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© Springer International Publishing 2016
M.J. Budoff, J.S. Shinbane (eds.), Cardiac CT Imaging: Diagnosis of Cardiovascular Disease,
DOI 10.1007/978-3-319-28219-0_21
Coronary Computed Tomographic
Angiography for Detection of Coronary
Artery Disease: Analysis of Large-Scale
Multicenter Trials and Registries
Leslee J. Shaw
Abstract
The fi eld of coronary computed tomographic angiography (CCTA) has evolved dramatically
with an ever increasing and robust evidence base to support its clinical utility in terms of an
unparalleled diagnostic accuracy and effective risk stratifi cation rivaling the more commonly
applied, comparative stress imaging procedures. This chapter seeks to highlight the available
high quality effectiveness evidence, including large observational and randomized trial data,
that support the utility of CCTA as a valuable tool in the diagnosis of coronary artery
disease.
Keywords
Quality Research • Effectiveness Research • Multicenter Trial • Randomized Trials
Introduction
The fi eld of coronary computed tomographic angiography
(CCTA) has evolved dramatically with an ever increasing
and robust evidence base to support its clinical utility in
terms of an unparalleled diagnostic accuracy and effective
risk stratifi cation rivaling the more commonly applied, comparative stress imaging procedures. It is diffi cult to fathom
but, in 2005, 64-slice CCTA was introduced and, in less than
a decade, all of our knowledge base on the strengths and
limitations of this noninvasive, anatomic procedure have
been revealed. The CCTA community, including combined
expertise in cardiology and radiology, has strategically
sought to answer both technical and clinical questions with
regards to the accuracy and effectiveness of this procedure to
guide optimal patient care strategies.
In this chapter, we will highlight the current high quality
evidence based on the clinical utility of CCTA. Importantly,
given the enormity of this task, we cannot be all inclusive but
hope to provide readers with a smattering of the available
evidence within selective indications which strongly support
CCTA as clinically effective and enhancing patient care.
Moreover, we will highlight specifi c leadership on the part of
CCTA investigators to provide a clinically effective tool
while enhancing radiation safety profi les.
Coverage with Evidence Development
In 2008, the Centers for Medicaid and Medicare Services
reviewed the available evidence with CCTA and recommended that there be no national coverage determination due
to a paucity of evidence in certain indications. Although one
may argue that none of the other competitive and commonlyemployed models were held to such a high standard, these
new standards refl ect our current state of affairs for payer
policies. In today’s challenging healthcare environment, coverage policies are garnered by a suffi ciently high level of evidence noting that an imaging modality is capable of
improving clinical outcomes of patients. This new standard
has been termed patient-centered imaging and places the
core aims of imaging aligned with each patient and the
L. J. Shaw , PhD
Department of Medicine , Emory Clinical Cardiovascular
Research Institute, Emory University School of Medicine ,
1462 Clifton Rd NE, Rm 529 , Atlanta 30324 , GA , USA
e-mail: lshaw3@emory.edu
2 1
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ultimate goal of improved quality or quantity of life as
initiated based on anatomic markers identifi ed during the
CCTA procedure. Given this new standard, where are we
today in evidence for clinical indications?
Growth in CCTA Research
Since 2005, there has been an explosion in published research on
CCTA. Based on statistics from Thomson Reuters’ Web of
Knowledge which collects data on all published manuscripts,
approximately 30 peer-reviewed manuscripts were published in
2004 and this number has grown to over 180 for 2013. This is
dramatic growth and refl ects the fact that, in 2013, CCTA articles
were cited over 3500 times. This acceleration in the published
literature, as we will highlight, refl ects not only the expansiveness of the evidence but also high quality evidence supporting
CCTA as a highly effective diagnostic test procedure.
Specifi c Clinical Indications for CCTA
with High Level Evidence Supporting Clinical
Effectiveness
In this chapter, we will highlight specifi c evidence on three
specifi c clinical indications for the use of CCTA including:
1. Diagnostic Testing for the Detection of High Risk Patients
with Coronary Artery Calcium (CAC) Scoring
2. Acute Evaluation of Low Risk Chest Pain in the
Emergency Department (ED)
3. Diagnosis and Risk Stratifi cation of Patients with Stable
Chest Pain
Detecting High Risk Patients with CAC
Scoring
Let us begin our review of the CCTA evidence by focusing
on the available and high quality evidence on screening of
apparently healthy individuals. In 2010, the American
College of Cardiology published a thorough review of the
available evidence across all cardiovascular screening
modalities [ 1 ]. We will highlight the results of this guideline
but also discuss more recent publications which have
extended these fi ndings on the use of CAC screening.
Although numerous reports were published using patient
series, the National Institutes of Health – National Heart,
Lung, and Blood Institute-sponsored Multi-Ethnic Study of
Atherosclerosis (MESA) published 5-year outcome data
following CAC scoring in 6724 asymptomatic apparently
healthy people ages 45–84 years [ 2 ]. The evidence from this
population cohort revealed that CAC scoring was
independently predictive and highly effective at risk
stratifi cation of major adverse cardiac events (MACE) (i.e.,
cardiac death or nonfatal myocardial infarction). These
results were confi rmatory of prior fi ndings noting a directly
proportional relationship between CAC scores and MACE
risk. That is, there is a very low risk of MACE in patients
with no CAC or a zero score. As the CAC score increases
(i.e., becomes more extensive), the overall MACE risk
increases; such that for patients with a CAC score of 300–
400 or higher, the MACE risk is at least 10 % over 5 years
[ 2 ]. This risk is exceedingly high for asymptomatic
individuals and has been consistently reported across
numerous patient and population cohorts [ 3 , 4 ].
One may actually quantify the added contribution to risk
estimation using the net reclassifi cation improvement (NRI)
statistic [ 5 ]. Two reports have been published on the calcula-
tion of the NRI using the MESA population registry [ 6 , 7 ]. In
the fi rst of these series, the NRI was 0.25 revealing that CAC
fi ndings improve the detection of lower or higher risk status
for 1 in 4 individuals when compared to risk estimation using
the Framingham risk score [ 6 ]. This NRI statistic for CAC is
much higher than for other markers, such as high sensitivity
C-reactive protein (CRP) [ 8 ]. An updated report from MESA,
in intermediate risk individuals, compared the NRI for CAC
as compared to other markers such as a family history of premature coronary heart disease, CRP, ankle brachial index, and
carotid intima-media thickness (Fig. 21.1 ) [ 7 ]. If one exam-
ines the NRI results for a prognostic model estimating 7-year
incidence of MACE (defi ned as myocardial infarction, coronary heart disease death, resuscitated cardiac arrest, or angina
followed by coronary revascularization), the statistic for CAC
was 0.66 and at least 6-fold higher than for many of the other
risk markers [ 7 ].
A limitation with the available CAC evidence is the lack
of randomized trials noting improved outcomes. Despite this
there are several additional publications that are relevant to
answering this question. In a related secondary analysis from
the MESA registry, Blaha and colleagues reported on the
number needed to treat (NNT) to save a life if CAC screening
was employed to target treatment with statin therapy (in this
case, 20 mg of rosuvastatin) [ 9 ]. This result revealed that if
all patients with a 0 CAC score were treated with statins, the
NNT would be over 500. However, if only patients with a
CAC score of 100 or higher were targeted, then the NNT
would be dramatically reduced to 24 [ 9 ].
There have been several intermediate outcome trials which
have randomized patients to CAC scanning versus no scanning
with primary outcomes of change in the Framingham risk score
[ 10 , 11 ]. In the Early Identifi cation of Subclinical Atherosclerosis
by Noninvasive Imaging Research (EISNER) trial, a 2:1 randomization had 1311 patients receiving CAC scanning and 623
did not receive CAC scanning [ 10 ]. The primary fi ndings from
this trial revealed that CAC scanning resulted in minimal change
in the Framingham risk score (0.002 %) by comparison there
was a marked worsening of this risk score in patients not
L.J. Shaw
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383
receiving the CAC scan (0.7 %, p = 0.0003). As well, patients
randomized to receive the CAC scan showed net favorable
changes in systolic blood pressure (p = 0.02), LDL cholesterol
(p = 0.04), and for improvements in waist circumference for
those with an increased abdominal girth (p = 0.01) [ 10 ].
The compilation of evidence is quite strong and does
reveal that CAC scoring is highly effective at identifying
high risk patients. Yet, to date, this body of evidence has not
been compelling to support universal coverage for CAC
scoring. Medicare covers CAC for asymptomatic persons in
17 states, however, most current Medicare policies are based
on treatment for illness and not screening of the well. All
screening coverage policies, such as mammography, must be
legislated. To date, there is a lack of trial evidence, similar to
that recently reported for lung cancer, which demonstrates
improved outcomes for patients randomized to CAC scoring
as compared to those without CAC scanning.
E f fi ciency of CCTA in the Acute Evaluation
of Low Risk Chest Pain in the Emergency
Department (ED)
As we turn to the available evidence in symptomatic patients,
our initial review of the evidence is on the use of CCTA for
the evaluation of low risk chest pain in the ED. This would
largely include patients with a low risk Thrombolysis in
Myocardial Ischemia (TIMI) risk score whose index troponin level was negative. For this indication, there are three
relatively large randomized clinical trials which have been
published and include a total of 3069 patients [ 12 – 14 ]. Each
of the trials compared a CCTA-driven strategy as compared
to the current standard of care (SOC); with this largely
including some form of stress testing [ 12 – 14 ]. The most
prominent fi nding from all 3 trials has been the time to
diagnosis, length of stay, and the proportion of patients that
were discharged from the ED [ 12 – 14 ]. For all trials, time
effi ciency was demonstrably superior with CCTA as
compared to the SOC. For example, from one trial, 47 % of
patients in the CCTA arm were discharged from the ED as
compared to only 12 % of the SOC arm [ 12 ]. Thus, CCTA
reduced the overall length of stay in the ED by 7.6 h [ 14 ].
Figure 21.2 depicts the proportional rate of discharge across
the length of time spent in the ED [ 12 ].
The longer length of stay in those receiving the SOC led
to higher costs of care for one trial (on average $1321 cost
savings with CCTA) but in another trial, the CCTA arm led
to more intensive care and resulted in similar ED costs
(p = 0.7) [ 13 , 14 ]. To this extent, it remains uncertain as to
whether the CCTA-guided diagnostic effi ciency can lead to
economic savings for the healthcare system. Moreover, we
may learn that the prevalence of CAD identifi ed by CCTA in
2
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
0.024
FRS + Brachial FMD FRS + Ankle Brachial
Index
FRS + CRP FRS + Family History FRS + C-IMT FRS + CAC
0.036
0.079
0.16
0.102
0.659
Fig. 21.1 Net reclassifi cation improvement (NRI) results form the
NIH-NHLBI-sponsored MESA registry including intermediate
Framingham risk score ( FRS ) patients. The results indicate the NRI
based on an array of screening tests including brachial fl ow mediate
dilation ( FMD ), high sensitivity C-reactive protein ( CRP ), carotid
intima media thickness ( C-IMT ), and coronary artery calcium ( CAC ).
The NRI compares the added value of each of the sreening tests when
compared to the FRS alone. The endpoint for this analysis is 7-year
myocardial infarction, coronary heart disease death, resuscitated cardiac arrest, or angina followed by coronary revascularization
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384
the ED may be the key factor in defi ning cost savings. That
is, should the likelihood of CAD be elevated, the higher
prevalence of CAD may require more intensive follow-up
including invasive angiography or stress imaging studies that
increase the overall costs of care. By comparison, should we
be able to defi ne patients with largely negative CCTA
fi ndings, then the lack of anatomic fi ndings may prove to
impact on cost savings to a greater extent when compared to
higher risk populations. Of course, with this latter statement,
one has to take care not to employ CCTA in too low risk
patients where the radiation exposure would be unwarranted.
Suffi ce it to say that additional explorations of the potential
for cost minimization in the ED by selectively employing
CCTA remains an area of active exploration.
An additional challenge with the current evidence base is
the lack of longterm data on clinical effectiveness of randomization to CCTA versus SOC. The randomized trials employed
thus far have largely examined near-term outcomes of 1–6
months [ 12 – 14 ]. From the ACRIN-PA trial, none of the 640
patients with a negative CCTA died or had a nonfatal myocardial infarction within one month of discharge from the ED [ 13 ].
The UK’s National Health Service technology assessment supported the use of CCTA in the ED as a cost effective strategy
for troponin negative patients [ 15 ]. A recent meta-analysis
revealed that the near-term odds of readmission for an acute
coronary syndrome were non- signifi cant with an odds ratio of
1.2 (95 % confi dence intervals: 0.7–2.2) [ 16 ]. In one recent
report examining long- term (i.e., ~4 years follow-up) of 506
discharged patients without plaque and patients with nonobstructive plaque, only 1 % were readmitted for chest pain and
none of the patients underwent revascularization, died, or had
an acute coronary syndrome [ 17 ]. Data such as this on the long-
term consequences of CCTA-guided discharge will surely help
to ensure confi dence and defi ne the warranty period of the
index diagnosis as to the presence and extent of CAD.
Despite the limitations, this robust body of evidence is superior to the stress imaging data. For example, there is but one
large clinical trial on the impact of stress nuclear in the (ER
Assessment of Sestamibi for Evaluation of Chest Pain [ERASE]
Trial). The ERASE trial enrolled a total of 2127 patients who
were randomized to receive an index resting nuclear scan as
compared to usual care [ 18 ]. In 2127 patients, a total of 52 %
of the usual care arm were discharged as compared to 42 % of
those randomized to the nuclear scan arm (odds ratio: 0.68,
95 % confi dence intervals = 0.57–0.82) [ 18 ]. Similar to CCTA,
the extent to which patients have prior CAD which impacts on
resting perfusion abnormalities are likely the critical factor in
early discharge for patients presenting with acute chest pain.
Despite this, the differential in discharge appears greater for
CCTA as compared to that of the ERASE trial.
A point worth making in this discussion is the extent to
which identifi cation of an obstructive lesion is the source of
the presenting symptoms. Despite a stenosis, the presence of
collateral fl ow or the distal site of the stenosis may not
prompt presenting symptoms and this remains an important
consideration and challenge for CCTA. However, issues
related to soft tissue attenuation with stress nuclear can result
in a false positive rate of follow-up angiography that is
unacceptably high [ 19 ]. The incorporation of CT fractional
fl ow reserve (CT-FFR) calculations in conjunction with the
anatomic fi ndings may prove optimal for guiding patient
care in the acute evaluation of chest pain [ 20 ]. The addition
of FFR improves the diagnostic accuracy of anatomy defi ned
by CCTA but is limited by the length of time required for the
complex calculations and remote calculation of the FFR
measurement. Despite this, improvements in the technology
and the addition of this FFR measurement in the near-term
post-discharge may prove optimal for long-term effectiveness
of a CCTA-guided strategy following acute evaluation of
chest pain in the ED.
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
0 6 12 18 24 30 36 42 48
CCTA
SOC
Fig. 21.2 An approximation of
the proportion of patients
discharged from the ED for those
patients randomized to CCTA as
compared with SOC. The
medianlength of stay was 8.6 h
for patients receiving CCTA as
compared to 26.7 h for those
within the SOC arm of the
ROMICAT II trial
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385
We highlighted the high quality of evidence on the use of
CCTA in the ED and it is worth noting that the depth of evidence far exceeds that of other modalities. Likely, when
additional clinical practice guidelines are updated on acute
coronary syndrome care that CCTA will garner a high level
recommendation based on these three randomized trials
[ 12 – 14 ].
Diagnostic and Prognostic Value of CCTA
in Multicenter Trials and Registries
Our next set of indications is to examine the available evidence supporting the use of CCTA in the evaluation of
patients with stable chest pain. Notably, the evidence with
CCTA is largely based on large, multicenter registries and
several controlled clinical trials. If we start with the early evidence that examined the correlation of fi ndings between
CCTA and invasive coronary angiography, there are three
controlled clinical trials that have been published [ 21 – 23 ].
These trials represented pivotal evidence that the anatomic
fi ndings that we commonly observe with invasive angiography were concordant with the newly introduced CCTA anatomic fi ndings. In fact, the results revealed a high degree of
accuracy for CCTA when compared to invasive anatomic
fi ndings. From one cohort with a low-intermediate risk of
CAD, the diagnostic sensitivity and specifi city for obstructive
CAD on invasive angiography was 94 and 83 % [ 3 ]. From the
CorE64 trial, the diagnostic sensitivity and specifi city was 85
and 90 % [ 22 ]. As well, from one meta- analysis of the data on
64 slice CCTA, the diagnostic sensitivity and specifi city was
94 and 85 % [ 24 ]. These data reveal an overall higher diag-
nostic accuracy for CCTA in the detection of obstructive
CAD when compared to that of stress imaging [ 25 ].
Extending beyond these trials, there have been numerous
reports on the prognostic relationship between obstructive
and nonobstructive CAD fi ndings on CCTA [ 26 – 31 ]. The
largest of the registry data is that from the COronary CTA
EvaluatioN For Clinical Outcomes: An InteRnational
Multicenter (CONFIRM) multicenter and multinational
registry enrolling more than 30,000 patients who have been
followed for approximately 3–5 years for the occurrence of
death from all-causes and nonfatal myocardial infarction
[ 32 ]. Several important fi ndings have been revealed by
examining risk stratifi cation data in a diverse and expansive
group of patients. First, in all of these reports, CCTA fi ndings
of the extent and severity of CAD provide effective means to
risk stratify patients [ 28 ]. Reports have been published
across an array of age and gender subsets of diverse race/
ethnicity [ 28 , 33 , 34 ], in the diabetic [ 35 , 36 ], post-coronary
bypass surgery [ 37 ], in patients with a family history of CAD
[ 38 ], to name a few. The extensiveness of this evidence and
its rapid accrual is a testimony to the CCTA’s community of
investigators who are eager to defi ne the strengths and limitations of CCTA as an index diagnostic procedure.
Secondly, from this evidence base, multiple reports from
diverse countries now report that patients with a normal
CCTA have a very low rate of CAD events [ 28 , 39 – 41 ]. A
synthesis of this evidence examining follow-up through 7
years reveals that the major CAD event rate is approximately
0.2 % per year (Fig. 21.3 ) [ 28 , 39 – 41 ]; similar to that of the
general population. For stress echocardiography and nuclear
imaging, the annual rate of major CAD event rates is generally <1 % per year but exceeds that for CCTA; generally in
the range of 0.4–0.9 % [ 25 , 42 ].
Third, several reports now reveal that the presence of mild
but nonobstructive CAD is associated with an elevated hazard
for death above and beyond that of patients with a normal
CCTA [ 26 – 28 , 31 ]. From one series of 2583 symptomatic
patients with <50 % stenosis on CCTA and followed for
approximately 3 years, the mortality hazard for all-cause
death was elevated 2- to 6-fold for patients with 1–3 vessel
1.00 %
0.80 %
0.60 %
0.40 %
0.20 %
0.00 %
CCTA
Stress Nuclear
0.20 %
0.66 %
Fig. 21.3 Annual rate of major
CAD events for patients with a
negative CCTA and stress
nuclear result
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nonobstructive CAD [ 31 ]. In ground-breaking work by
Motoyama and Narula [ 26 , 27 ], the presence of high risk
plaque, defi ned as positive arterial remodeling and low attenuation plaque, was associated with a very high risk of incident
acute coronary syndromes. In patients without any high risk
plaque, the acute coronary syndrome rate was 0.5 % at 4-years
of follow-up. By comparison, for patients with both positive
remodeling and low attenuation plaque, the acute coronary
syndrome rate was an astonishing 22 % at 4-years of followup. These data, as exploratory as they are, represent very
exciting fi ndings that we are only beginning to unfold. If we
can further defi ne and more reliably measure the burden of
nonobstructive plaque and its relationship to acute coronary
events, then this could revolutionize the fi eld of diagnostic
testing. We await further explorations from these groups that
will help to improve risk detection of symptomatic patients.
A fourth important fi nding on the use of CCTA in the index
evaluation of symptomatic patients is the identifi cation of
severe CAD, including multivessel and left main CAD, and
the associated high risk status of these anatomic subsets. In
patients with multivessel CAD, the annualized CAD event
rates often are in the range of 8–10 % or higher [ 43 ]. Important
observational fi ndings from CONFIRM reveal that patients
with high risk CAD receive a proportional risk reduction with
coronary revascularization as compared to medical therapy
[ 43 ]. Over 2 years of follow-up, the all- cause mortality rate for
patients with high risk CAD was 5.3 % for those treated medically as compared to 2.3 % for those undergoing coronary
revascularization (Fig. 21.4 , p = 0.0075). Additional data are
required from a randomized trial setting to further unfurl the
possibilities for therapeutic risk reduction based on CCTA
fi ndings. This latter point should also entail the initiation and
intensifi cation of preventive therapies and their impact on outcome among patients with nonobstructive CAD.
2012 Stable Ischemic Heart Disease Clinical
Practice Guidelines: Indications for CCTA
Recently, a culmination of evidence among patients with stable chest pain was published in the 2012 American College of
Cardiology’s Stable Ischemic Heart Disease clinical practice
guideline [ 44 ]. Based on this sizeable evidence base with
CCTA, there are now 6 indications for CCTA in low-intermediate probability patients. There has been confusion on the
part of readers of this guideline because the indications for
CCTA mirror that of stress imaging. Despite this, all of the
indications are Class IIa – IIb levels of evidence and the result
of this strong body of evidence highlighted above.
Stable Ischemic Heart Disease Trials
There are a number of stable ischemic heart disease trials
which have recently been completed and provide high
quality evidence for CCTA (Table 21.1 ). One of these tri-
als is the NIH-NHLBI-sponsored PRO spective M ulticenter
I maging S tudy for E valuation of Chest Pain (PROMISE)
Trial which has enrolled 10,000 patients who were followed for ~2.5 years. The PROMISE trial randomized
patients to CCTA as compared to functional testing
including stress electrocardiography, echocardiography,
and nuclear imaging. Results from the PROMISE trial
revealed no difference in the primary endpoint of
death, acute coronary syndrome or major procedural
complications, with a hazard ratio of 1.04 (95% confi dence interval: 0.83–1.29, p=0.75) [ 48 ]. The challenge
with the PROMISE trial was the enrollment of low risk
patients with few reported events and including a population with the majority of patients having atypical chest
6.00%
5.00%
4.00%
3.00%
2.00%
1.00%
0.00%
Coronary Revascularization Medical Therapy
2.3%
5.3%
High Risk CAD
Fig. 21.4 Observational
evidence on the impact of
coronary revascularization
based on CCTA-defi ned high
risk CAD
L.J. Shaw
https://t.me/medicina_free
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