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KCE reports 82 C Multislice CT in Coronary Heart Disease ii FOREWORD
iii Multislice CT in Coronary Heart Disease KCE Reports 82 C SCOPE Executive summary This Health Technology Assessment (HTA) report summarises current evidence supporting the use of multislice computed tomography (MSCT) as a diagnostic aid in patients suspected for coronary artery disease (CAD). It is primarily concerned with the diagnostic use of MSCT as an imaging technique of native coronary arteries, by which coronary bypass grafts and intracoronary stents are excluded. BACKGROUND CAD refers to cardiac disease caused by an impaired blood flow and deficient oxygen supply to the myocardium, mostly induced by atheromatous narrowing of one or more coronary arteries. It can be manifested by angina pectoris, myocardial infarction or sudden death. It is traditionally accepted that an atheromatous plaque has to reduce the internal diameter of a vessel by at least 50% in order to reduce blood flow through the artery during exertion, and to provoke ischemia and angina pectoris. An acute myocardial infarction on the other hand results from a sudden thrombotic blockage of coronary blood flow, not necessarily involving flow-limiting stenoses. Diagnosis of CAD can often be made by history taking alone, based on the pain characteristics and taking into account the patient’s cardiovascular risk profile. Further noninvasive diagnostic testing by means of an electrocardiogram at rest, echocardiography, exercise testing, myocardial perfusion scintigraphy and dobutamine stress echocardiography can be performed. This may lead to a better estimate of the likelihood of CAD and the risk for future serious events (MI and death). Some patients, especially those in whom medical therapy is not sufficient for symptom control, benefit from myocardial revascularisation, i.e. the restoration of the impaired blood flow surgically or percutaneously by balloon angioplasty. In these cases, prior imaging of the coronary arteries to confirm the diagnosis and to guide the revascularisation strategy is needed. This diagnostic part involves cardiac catheterisation and coronary angiography, an invasive procedure by which contrast material is injected into the coronary arteries that are subsequently radiologicaly visualised. The potential role of MSCT is to be situated in this context, and it has been advocated as a technique that might prevent invasive coronary angiography in patients who turn out to have no obstructive CAD. MULTISLICE CT TECHNOLOGY Conventional computed tomography (CT) is a radiological technique that generates a 3-dimensional picture of an object from a large series of 2-dimensional X-ray images taken around a single axis of rotation. Continuous cardiac moving makes conventional CT examination of the heart unsuitable because of the poor temporal resolution of the technique. Moreover, coronary arteries are small structures requiring high spatial resolution. Multislice computed tomography (MSCT) has been introduced in 1998 and has partly overcome these limitations. Compared to conventional CT scanning, MSCT provides smaller pieces of information and cover a larger area faster. The whole heart is covered within one single breathhold after intravenous administration of an iodinated contrast medium. Improvements in hardware and software have lead to advanced MSCT technology that produced more images in less time. 64-SCT scanners were introduced into clinical practice in 2004. Since motion artefacts due to limitations in the temporal resolution remained a problem, dual-source CT has been introduced which allowed for a further shortening of effective scan time. In 2007, scanners with 256 and 320 slices became available, enabling imaging of the coronary arteries during one or two heartbeats. The three main areas of concern for MSCT include motion artifacts from rapid or irregular heart rhythm, artifacts from coronary artery calcium and a substantial radiation dose. Motion artifacts from rapid heart rate have been partly overcome by higher-generations MSCTs and by the administration
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KCE reports 33 Effects and costs of
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