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Objectives: This study was designed to determine whether multislice computed tomography (MSCT) coronary angiography has incremental prognostic value over single-photon emission computed tomography myocardial perfusion imaging (MPI) in patients with suspected coronary artery disease (CAD)., Background: Although MSCT is used for the detection of CAD in addition to MPI, its incremental prognostic value is unclear., Methods: In 541 patients (59% male, age 59 +/- 11 years) referred for further cardiac evaluation, both MSCT and MPI were performed. The following events were recorded: all-cause death, nonfatal infarction, and unstable angina requiring revascularization., Results: In the 517 (96%) patients with an interpretable MSCT, significant CAD (MSCT > or =50% stenosis) was detected in 158 (31%) patients, and abnormal perfusion (summed stress score [SSS]: > or =4) was observed in 168 (33%) patients. During follow-up (median 672 days; 25th, 75th percentile: 420, 896), an event occurred in 23 (5.2%) patients. After correction for baseline characteristics in a multivariate model, MSCT emerged as an independent predictor of events with an incremental prognostic value to MPI. The annualized hard event rate (all-cause mortality and nonfatal infarction) in patients with none or mild CAD (MSCT <50% stenosis) was 1.8% versus 4.8% in patients with significant CAD (MSCT > or =50% stenosis). A normal MPI (SSS <4) and abnormal MPI (SSS > or =4) were associated with an annualized hard event rate of 1.1% and 3.8%, respectively. Both MSCT and MPI were synergistic, and combined use resulted in significantly improved prediction (log-rank test p value <0.005)., Conclusions: MSCT is an independent predictor of events and provides incremental prognostic value to MPI. Combined anatomical and functional assessment may allow improved risk stratification.

Objectives: This study sought to determine the diagnostic accuracy of 64-slice computed tomographic coronary angiography (CTCA) to detect or rule out significant coronary artery disease (CAD)., Background: CTCA is emerging as a noninvasive technique to detect coronary atherosclerosis., Methods: We conducted a prospective, multicenter, multivendor study involving 360 symptomatic patients with acute and stable anginal syndromes who were between 50 and 70 years of age and were referred for diagnostic conventional coronary angiography (CCA) from September 2004 through June 2006. All patients underwent a nonenhanced calcium scan and a CTCA, which was compared with CCA. No patients or segments were excluded because of impaired image quality attributable to either coronary motion or calcifications. Patient-, vessel-, and segment-based sensitivities and specificities were calculated to detect or rule out significant CAD, defined as >or=50% lumen diameter reduction., Results: The prevalence among patients of having at least 1 significant stenosis was 68%. In a patient-based analysis, the sensitivity for detecting patients with significant CAD was 99% (95% confidence interval [CI]: 98% to 100%), specificity was 64% (95% CI: 55% to 73%), positive predictive value was 86% (95% CI: 82% to 90%), and negative predictive value was 97% (95% CI: 94% to 100%). In a segment-based analysis, the sensitivity was 88% (95% CI: 85% to 91%), specificity was 90% (95% CI: 89% to 92%), positive predictive value was 47% (95% CI: 44% to 51%), and negative predictive value was 99% (95% CI: 98% to 99%)., Conclusions: Among patients in whom a decision had already been made to obtain CCA, 64-slice CTCA was reliable for ruling out significant CAD in patients with stable and unstable anginal syndromes. A positive 64-slice CTCA scan often overestimates the severity of atherosclerotic obstructions and requires further testing to guide patient management.

Objectives: Our aim was to evaluate the atherosclerotic plaque burden and morphology as determined by 64-slice multislice computed tomography (MSCT) coronary angiography in relation to the calcium score in patients presenting with suspected acute coronary syndrome (ACS)., Background: The absence of coronary calcium during coronary calcium scoring has been proposed to rule out significant coronary artery disease (CAD). However, data in patients presenting with suspected ACS are scarce., Methods: In 40 patients (age 57 +/- 11 years, 26 men) presenting with suspected ACS, MSCT coronary angiography in combination with coronary calcium scoring was performed before conventional coronary angiography. MSCT angiograms were evaluated for the presence or absence of coronary atherosclerotic plaque and the presence or absence of obstructive (> or =50% luminal narrowing) CAD. In addition, plaque type was determined, and findings were related to the calcium score., Results: Coronary artery disease was observed in 38 patients, of whom 10 patients had nonobstructive and 28 patients had obstructive CAD, confirmed by conventional coronary angiography in all patients. In patients with CAD, plaques were distributed as follows: 39% noncalcified plaques, 47% mixed plaques, and 14% calcified plaques. Coronary calcium was detected in 27 patients, of whom 10 had a score >400. In 13 (33%) patients, no coronary calcium was observed, but in 11 (85%), atherosclerotic plaques were detected on MSCT angiography., Conclusions: In patients presenting with suspected ACS, noncalcified plaques are highly prevalent and the absence of coronary calcium does not reliably exclude the presence of (significant) atherosclerosis. This information may be of value to improve our understanding of the potential role of MSCT in this patient population.

Objectives: This study sought to evaluate the diagnostic accuracy of 64-slice multislice computed tomography (MSCT) coronary angiography in the follow-up of patients with previous coronary stent implantation., Background: Recent investigations have shown increased image quality and diagnostic accuracy for noninvasive coronary angiography with 64-slice MSCT as compared with previous-generation MSCT scanners, but data on the evaluation of coronary stents are scarce., Methods: In 182 patients (152 [84%] male, ages 58 +/- 11 years) with previous stent (> or =2.5 mm diameter) implantation (n = 192), 64-slice MSCT angiography using either a Sensation 64 (Siemens, Forchheim, Germany) or Aquilion 64 (Toshiba, Otawara, Japan) was performed. At each center, coronary stents were evaluated by 2 experienced observers and evaluated for the presence of significant (> or =50%) in-stent restenosis. Quantitative coronary angiography served as the standard of reference., Results: A total of 14 (7.3%) stented segments were excluded because of poor image quality. In the interpretable stents, 20 of the 178 (11.2%) evaluated stents were significantly diseased, of which 19 were correctly detected by 64-slice MSCT. Accordingly, sensitivity, specificity, and positive and negative predictive value to identify in-stent restenosis in interpretable stents were 95.0% (95% confidence interval [CI] 85% to 100%), 93.0% (95% CI 90% to 97%), 63.3% (95% CI 46% to 81%), and 99.3% (95% CI 98% to 100%), respectively., Conclusions: In-stent restenosis can be evaluated with 64-slice MSCT with good diagnostic accuracy. In particular, a high negative predictive value of 99% was observed, indicating that 64-slice MSCT may be most valuable as a noninvasive method of excluding in-stent restenosis.

Objectives: This study sought to determine the prognostic value of multislice computed tomography (MSCT) coronary angiography in patients with known or suspected coronary artery disease (CAD)., Background: It is expected that MSCT will be used increasingly as an alternative imaging modality in the diagnosis of patients with suspected CAD. Data on the prognostic value of MSCT, however, are currently not available., Methods: A total of 100 patients (73 men, age 59 +/- 12 years) who were referred for further cardiac evaluation due to suspicion of significant CAD underwent additional MSCT coronary angiography to evaluate the presence and severity of CAD. Patients were followed up for the occurrence of: 1) cardiac death, 2) nonfatal myocardial infarction, 3) unstable angina requiring hospitalization, and 4) revascularization., Results: Coronary plaques were detected in 80 (80%) patients. During a mean follow-up of 16 months, 33 events occurred in 26 patients. In patients with normal coronary arteries on MSCT, the first-year event rate was 0% versus 30% in patients with any evidence of CAD on MSCT. The observed event rate was highest in the presence of obstructive lesions (63%) and when obstructive lesions were located in the left main (LM)/left anterior descending (LAD) coronary arteries (77%). Nonetheless, an elevated event rate was also observed in patients with nonobstructive CAD (8%). In multivariate analysis, significant predictors of events were the presence of CAD, obstructive CAD, obstructive CAD in LM/LAD, number of segments with plaques, number of segments with obstructive plaques, and number of segments with mixed plaques., Conclusions: Multislice computed tomography coronary angiography provides independent prognostic information over baseline clinical risk factors in patients with known and suspected CAD. An excellent prognosis was noted in patients with a normal MSCT.

Objectives: The aim of this study was to perform a head-to-head comparison between multi-slice computed tomography (MSCT) and myocardial perfusion imaging (MPI) in patients with an intermediate likelihood of coronary artery disease (CAD) and to compare non-invasive findings to invasive coronary angiography., Background: Multi-slice computed tomography detects atherosclerosis, whereas MPI detects ischemia; how these 2 techniques compare in patients with an intermediate likelihood of CAD is unknown., Methods: A total of 114 patients, mainly with intermediate likelihood of CAD, underwent both MSCT and MPI. The MSCT studies were classified as having no CAD, nonobstructive (<50% luminal narrowing) CAD, or obstructive CAD. Myocardial perfusion imaging examinations were classified as showing normal or abnormal (reversible and/or fixed defects). In a subset of 58 patients, invasive coronary angiography was performed., Results: On the basis of the MSCT data, 41 patients (36%) were classified as having no CAD, of whom 90% had normal MPI. A total of 33 patients (29%) showed non-obstructive CAD, whereas at least 1 significant (> or =50% luminal narrowing) lesion was observed in the remaining 40 patients (35%). Only 45% of patients with an abnormal MSCT had abnormal MPI; even in patients with obstructive CAD on MSCT, 50% still had a normal MPI. In the subset of patients undergoing invasive angiography, the agreement with MSCT was excellent (90%)., Conclusions: Myocardial perfusion imaging and MSCT provide different and complementary information on CAD, namely, detection of atherosclerosis versus detection of ischemia. As compared to invasive angiography, MSCT has a high accuracy for detecting CAD in patients with an intermediate likelihood of CAD.

Objectives: This study was designed to evaluate the value of 64-slice computed tomography (CT) to visualize the cardiac veins and evaluate the relation between variations in venous anatomy and history of infarction., Background: Cardiac resynchronization therapy (CRT) is an attractive treatment for selected heart failure patients. Knowledge of venous anatomy may help in identifying candidates for successful left ventricular lead implantation., Methods: The 64-slice CT of 100 individuals (age 61 +/- 11 years, 68% men) was studied. Subjects were divided into 3 groups: 28 control patients, 38 patients with significant coronary artery disease (CAD), and 34 patients with a history of infarction. Presence of the following coronary sinus (CS) tributaries was evaluated: posterior interventricular vein (PIV), posterior vein of the left ventricle, and left marginal vein (LMV). Vessel diameters were also measured., Results: Coronary sinus and PIV were identified in all individuals. Posterior vein of the left ventricle was observed in 96% of control patients, 84% of CAD patients, and 82% of infarction patients. In patients with a history of infarction, a LMV was significantly less observed as compared with control patients and CAD patients (27% vs. 71% and 61%, respectively, p < 0.001). None of the patients with lateral infarction and only 22% of patients with anterior infarction had a LMV. Regarding quantitative data, no significant differences were observed between the groups., Conclusions: Non-invasive evaluation of cardiac veins with 64-slice CT is feasible. There is considerable variation in venous anatomy. Patients with a history of infarction were less likely to have a LMV, which may hamper optimal left ventricular lead positioning in CRT implantation.

Objectives: We sought to evaluate the value of multislice computed tomography (MSCT) to depict the cardiac venous anatomy., Background: During cardiac resynchronisation therapy (CRT), left ventricular (LV) pacing is established by a pacemaker lead in a tributary of the coronary sinus (CS). Knowledge of the CS anatomy and variations may facilitate the implantation of LV leads., Methods: The MSCT scans of 38 patients (34 men; age 60 +/- 12 years) were studied. Anatomical variants were divided in three groups, dependent on the continuity of the cardiac venous system at the crux cordis. The CS ostium and distances between the main tributaries were measured., Results: The most frequently observed variant had a separate insertion of the CS and the small cardiac vein in the right atrium (24 patients [63%]). In 11 patients (29%), there was continuity of the anterior and posterior venous system at the crux cordis. In three patients (8%), the posterior interventricular vein (PIV) did not connect to the CS. The mean distance from the PIV to the posterior vein of the left ventricle (PVLV) was 42.4 +/- 18.1 mm, from the PVLV to the left marginal vein (LMV) 39.9 +/- 15.6 mm, and from the LMV to the anterior interventricular vein 45.4 +/- 15.3 mm. The diameter of the CS ostium was 12.6 +/- 3.6 mm in anteroposterior and 15.5 +/- 4.5 mm in the superoinferior direction (p < 0.01)., Conclusions: The anatomy of the CS and its tributaries can be evaluated using MSCT. As substantial variation in anatomy was observed, pre-implantation knowledge of the venous anatomy may help to decide whether transvenous LV lead placement for CRT is feasible.