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26 Multislice CT in Coronary Heart Disease KCE Reports 82 Table 6: Recent SRs of 64-SCT diagnostic imaging studies of CAD in native coronary arteries. First author ref Abdulla 66 (search until April 2007) Sun 82 (search until March 2007) Hamon 39 (search until October 2006) Ehara 90 * * * Fine 89 * Ghostine 91 * Vanhoenacker 73 (search until May 2006) Leber 35 * * * * Leschka 85 * * * * Meijboom pre-op 92 * * Meijboom ACS 93 * * Mollet 87 * * * Muhlenbruch 94 * * * Nikolaou 95 * * * Oncel 96 * * Ong 97 * * Plass 98 * * * Pugliese 99 * * * * Raff 88 * * * * Ropers 100 * * * * Scheffel 75 * * Schuijf 101 * * * Sheth 102 * Schlosser 103 Pooled prevalence % * (angiographically significant stenosis) 57.5 Pooled sensitivity (patient level) Pooled specificity (patient level) 97.5 (96-99) 91 (87.5-94) 53 (range: 17-88) 97.0 (94- 99) 88 (79- 97) 59 (range: 25.7- 89.6) 67 97 (95-98) 99 (97-100) 90 (86-93) 93 (89-98) In 2008 another systematic review was published that searched the literature until March 2006 and that included five 64-SCT studies, all of them included in Abdulla’s SR. 104 Key points • Recently published meta-analyses on the diagnostic performance of 64-SCT in the diagnosis of CAD revealed a good sensitivity and an acceptable specificity, obtained from selected intermediate to high pre-test likelihood populations. • All the trials included in these meta-analyses selected patients that were already scheduled for CCA, questioning the external validity of the findings. 3.2.3 Primary diagnostic trials Trials are ordered alphabetically. In six clinical trials a standard 64-SCT device was used. In four other studies, patients were scanned on the newer generation dual-source 64-
KCE Reports 82 Multislice CT in Coronary Heart Disease 27 SCT. Coronary artery stenoses were quantified either visually or digitally. In all studies, lesions were classified as significant if the luminal diameter reduction on CCA was ≥50%. Some trials additionally assessed MSCT performance in detecting stenoses ≥70% 40 or >75% 68 . Radiation burden and kappa values for interobserver variation in the detection of significant coronary stenoses were reported by some but not all authors. 3.2.3.1 Alkadhi et al. 33 Hundred and fifty patients that were referred for CCA for clinical reasons, underwent dual-source 64-SCT without heart rate control. Inclusion criteria were a clinical assessed intermediate pre-test risk for CAD. Exclusion criteria were known CAD and renal failure (crea>130µmol/L). Patients were divided into subgroups depending on their BMI, Agatston score, and heart rate. Not-evaluative segments at MSCT were considered as false-positive. CAD prevalence by CCA turned out to be 39.3%. Overall per-patient sensitivity, specificity, positive, and negative predictive value were 96.6%, 86.8%, 82.6%, and 97.5%, respectively. High heart rate did not deteriorate diagnostic accuracy of MSCT. High BMI and Agatston score were associated with a decrease in per-patient specificity to 84.1% and 77.8%, respectively, while sensitivity and negative predictive value remained high. The diagnostic perfomance thus identified resembles that obtained by standard 64-SCT (cf lower), but in this study using dual-source 64-SCT, no additional heart rate control was implemented before scanning. 31% of patients were on prior beta-blockade for clinical reasons. 3.2.3.2 Hausleiter et al. 77 243 patients with an intermediate pre-test probability for having CAD were studied by 16- or 64-slice CT angiography before a planned CCA. Per-artery and per-segment based analyses obtained from 16-SCT (129) and 64-SCT (114) were reported separately. The intermediate pre-test probability for having CAD was rather poorly defined and included both patients with chest pain in the absence of a positive stress test or with an equivocal stress test as well as asymptomatic patients with a positive stress test. Exclusion criteria included absence of sinus rhythm, patients with known CAD or with previous myocardial infarction, patients with previous revascularization procedures, patients at risk for iodinated contrast agents (dye allergy, elevated serum creatinine >1.8 mg/dL or reduced thyroid stimulating hormone 60/min (in 68.7%) up to four doses of 5 mg of metoprolol were administered intravenously to lower heart rate at the time of the CT study. Coronary artery segments with a diameter of 2.0 mg/dl). Irregular heart rate and marked coronary calcifications were not considered exclusion criteria. Patients with average heart rates greater than 65 b.p.m. and no contraindications to the use of beta-blockers received up to three intravenous injections of 5 mg (up to 15 mg total) of metoprolol immediately prior to the examination. There was no lower diameter of vessels to be included in the analysis. In 7.6% of segments, image quality was compromised either by misregistration (16%), motion artifacts (30%), or small vessel size, i.e.
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KCE reports 33 Effects and costs of
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