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8 Multislice CT in Coronary Heart Disease KCE Reports 82 Table 2: Probability estimates for angiographic CAD, depending on clinical variables. Table from Diamond and Forrester. 7 In a patient series of the late 1970s, high-risk CAD, as defined by left main stem or three vessel disease, was common in middle-aged patients with typical angina and older patients with probable angina but is was rare in patients with atypical chest pain. It was almost non-existent in women with atypical chest pain. 8 2.2.2 Noninvasive testing The aim of further noninvasive diagnostic testing in patients in whom CAD is suspected following a baseline examination is twofold: (1) to better estimate the likelihood of CAD when baseline investigation is not decisive and (2) to indirectly estimate the risk for future events (MI and death). Asymptomatic patients with a high probability of CAD, and symptomatic patients with a low risk for serious events are treated with lifestyle measures and drugs in order to improve symptoms and in an attempt to prevent MI and prolong life. Subgroups of symptomatic patients with a high risk of future events may benefit from revascularisation. Identification of these patients is dependent on the location and extent of coronary disease and on left ventricular function, for which further invasive and noninvasive testing may be needed. According to the diagnostic algorithm as proposed by the ACC/AHA, angiography is only indicated when symptoms, clinical findings or results from noninvasive tests suggest high risk. 5 When history suggests a low probability of CAD (
KCE Reports 82 Multislice CT in Coronary Heart Disease 9 Figure 1: Cardiac ischemic cascade model. From: Monaghan MJ. Heart (British Cardiac Society) 2003; 89(12):1391-1393. 12 Therefore, noninvasive tests which are able to detect stress induced perfusion abnormalities have a better sensitivity for diagnosing reversible ischemia than tests that rely on ECG changes or on myocardial contractile dysfunction. For all noninvasive test methods, sensitivity is higher in patients with multivessel disease than in those with single vessel disease and in those with previous MI. 13 Stress tests other than those relying on ECG changes are further on denoted as stress imaging studies and include MPS, stress echocardiography, and stress function MRI, where stress most often is induced pharmacologically with dobutamine. They can provide information that is incremental and independent to that obtained by stress ECG and angiography because, rather than documenting coronary stenoses, they assess their functional consequences. 14 Noninvasive imaging tests can also be used as a substitute for exercise testing in patients who are unable to exercise or in whom the ST-segment on the (rest- )ECG is not interpretable. Classic noninvasive test used to diagnose CAD will be briefly discussed, in order for the reader to compare their diagnostic accuracy with that of multislice CT, which is the topic of interest of this report. 2.2.2.1 Resting electrocardiogram, chest X-ray and laboratory tests Resting ECG features are not very helpful in diagnosing CAD in patients with chronic chest pain. It is normal in more than 50% of these patients. On the other hand, the presence of pathologic Q-waves makes CAD very likely. Other ECG changes such as ST-segment alterations, left ventricular hypertrophy and arryhtmias increase the likelihood of CAD but with poor sensitivity and specificity. 5 ECG is however useful to detect abnormalities other than CAD that can induce chest pain (arrythmias, pericarditis) or it can be helpful for risk profiling (left chamber hypertrophy). Chest X-ray is very insensitive to detect CAD. It can help to direct further management when cardiomegaly or signs of heart failure are present. Laboratory testing can, in patients with non-acute chest pain, exclude anaemia or hyperthyroidism as a cause of angina. It can also help for establishing other causes of chest pain (pleuritis, pneumonia, etc). In patients with suspected CAD, laboratory tests
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KCE reports 33 Effects and costs of
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