98.6% of coronary segments with 120 kV. Therefore, the 100 kV setting allowed significant reductions in contrast material volume and effective radiation dose while maintaining adequate diagnostic image quality.
In the current issue of the International Journal of Cardiovascular Imaging, Wang et al. [36] investigated the feasibility of a body mass index-adapted low-dose 80 kV scan protocol using prospectively ECG-triggered high-pitch spiral coronary CT angiography in 106 patients referred for coronary CT angiography to rule out coronary artery disease. The image quality and dose performance were compared with 100 and 120 kV tube settings. The authors demonstrated that an adequate diagnostic image quality was obtained in more than 98% of coronary segments using the 80, 100, and 120 kV tube voltage settings (p = 0.482). Image noise was significantly higher with 80 kV compared to 100 and 120 kV tube voltage settings. The effective dose using 80 kV (0.36 ± 0.03 mSv) was significantly lower than that using 100 kV (0.86 ± 0.08 mSv), or the 120 kV tube voltage setting (1.77 ± 0.18 mSv). Use of a tube voltage of 80 kV for patients with a body mass index ≤ 22.5 kg/m² resulted in a further dose reduction of 58% and 80% compared with 100 and 120 kV protocols, while maintaining diagnostic image quality. Particularly in patients with slim body shape, a further reduction of tube voltage to 80 kV may be advisable. The authors concluded that 80 kV high-pitch spiral coronary CT angiography is feasible for patients with body mass index ≤ 22.5 kg/m². The authors also suggested that the amount of contrast material could be decreased, reducing contrast media-associated nephropathy and avoiding the obscuration of calcification caused by excessively high Hounsfield value. To further reduce the high image noise, they introduced iterative reconstruction in clinical routine practice. Consequently, the authors propose a combination of a low kV scan protocol, reduced contrast material injection protocol, and iterative reconstruction for an acceptable low radiation dose together with preserved image quality.
The above-mentioned findings by Wang et al. [36] have been underscored by Abada et al. [37], who used a 64-slice CT 80 kV tube voltage setting in 11 patients with body weight < 60 kg. The authors reported a dose reduction by up to 88% without a negative influence on image quality. Achenbach et al. [38] reported a case of 74-year-old patient with 63 kg body weight using 80 kV tube voltage and showed adequate diagnostic image quality and a dose reduction of 80% compared with a standard 120 kV tube voltage setting. In summary, the study by Wang et al. [36] validly demonstrates that further reduction in tube current may be feasible for reducing radiation exposure in patients undergoing CT coronary angiography.
References
Schuijf JD, Bax JJ, van der Wall EE (2005) Non-invasive visualization of the coronary arteries with multi-detector row computed tomography; influence of technical advances on clinical applicability. Int J Cardiovasc Imaging 21:343–345
Groen JM, Greuter MJ, Vliegenthart R et al (2008) Calcium scoring using 64-slice MDCT, dual source CT and EBT: a comparative phantom study. Int J Cardiovasc Imaging 24:547–556
Dirksen MS, Bax JJ, de Roos A et al (2002) Usefulness of dynamic multislice computed tomography of left ventricular function in unstable angina pectoris and comparison with echocardiography. Am J Cardiol 90:1157–1160
van de Veire NR, Schuijf JD, De Sutter J et al (2006) Non-invasive visualization of the cardiac venous system in coronary artery disease patients using 64-slice computed tomography. J Am Coll Cardiol 48:1832–1838
Roeters van Lennep JE, Westerveld HT, Erkelens DW, van der Wall EE (2002) Risk factors for coronary heart disease: implications of gender. Cardiovasc Res 53:538–549
van der Wall EE, Heidendal GA, den Hollander W, Westera G, Roos JP (1980) I-123 labeled hexadecenoic acid in comparison with thallium-201 for myocardial imaging in coronary heart disease. a preliminary study. Eur J Nucl Med 5:401–405
Groothuis JG, Beek AM, Meijerink MR, Brinckman SL, Hofman MB, van Rossum AC (2010) Towards a noninvasive anatomical and functional diagnostic work-up of patients with suspected coronary artery disease. Neth Heart J 18:270–273
van Mieghem CA, de Feyter PJ (2009) Combining noninvasive anatomical imaging with invasive functional information: an unconventional but appropriate hybrid approach. Neth Heart J 17:292–294
Knaapen P, de Haan S, Hoekstra OS et al (2010) Cardiac PET-CT: advanced hybrid imaging for the detection of coronary artery disease. Neth Heart J 18:90–98
van der Wall EE, van Dijkman PR, de Roos A et al (1990) Diagnostic significance of gadolinium-DTPA (diethylenetriamine penta-acetic acid) enhanced magnetic resonance imaging in thrombolytic treatment for acute myocardial infarction: its potential in assessing reperfusion. Br Heart J 63:12–17
Wijpkema JS, Dorgelo J, Willems TP et al (2007) Discordance between anatomical and functional coronary stenosis severity. Neth Heart J 15:5–11
van de Wal RM, van Werkum JW, le Cocq d’Armandville MC et al (2007) Giant aneurysm of an aortocoronary venous bypass graft compressing the right ventricle. Neth Heart J 15:252–254
de Leeuw JG, Wardeh A, Sramek A, van der Wall EE (2007) Pseudo-aortic dissection after primary PCI. Neth Heart J 15:265–266
Nollen GJ, Groenink M, Tijssen JG, Van Der Wall EE, Mulder BJ (2004) Aortic stiffness and diameter predict progressive aortic dilatation in patients with Marfan syndrome. Eur Heart J 25:1146–1152
ten Kate GJ, Wuestink AC, de Feyter PJ (2008) Coronary artery anomalies detected by MSCT-angiography in the adult. Neth Heart J 16:369–375
Bakx AL, van der Wall EE, Braun S, Emanuelsson H, Bruschke AV, Kobrin I (1995) Effects of the new calcium antagonist mibefradil (Ro 40–5967) on exercise duration in patients with chronic stable angina pectoris: a multicenter, placebo-controlled study. Ro 40–5967 International Study Group. Am Heart J 130:748–757
Schuijf JD, Bax JJ, van der Wall EE (2007) Anatomical and functional imaging techniques: basically similar or fundamentally different? Neth Heart J 15:43–44
Juwana YB, Wirianta J, Suryapranata H, de Boer MJ (2007) Left main coronary artery stenosis undetected by 64-slice computed tomography: a word of caution. Neth Heart J 15:255–256
van der Laarse A, Kerkhof PL, Vermeer F et al (1988) Relation between infarct size and left ventricular performance assessed in patients with first acute myocardial infarction randomized to intracoronary thrombolytic therapy or to conventional treatment. Am J Cardiol 61:1–7
Ertas G, van Beusekom HM, van der Giessen WJ (2009) Late stent thrombosis, endothelialisation and drug-eluting stents. Neth Heart J 17:177–180
Bleeker GB, Schalij MJ, Boersma E et al (2007) Relative merits of M-mode echocardiography and tissue Doppler imaging for prediction of response to cardiac resynchronization therapy in patients with heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol 99:68–74
Ypenburg C, van der Wall EE, Schalij MJ, Bax JJ (2008) Imaging in cardiac resynchronisation therapy. Neth Heart J 16:S36–S40
Nemes A, Geleijnse ML, van Geuns RJ et al (2008) Dobutamine stress MRI versus threedimensional contrast echocardiography: it’s all black and white. Neth Heart J 16:217–218
van der Geest RJ, Niezen RA, van der Wall EE, de Roos A, Reiber JH (1998) Automated measurement of volume flow in the ascending aorta using MR velocity maps: evaluation of inter- and intraobserver variability in healthy volunteers. J Comput Assist Tomogr 22:904–911
van Rugge FP, Boreel JJ, van der Wall EE et al (1991) Cardiac first-pass and myocardial perfusion in normal subjects assessed by sub-second Gd-DTPA enhanced MR imaging. J Comput Assist Tomogr 15:959–965
van der Wall EE, Vliegen HW, de Roos A, Bruschke AV (1995) Magnetic resonance imaging in coronary artery disease. Circulation 92:2723–2739
Underwood SR, Bax JJ, vom Dahl J et al (2004) Study group of the European Society of Cardiology. Imaging techniques for the assessment of myocardial hibernation. report of a study group of the European Society of Cardiology. Eur Heart J 25:815–836
Portegies MC, Schmitt R, Kraaij CJ et al (1991) Lack of negative inotropic effects of the new calcium antagonist Ro 40–5967 in patients with stable angina pectoris. J Cardiovasc Pharmacol 18:746–751
Zhang LJ, Yang GF, Huang W, Zhou CS, Chen P, Lu GM (2010) Incidence of anomalous origin of coronary artery in 1879 Chinese adults on dual-source CT angiography. Neth Heart J 18:466–470
van der Wall EE (2009) CT angiography, underuse, overuse, or appropriate use? Neth Heart J 17:223
Rogalla P, Blobel J, Kandel S et al (2010) Radiation dose optimisation in dynamic volume CT of the heart: tube current adaptation based on anterior-posterior chest diameter. Int J Cardiovasc Imaging 26:933–940
Buechel RR, Husmann L, Herzog BA et al (2011) Low-dose computed tomography coronary angiography with prospective electrocardiogram triggering: Feasibility in a large population. J Am Coll Cardiol 57:332–336
Blankstein R, Bolen MA, Pale R et al. (2010) Use of 100 kV versus 120 kV in Cardiac Dual source computed tomography: effect on radiation dose and image quality. Int J Cardiovasc Imaging. [Epub ahead of print]
Hausleiter J, Martinoff S, Hadamitzky M et al (2010) Image quality and radiation exposure with a low tube voltage protocol for coronary ct angiography results of the PROTECTION II trial. JACC Cardiovasc Imaging 3:1113–1123
Zhang C, Zhang Z, Yan Z, Xu L, Yu W, Wang R. 320-row CT coronary angiography: effect of 100-kV tube voltages on image quality, contrast volume, and radiation dose. Int J Cardiovasc Imaging. [Epub ahead of print]
Wang D, Hu X, Zhang S et al. Image quality and dose performance of 80 kV low dose scan protocol in high-pitch spiral coronary CT angiography: feasibility study. Int J Cardiovasc Imaging. [Epub ahead of print]
Abada HT, Larchez C, Daoud B, Sigal-Cinqualbre A, Paul JF (2006) MDCT of the coronary arteries: feasibility of low-dose CT with ECG-pulsed tube current modulation to reduce radiation dose. AJR Am J Roentgenol 186(6 Suppl 2):S387–S390
Achenbach S, Anders K, Kalender WA (2008) Dual-source cardiac computed tomography: image quality and dose considerations. Eur Radiol 18:1188–1198
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van der Wall, E.E., van Velzen, J.E., de Graaf, F.R. et al. Reduction of radiation dose using 80 kV tube voltage: a feasible strategy?. Int J Cardiovasc Imaging 28, 425–428 (2012). https://doi.org/10.1007/s10554-011-9845-y
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DOI: https://doi.org/10.1007/s10554-011-9845-y