SCCT Releases New Guidance on Coronary CTA

There are new recommendations for the use of coronary computed tomographic angiography (CCTA) from the Society of Cardiovascular Computed Tomography (SCCT).

In a new expert consensus document published in the Journal of Cardiovascular Computed Tomography, industry leaders address new evidence, previous recommendation updates, and key questions about CCTA use in a variety of different cardiac scenarios.

“There have been many substantial advances in CCTA technology and a growing body of evidence for the use of cardiac CT in diagnoses of heart disease, prognostication, and modulating medical and interventional therapy,” said Harvey Hecht, Ph.D., FSCCT, chair and senior author of the expert consensus. “This expert consensus aims to address recent data and bridge the knowledge gap since the last update of the CCTA guidelines.”

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The new consensus recommendations cover the evaluation of five areas:

Stable coronary artery disease: CCTA in Native Vessels

• CCTA is appropriate as a first-line test for evaluating patients with or without CAD history who present with stable typical or atypical chest pain or other symptoms potentially indicating possible anginal equivalent.
• CCTA is appropriate after a non-conclusive functional test to gather more information if it will affect subsequent patient management.
• CCTA is recommended as a first-line test when considering evaluation for re-vascularization strategies using the ISCHEMIA Trial.
• CCTA may be appropriate in some asymptomatic high-risk individuals, such as those with a higher likelihood of non-calcified plaque.
• CCTA is rarely appropriate in very low-risk symptomatic patients – those under age 40 with non-cardiac symptoms – or those with low- to intermediate-risk asymptomatic patients.

Stable Coronary Artery Disease: CCTA Post-Revascularization

• CCTA is appropriate in symptomatic patients with intra-coronary stent diameters great than or equal to 3.0 mm, implementing measures to improve stent imaging accuracy, such as heart-rate control, iterative, sharp kernel, and mono-energetic reconstruction.

• CCTA may be appropriate in symptomatic patients with stents larger than 3.0 mm, especially those with thin stent struts in proximal, non-bifurcation locations.
• CCTA is appropriate to evaluate patients with prior CABG, particularly for graft patency, and to visualize grafts and other structures prior to cardiac surgery re-do.

Stable Coronary Artery Disease: CCTA with FFR or CTP

• CT-derived FFR and CT myocardial perfusion imaging may be appropriate to evaluate the functional significant of intermediate stenoses on CTA.
• Add FFRCT and stress-CTP to CTA to increase specificity, positive predictive value, and diagnostic accuracy.
• CTP can be a valuable alternative when CT-FFR is technically difficult.

Stable Coronary Artery Disease: CCTA in Other Conditions

• CTA is appropriate for coronary artery evaluation before non-coronary cardiac surgery as an equivalent alternative to invasive angiography in patients with low-to-intermediate probability of CAD and younger patients with primarily non-degenerative valvular conditions.
• CTA may be an appropriate alternative to other non-invasive tests to evaluate some patients before non-cardiac surgery.
• CTA is appropriate to exclude coronary artery disease in patients with suspected non-ischemic cardiomyopathy
• Late enhancement CT imaging may be appropriate to pinpoint infiltrative heart disease or scar in some patients who have non-ischemic or ischemic cardiomyopathy who cannot undergo cardiac MRI.
• CTA is appropriate for the evaluation of coronary anomalies.
• EKG is appropriate for gate aortic dissection, aneurysm CTA, pulmonary embolus studies in men over age 45 and women over age 55, as well as analyze and report the coronary arteries.
• Limited delay image CTA (60 seconds-to-90 seconds) is appropriate alternative to TEE to exclude LA/LAA thrombus, as well as in patients where TEE-associated risks outweigh the benefits.
• Late enhancement CT imaging may be appropriate to evaluate myocardial viability in some patients who cannot undergo cardiac MRI if it has the potential to impact diagnosis and treatment.

Reporting on CTA: Coronary and Non-Coronary Information

• CAD-RADs reporting is recommended.
• Report prior myocardial infarction when features are evident on CTA.
• Report remote myocardial infarction when fatty metaplasia or calcification within an area of infarction is present.

The full consensus document can be found here.