Title: ACCF/ACR/AHA/ASNC/NASCI/SAIP/SCAI/SCCT 2010 Expert Consensus Document on Coronary Computed Tomographic Angiography: A Report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents
Topic: Noninvasive Cardiology
Date Posted: 4/7/2010
Author(s): Mark DB, Berman DS, Budoff MJ, et al.
Citation: J Am Coll Cardiol 2010;Mar 1:[Epub ahead of print].
Clinical Trial: No
Perspective: The following are 10 points to remember about coronary computed tomographic angiography (CTA).
1. This document presents an expert consensus overview of the current and emerging clinical uses of coronary CTA in patients with suspected or known coronary artery disease.
2. Multidetector CT (MDCT) technology prior to 64-channel or “slice” systems should now be considered inadequate for cardiac imaging (except for studies limited to assessing coronary calcium).
3. As with any diagnostic technology, coronary CTA has technical limitations with which users should be familiar, and proper patient selection and preparation are important to maximize the diagnostic accuracy of the test.
4. Overall sensitivity and specificity of 64-channel coronary CTA compared with invasive coronary angiography on a per-patient basis are both high, and the number of indeterminate studies due to inability to image important coronary segments in the select cohorts represented is <5%.
5. In the context of the emergency department evaluation of patients with acute chest discomfort, currently available data suggest that coronary CTA may be useful in the evaluation of patients presenting with an acute coronary syndrome (ACS) who do not have either acute electrocardiogram changes or positive cardiac markers.
6. At heart rates between 55 and 65 bpm, current 64-channel CT provides sufficient cine frame rates to provide left ventricular function information with accuracy comparable to other noninvasive and invasive modalities.
7. The evaluation of stents by MDCT is significantly more difficult than the evaluation of coronary artery segments without stents, even using current generation 64-channel MDCT scanners. In clinical studies, stent size was an important determinant of the results, with 100% of ≥3.5 mm, 80% of 3 mm, and 33% of <3 mm stents being judged assessable.
8. To date, there are no published trials evaluating the impact of specific therapy on clinical outcome in asymptomatic subjects identified as having only noncalcified atheroma by coronary CTA.
9. Routine use of a “triple rule-out” CT scan for ACS, acute aortic syndrome, and pulmonary embolism should not be used as a substitute for a careful clinical evaluation, with targeted testing for the most likely causes of the patient’s symptoms.
10. The typical doses of radiation reported to be associated with coronary CTA exceed those reported for invasive coronary angiography. Close monitoring of radiation exposure administered to patients is necessary to weigh the benefits of this noninvasive test and potential future unintended consequences and costs. Debabrata Mukherjee, M.D., F.A.C.C., Christopher P. Cannon, M.D., F.A.C.C.
Title: Mortality in Adult Congenital Heart Disease
Topic: Congenital Heart Disease
Date Posted: 4/7/2010
Author(s): Verheugt CL, Uiterwaal CS, van der Velde ET, et al.
Citation: Eur Heart J 2010;Mar 5:[Epub ahead of print].
Clinical Trial: No
Study Question: What are the mortality rates, modes of death, and risk factors for mortality in adults with congenital heart disease?
Methods: The Dutch CONCOR (CONgenital CORvitia) national registry was used and linked to the national mortality registry. The goal of the CONCOR registry is to facilitate the study of outcomes of patients with congenital heart disease. Between November 2001 and December 2009, over 11,400 patients greater than age 18 have been recruited into the database.
Results: Of 6,933 adults with congenital heart disease, 197 (2.8%) died during a follow-up of 24,865 patient-years. Excess mortality was seen in patients with congenital heart disease, particularly in the young. Median age of death was 48.8 years, with 77% dying of cardiovascular causes. The most common causes of death included chronic heart failure (26%) and sudden death (19%). Predictors of mortality included age, severity of defect, number of interventions, and number of complications. Complications particularly associated with increased risk included endocarditis, supraventricular arrhythmias, ventricular arrhythmias, conduction disturbances, myocardial infarction, and pulmonary hypertension (hazard ratio range, 1.4-3.1; p < 0.05).
Conclusions: Mortality is increased in adults with congenital heart disease, with the majority of deaths due to cardiovascular causes. Mortality is increased by the presence of various known complications of congenital heart disease.
Perspective: Knowledge of the risk factors for and causes of mortality in adults with congenital heart disease is important to developing risk-reducing management strategies. The Dutch CONCOR database has become an important tool in assessing outcomes for adults with congenital heart disease. It is imperative that other countries follow suit. Recent health care legislation adopted in the United States includes provisions for the development of a national registry for patients with congenital heart disease. Timothy B. Cotts, M.D., F.A.C.C.