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demonstrated that in patients with suspected CAD and an intermediate pretest likelihood, CTA can efficiently make a distinction between patients at low or at high risk for future events. found that in symptomatic patients without known CAD, the diagnosis of significant (≥50% narrowing) stenosis on electron beam CTA was an independent predictor of mortality in a multivariable model adjusted for age, gender, cardiac risk factors, and coronary artery calcification. Recent data suggest that CTA had incremental prognostic value over traditional risk factors.
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Prognosis is predicted by coronary anatomy (Table 2). In addition to refining diagnostic accuracy in patients with suspected CAD, CTA also predicts the likelihood of coronary events and mortality. Thus, the choice between anatomical and functional modalities potentially depends on the clinical question at hand.ĭata from randomized trials suggest that low-risk, noninvasive tests have been associated with a hard annual cardiac event rate of 400. The distinction between anatomical and functional imaging modalities is important because anatomical stenosis does not reliably predict ischemia or hemodynamic significance. Alternatively, functional imaging modalities such as SPECT, PET, CMR, and stress ECHO provide measures of ischemia. Modalities such as CTA and CMR angiography provide primarily anatomical data, allowing for the assessment of coronary stenosis.
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4 An understanding of the patient population, patient pretest probability of CAD, Bayes’ theorem, and the risk, benefits and limitations of each technology will enable the medical imaging professional to assist clinicians with test selection.įunctional versus anatomical imaging for CADĬardiac imaging modalities can be divided into 2 broad groups, though some overlap does exist (Figure 1). Though all are available for the diagnosis and prognostication of patients with suspected and documented coronary artery disease (CAD), selecting the “best test” can be daunting to clinicians.
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3 Critical to management of symptomatic patients is the appropriate use of noninvasive diagnostic tests.Īt the clinician’s disposal is a large armamentarium of tests, including treadmill stress tests, stress echocardiography (ECHO), myocardial perfusion imaging (MPI)-through both single photon emission computed tomography (SPECT) and positron emission tomography (PET)-CT coronary angiography (CTA), and cardiac magnetic resonance imaging (CMR). 1,2 With the aging of populations in developed countries and the industrialization of other nations, the prevalence of cardiovascular disease worldwide is likely to increase. Chow is supported by CIHR New Investigator Award #MSH-83718.Ĭardiovascular disease is the leading cause of morbidity and mortality in the Western world. Chow is the Co-Director of Cardiac Radiology, Director of Cardiac Imaging Fellowship Training, Associate Professor, Departments of Medicine (Cardiology) and Radiology, University of Ottawa Heart Institute, Ottawa, ON, Canada.ĭr. Small is a Cardiac Imaging Fellow, Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, ON, Canada and Dr. Al-Shehri is a Fellow in Cardiac Imaging, Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, ON, Canada Dr.