CCTA in the diagnosis of coronary artery disease
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CARDIAC RADIOLOGY
CCTA in the diagnosis of coronary artery disease Riccardo Marano1 · Giuseppe Rovere1 · Giancarlo Savino1 · Francesco Ciriaco Flammia1 · Maria Rachele Pia Carafa1 · Lorenzo Steri1 · Biagio Merlino1 · Luigi Natale1 Received: 8 June 2020 / Accepted: 3 September 2020 © Italian Society of Medical Radiology 2020
Abstract The world of cardiac imaging is proposing to physicians an ever-increasing spectrum of options and tools with the disadvantages of patients presently submitted to multiple, sequential, time-consuming, and costly diagnostic procedures and tests, sometimes with contradicting results. In the last two decades, the CCTA has evolved into a valuable diagnostic test in today’s patient care, changing the official existing guidelines and clinical practice with a pivotal role to exclude significant CAD, in the referral of patients to the Cath-Lab, in the follow-up after coronary revascularization, and finally in the cardiovascular risk stratification. Keywords Coronary CT angiography · Coronary artery disease · Chronic coronary syndrome · Acute chest pain · Coronary stent · Coronary artery bypass graft · Cardiovascular risk stratification · Cardiovascular prevention
Introduction The cardiovascular diseases (CVD) are the principal cause of death and health expenditure in western countries, more than all cancers combined and with the coronary artery disease (CAD) still the leading killer [1]. The CAD is a longterm pathological process characterized by a progressive atherosclerotic plaque accumulation along the wall of the epicardial arteries, whether obstructive or non-obstructive and with a more or less long subclinical phase [2], which can be modified by lifestyle adjustments, pharmacological therapies, and invasive interventions aimed to reach disease stabilization or regression. The CAD is a chronic disease with long and stable periods but most often progressive, even in clinically apparently silent periods and can become unstable at any time, typically due to an acute atherothrombotic event caused by plaque rupture or erosion [2]. Not rarely, the fatal event may be the first clinical presentation [3]. Following the recent guidelines of the European Society of Cardiology (ESC), the dynamic nature of the CAD results
in various clinical presentations, classifiable as acute coronary syndrome (ACS) or chronic coronary syndrome (CCS) [2]. In general, in stable patients, a high suspicion of CAD with a clinical indication to invasive coronary angiography (ICA), in order to pursue an invasive treatment, is placed by the pretest probability assessment (PTP) of disease based on appropriate clinical risk scores such as the Framingham Risk Score (FRS) [4] or the Diamond and Forrester Score modified and updated [5]. To date, in clinical practice, between one half and two-thirds of elective ICA are completed without intervention [6], which indicates that current diagnostic strategies for stable patients suspected of having CAD may overestimate disease [7]. Given the lower than expected real prevalence
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