Dear reader,

For this April 2022 issue, I would like to recommend the paper by the team of Dr Reis and colleagues from the Departments of Cardiology and Radiology, Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, in Lisbon, Portugal [1]. The goal of their study was to determine the impact of the use of systematic coronary computed tomographic angiography (CCTA) following an abnormal non-invasive ischemia test (NIST), which could be either exercise treadmill test or SPECT, on the patient selection strategy for invasive coronary angiography. In this single center study, a total of 105 patients underwent directly invasive coronary angiography (ICA), while 115 patients underwent CCTA prior to the ICA. In this CCTA group, ICA was cancelled by referring physicians in 83 patients (72.2%) after the CCTA results became available. For those patients undergoing ICA, the diagnostic (84.4% vs. 41.7%, p < 0.001) and revascularization (71.9% vs. 38.8%, p = 0.001) yields were significantly higher for CCTA-guided ICA than for standard NIST-guided ICA. Also, the cumulative radiation exposure was significantly lower in the CCTA-guided ICA arm than in the NIST-guided ICA arm. There were also no significant differences in the primary safety endpoint rates between the strategies.

An example of one of their cases is presented in Fig. 1 of their manuscript.

Fig. 1
figure 1

A Cardiac single-photon emission computerized tomography (SPECT) revealing anterior ischemia; B, C CCTA showing a non-obstructive plaque in the proximal left anterior descending artery; and D circumflex artery with no coronary artery disease in a patient with left dominant coronary circulation

Full size image

The main conclusion from their work is, that in patients with suspected CAD and mild-to-moderately abnormal ischemia tests, a diagnostic strategy including CCTA as a gatekeeper is safe and effective and significantly improves the diagnostic and revascularization yields of ICA.

There are of course a number of limitations in this study as described in their Discussion, but the overall results are in line with the latest guidelines of CCTA [2], which support the usage of CCTA at an early point in the diagnostic process to determine whether a patient should undergo a cardiac catheterization procedure or not.

Again, in this issue of the International Journal of Cardiovascular Imaging, there are many more papers that are very worthwhile to read, also in the other imaging domains.


Johan H. C. Reiber, PhD

Editor-in-chief

e-mail: J.H.C.Reiber@lumc.nl