Coronary Computed Tomography Angiography From Clinical Uses to Emerging Technologies

JACC State-of-the-Art Review

Khaled M. Abdelrahman, BS; Marcus Y. Chen, MD; Amit K. Dey, MD; Renu Virmani, MD; Aloke V. Finn, MD; Ramzi Y. Khamis, MBCHB, PHD; Andrew D. Choi, MD; James K. Min, MD; Michelle C. Williams, MBCHB, PHD; Andrew J. Buckler, MS; Charles A. Taylor, PHD; Campbell Rogers, MD; Habib Samady, MD; Charalambos Antoniades, MD, PHD; Leslee J. Shaw, PHD; Matthew J. Budoff, MD; Udo Hoffmann, MD, MPH; Ron Blankstein, MD; Jagat Narula, MD; Nehal N. Mehta, MD, MSCE

Disclosures

J Am Coll Cardiol. 2020;76(10):1226-1243. 

In This Article

Abstract and Introduction

Abstract

Evaluation of coronary artery disease (CAD) using coronary computed tomography angiography (CCTA) has seen a paradigm shift in the last decade. Evidence increasingly supports the clinical utility of CCTA across various stages of CAD, from the detection of early subclinical disease to the assessment of acute chest pain. Additionally, CCTA can be used to noninvasively quantify plaque burden and identify high-risk plaque, aiding in diagnosis, prognosis, and treatment. This is especially important in the evaluation of CAD in immune-driven conditions with increased cardiovascular disease prevalence. Emerging applications of CCTA based on hemodynamic indices and plaque characterization may provide personalized risk assessment, affect disease detection, and further guide therapy. This review provides an update on the evidence, clinical applications, and emerging technologies surrounding CCTA as highlighted at the 2019 National Heart, Lung and Blood Institute CCTA Summit.

Introduction

Coronary computed tomography angiography (CCTA) is an effective imaging modality increasingly accepted as a first-line test to diagnose coronary artery disease (CAD), and it has prognostic implications for patient management.[1,2] Furthermore, CCTA can be leveraged to image various stages of atherosclerosis ranging from plaque formation to plaque progression and rupture (Central Illustration). Innovative tools derived from CCTA permit understanding of the development of atherosclerotic plaque and aid in risk stratification and medical decision making for patients with CAD. Advancements in CCTA have allowed for minimal radiation exposure, effective coronary characterization, and detailed imaging of atherosclerosis over time. Thus, CCTA provides a central platform for a multidisciplinary approach, including immunology, pathology, radiology, and cardiology, to further our understanding of CAD and to improve patient care.

Central Illustration.

Utility of Coronary Computed Tomography Angiography in Coronary Artery Disease
Coronary computed tomography angiography is a powerful clinical tool that can be used to detect and characterize coronary artery disease across various stages, from early, subclinical disease to myocardial infarction.

In November 2019, a summit held at the National Heart, Lung, and Blood Institute convened world experts on CCTA to discuss the latest developments in the field, synthesize the available evidence, and discuss the evolving clinical applications of CCTA. In this review, we highlight the discussions put forth in this symposium, including the current understanding of atherosclerotic plaque pathology and its translation to CCTA in clinical practice. Further described are approaches to how CCTA can be used to characterize coronary artery plaque composition and morphology and to prognosticate cardiovascular outcomes. Finally, emerging CCTA technologies concomitant with advances in imaging acquisition, advanced techniques for analysis and characterization, as well as computational fluid dynamics are reviewed.

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