Computed Tomography Angiography and Myocardial Computed Tomography Perfusion in Patients With Coronary Stents

• Published in: Journal of the American College of Cardiology 2013-10, Vol.62 (16), p.1476-1485
• Main Authors: Rief, Matthias, MD, Zimmermann, Elke, MD, Stenzel, Fabian, MD, Martus, Peter, PhD, Stangl, Karl, MD, Greupner, Johannes, MD, Knebel, Fabian, MD, Kranz, Anisha, MS, Schlattmann, Peter, PhD, Laule, Michael, MD, Dewey, Marc, MD
• Format: Article
• Language: English
• Subjects: Accuracy; Automation; Body mass index; Cardiology; Cardiovascular; Cardiovascular disease; computed tomography; Confidence intervals; coronary angiography; Coronary vessels; coronary vessels; diagnostic accuracy; Heart; Internal Medicine; Medical imaging; Patients; Stents; Work stations
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2013.03.088

Objectives This study sought to determine whether adding myocardial computed tomography perfusion (CTP) to computed tomography angiography (CTA) improves diagnostic performance for coronary stents. Background CTA of coronary stents has been limited by nondiagnostic studies caused by metallic stent material and coronary motion. Methods CTA and CTP were performed in 91 consecutive patients with stents before quantitative coronary angiography, the reference standard for obstructive stenosis (≥50%). If a coronary stent or vessel was nondiagnostic on CTA, adenosine stress CTP in the corresponding myocardial territory was read for combined CTA/CTP. Results Patients had an average of 2.5 ± 1.8 coronary stents (1 to 10), with a diameter of 3.0 ± 0.5 mm. Significantly more patients were nondiagnostic for stent assessment by CTA (22%; mainly due to metal artifacts [75%] or motion [25%]) versus CTP (1%; p < 0.001; severe angina precluded CTP in 1 case). The per-patient diagnostic accuracy of CTA/CTP for stents (87%, 95% confidence interval [CI]: 78% to 93%) was significantly higher than that of CTA alone (71%, 95% CI: 61% to 80%; p < 0.001), mainly because nondiagnostic examinations were significantly reduced (p < 0.001). In the analysis of any coronary artery disease, diagnostic accuracy and nondiagnostic rate were also significantly improved by the addition of CTP (p < 0.001). CTA/CTP (7.9 ± 2.8 mSv) had a significantly lower effective radiation dose than angiography (9.5 ± 5.1 mSv; p = 0.005). The area under the receiver-operating characteristic curve for CTA/CTP (0.82, 95% CI: 0.69 to 0.95) was superior to that for CTA (0.69, 95% CI: 0.57 to 0.82; p < 0.001) in identifying patients requiring stent revascularization. Conclusions Combined coronary CTA and myocardial CTP improves diagnosis of CAD and in-stent restenosis in patients with stents compared with CTA alone. (Coronary Artery Stent Evaluation With 320-Slice Computed Tomography—The CArS 320 Study [CARS-320]; NCT00967876 )