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KCE Reports 82 Multislice CT in Coronary Heart Disease 13
to an acute coronary event. 28 Therefore, and owing to the high cost and the potential
complications, routine use of CCA without prior noninvasive testing is not advisable. 14 If
noninvasive functional testing is not feasable, functional testing can be done invasively by
means of pressure-derived fractional flow reserve (FFR) measurements. 28 This can be
done immediately after the imaging procedure by intravascular pressure recordings
through the catheter that was used for contrast injection into the coronary arteries.
CCA is an invasive procedure, carrying a certain risk that is related to radiation
exposure, the direct access of the heart and vascular structures and the administration
of contrast media. The most serious complications of CCA are death (0.1–0.2%), nonfatal
MI (0.1%) and cerebrovascular accidents (0.1%). 24 Allergic contrast reactions and
renal failure may result from contrast medium exposure. Bleeding from vascular access
sites (groin) may result in substantial bleeding, requiring transfusion and sometimes,
vascular surgery is needed to repair the damage to the femoral artery. In addition,
patients are temporarily subjected to bed rest, often staying overnight in hospital and
delayed in returning to work. The composite rate of major complications associated
with routine diagnostic catheterisation is between 1 and 2%. 4
It has been a matter of concern that in some series up to 50% of CCAs reveal normal
coronary arteries or do not lead to revascularisation. Consequently, in order to try to
avoid these “unnecessary” invasive procedures, there has been increasing interest in
noninvasive imaging techniques.
Some of the inconveniences and complications of CCA, related to the intravascular
access by means of a catheter, can be avoided by using CT scanning for coronary artery
imaging, which is the topic of further discussion in this report.
Key points
• Conventional coronary angiography (CCA) is considered the gold
standard for assessing coronary anatomy.
• It is however not a reliable indicator of the functional significance of
a coronary stenosis indicating that the results of a functional test
are necessary before proceeding to revascularisation.
• Another limitation is that it carries risks related to radiation
exposure, the direct access of the heart and the administration of
contrast media. The most serious complications of CCA are death
(0.1–0.2%), non-fatal MI (0.1%) and cerebrovascular accidents (0.1%)
2.3 DIAGNOSIS OF CAD IN ACUTE CONDITIONS
Based on history taking and an electrocardiogram (ECG), a qualified physician must be
able to assign a diagnosis of “ACS” or “highly unlikely ACS” within 10 minutes after the
first medical contact. 29 In patients with an atypical history, negative clinical findings and a
non-evolutive ECG, serum biomarkers are useful in diagnosing the cardiac origin of the
patient’s complaints and in assessing prognosis.
Troponins are the best biomarkers to predict short and long-term outcome (beyond 1
year) with respect to MI and death. 29 Even minor myocardial damage can be excluded
based on two repetitive troponin measurements, one on admission and a second
between 6 and12 hours later. Patients fulfilling the following criteria may be considered
at low risk for future events and should not be submitted to early invasive evaluation:
no recurrence of chest pain, no heart failure, no abnormalities on the first and a
subsequent ECG and no elevation of troponins (at arrival and after 6 to12 hours).
Patients who cannot be excluded by the above criteria should go on to cardiac
catheterisation.