Comparison of Diagnostic Accuracy of 64-Slice Computed Tomography Coronary Angiography in Women Versus Men With Angina Pectoris

doi:10.1016/j.amjcard.2007.06.061

The American Journal of Cardiology

Volume 100, Issue 10, 15 November 2007, Pages 1532-1537

https://doi.org/10.1016/j.amjcard.2007.06.061 Get rights and content

We compared the diagnostic accuracy of 64-slice computed tomographic (CT) coronary angiography to detect significant coronary artery disease (CAD) in women and men. The 64-slice CT coronary angiography was performed in 402 symptomatic patients, 123 women and 279 men, with CAD prevalence of 51% and 68%, respectively. Significant CAD, defined as ≥50% coronary stenosis on quantitative coronary angiography, was evaluated on a patient, vessel, and segment level. The sensitivity and negative predictive value to detect significant CAD was very good, both for women and men (100% vs 99%, p = NS; 100% vs 98%, p = NS), whereas diagnostic accuracy (88% vs 96%; p <0.01), specificity (75% vs 90%, p <0.05), and positive predictive value (81% vs 95%, p <0.001) were lower in women. The per-segment analysis demonstrated lower sensitivity in women compared with men (82% vs 93%, p <0.001). The sensitivity in women did not show a difference in proximal and midsegments, but was significantly lower in distal segments (56% vs 85%, p <0.05) and side branches (54% vs 89%, p <0.001). In conclusion, CT coronary angiography reliably rules out the presence of obstructive CAD in both men and women. Specificity and positive predictive value of CT coronary angiography were lower in women. The sensitivity to detect stenosis in small coronary branches was lower in women compared with men.

Section snippets

Methods

During a 24-month period 402 patients with acute or stable chest pain symptoms who were referred for conventional coronary angiography (CCA) were included in the study. No patients with a history of percutaneous coronary intervention or coronary artery bypass surgery, impaired renal function (serum creatinine >120 μmol/L), persistent arrhythmias, and known intolerance to iodinated contrast material were included. CCA was performed before or after CTCA and served as the standard of reference.

Results

The analysis comprised 123 women and 279 men (Table 1). On average women were older (62 ± 11 vs 58 ± 11 years, p <0.01). Hypertension and diabetes were more frequent in women, with no significant difference for body mass index. There were more active smokers among men. Women had lower disease prevalence (51% vs 68%, p <0.01), which was defined as having ≥1 significant stenosis. The severity and extent of obstructive CAD was significantly lower in women compared with men (p <0.05), with fewer

Discussion

We demonstrated that the sensitivity of 64-slice CTCA to detect significant CAD was almost equally high in women and men (100% vs 99%) due to the very low occurrence of false-negative outcomes. Therefore, the diagnostic accuracy of 64-slice CTCA to rule out the presence of significant obstructive CAD was equally high in women and men and a negative CT scan reliably obviates the need for further downstream evaluation with invasive coronary angiography. The lower prevalence of CAD in women, with

References (19)

S. Leschka et al.
Accuracy of MSCT coronary angiography with 64-slice technology: first experience
Eur Heart J
(2005)
G.L. Raff et al.
Diagnostic accuracy of noninvasive coronary angiography using 64-slice spiral computed tomography
J Am Coll Cardiol
(2005)
A.W. Leber et al.
Quantification of obstructive and nonobstructive coronary lesions by 64-slice computed tomography: a comparative study with quantitative coronary angiography and intravascular ultrasound
J Am Coll Cardiol
(2005)
N.R. Mollet et al.
High-resolution spiral computed tomography coronary angiography in patients referred for diagnostic conventional coronary angiography
Circulation
(2005)
D. Ropers et al.
Usefulness of multidetector row spiral computed tomography with 64- × 0.6-mm collimation and 330-ms rotation for the noninvasive detection of significant coronary artery stenoses
Am J Cardiol
(2006)
J.D. Schuijf et al.
Diagnostic accuracy of 64-slice multislice computed tomography in the noninvasive evaluation of significant coronary artery disease
Am J Cardiol
(2006)
K. Nikolaou et al.
Accuracy of 64-MDCT in the diagnosis of ischemic heart disease
AJR
(2006)
J.J. Fine et al.
Comparison of accuracy of 64-slice cardiovascular computed tomography with coronary angiography in patients with suspected coronary artery disease
Am J Cardiol
(2006)
M. Ehara et al.
Diagnostic accuracy of 64-slice computed tomography for detecting angiographically significant coronary artery stenosis in an unselected consecutive patient population: comparison with conventional invasive angiography
Circ J
(2006)

There are more references available in the full text version of this article.

Cited by (60)

Cardiovascular Imaging for Ischemic Heart Disease in Women: Time for a Paradigm Shift
2022, JACC: Cardiovascular Imaging
Heart disease is the leading cause of death among men and women. Women have a unique phenotype of ischemic heart disease with less calcified lesions, more nonobstructive plaques, and a higher prevalence of microvascular disease compared with men, which may explain in part why current risk models to detect obstructive coronary artery disease (CAD) may not work as well in women. This paper summarizes the sex differences in the functional and anatomical assessment of CAD in women presenting with stable chest pain and provides an approach for using multimodality imaging for the evaluation of suspected ischemic heart disease in women in accordance to the recently published American Heart Association/American College of Cardiology guidelines for the evaluation and diagnosis of chest pain. A paradigm shift in the approach to imaging ischemic heart disease women is needed including updated risk models, a more profound understanding of CAD in women where nonobstructive disease is more prevalent, and algorithms focused on the evaluation of ischemia with nonobstructive CAD and myocardial infarction with nonobstructive CAD.
Myocardial ischaemia detection in women
2016, Annales de Cardiologie et d'Angeiologie
Rechercher une ischémie myocardique consiste à utiliser un ou plusieurs tests permettant le diagnostic de coronaropathie avec le double objectif de rapidité et d’à-propos diagnostique. Chez les femmes en comparaison aux hommes, la puissance diagnostique des différents tests est généralement plus faible. Ainsi, pour s’affranchir de cette pénalisation liée au sexe, il faut définir une stratégie diagnostique basée sur la stratification du niveau de risque a priori, et identifier avec précision les patientes relevant d’une exploration invasive. Cette mise au point reprend les performances des différents tests diagnostiques non invasifs au travers d’une approche volontairement féminine et définit en fonction du niveau de risque de coronaropathie et du caractère symptomatique ou non les outils de l’arsenal thérapeutique.
Screening of myocardial ischemia refers to the use of one or more diagnostic tests for coronary heart disease with a dual objective of appropriateness and promptness. In women, as compared to men, the accuracy of the different tests is worse. Thus, to overcome this sex-related penalty, we must define a diagnosis strategy based on risk stratification, enabling the identification of patients requiring invasive investigations. This review discusses various non-invasive diagnostic tests focusing on a female-specific approach and defines the use of numerous diagnostic tests with respect to both risk stratification and symptoms.
Cardiac computed tomography in current cardiology guidelines
2015, Journal of Cardiovascular Computed Tomography
Practice guidelines issued by professional societies significantly impact cardiology practice throughout the world. They increasingly incorporate cardiac CT imaging. This review systematically analyzes clinical practice guidelines issued by the American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) and the European Society of Cardiology (ESC) as well as the multi-societal appropriateness criteria in their latest versions as of September 1st, 2015, in order to identify the extent to which they include recommendations to use cardiac CT in specific clinical situations.
Diagnostic performance and cost of CT angiography versus stress ECG - A randomized prospective study of suspected acute coronary syndrome chest pain in the emergency department (CT-COMPARE)
2014, International Journal of Cardiology
Citation Excerpt :
For subjects presenting to the ED with acute chest pain, CCTA had better positive predictive value than ExECG, combined with a significantly reduced length of stay and reduced per-patient cost. In an outpatient population, CCTA has emerged as an accurate and rapid tool for the exclusion of coronary artery disease [15–19]. Recent randomized controlled trials in acute ED patients that compared CCTA to nuclear SPECT [7], or to a mixed standard-of-care [5,6] showed lower length of stay at lower cost.
Coronary CT angiography (CCTA) has high sensitivity, with 3 recent randomized trials favorably comparing CCTA to standard-of-care. Comparison to exercise stress ECG (ExECG), the most available and least expensive standard-of-care worldwide, has not been systematically tested.
CT-COMPARE was a randomized, single-center trial of low–intermediate risk chest pain subjects undergoing CCTA or ExECG after the first negative troponin. From March 2010 to April 2011, 562 patients randomized to either dual-source CCTA (n = 322) or ExECG (n = 240). Primary endpoints were diagnostic performance for ACS, and hospital cost at 30 days. Secondary endpoints were time-to-discharge, admission rates, and downstream resource utilization.
ACS occurred in 24 (4%) patients. ExECG had 213 negative studies and 27 (26%) positive studies for ACS with sensitivity of 83% [95% CI: 36, 99.6%], specificity of 91% [CI: 86, 94%], and ROC AUC of 0.87 [CI: 0.70, 1]. CCTA (> 50% stenosis considered positive) had 288 negative studies and 18/35 (51%) positive studies with a sensitivity of 100% [CI: 81.5, 100], specificity of 94% [CI: 91.2, 96.7%], and ROC of 0.97 [CI: 0.92, 1.0; p = 0.2]. Despite CCTA having higher odds of downstream testing (OR 2.0), 30 day per-patient cost was significantly lower for CCTA ($2193 vs $2704, p < 0.001). Length of stay for CCTA was significantly reduced (13.5 h [95% CI: 11.2–15.7], ExECG 19.7 h [95% CI: 17.4–22.1], p < 0.0005), which drove the reduction in cost. No patient had post-discharge cardiovascular events at 30 days.
CCTA had improved diagnostic performance compared to ExECG, combined with 35% relative reduction in length-of-stay, and 20% reduction in hospital costs. These data lend further evidence that CCTA is useful as a first line assessment in emergency department chest pain.
Radiation dose and diagnostic accuracy of multidetector computed tomography for the detection of significant coronary artery stenoses: A meta-analysis
2012, International Journal of Cardiology
Citation Excerpt :
Twenty-one out of 27 studies performed with retrospective ECG triggering used a modulation-dose protocol [34, 36–40, 42, 43, 46, 48, 49, 51–53, 55–61]. For what concerns the contrast injection protocol, the “bolus-tracking technique” [37, 38, 41–44, 48, 49, 55–62] was preferred over the “test bolus technique” [32–36, 46, 47, 50–54]. In 3 studies, the contrast injection protocol was not specified.
We conducted a meta-analysis evaluating the critical ratio between effective radiation dose (ED), feasibility (Fe) and diagnostic accuracy (Ac) of multidetector computed tomography (MDCT) for the detection of significant coronary artery disease. By using our predetermined criteria, we selected human studies published in English in which the ED and raw data of Ac vs. invasive coronary angiography in a segment based model were specified. Data from 31 studies including 3661 patients (mean age 61.9 ± 4.5 years, heart rate 62.5 ± 6.7 bpm) and 50,236 coronary artery segments were analysed and are reported. Overall, Fe, sensitivity, specificity, negative predictive value, positive predictive value, Ac and ED were 95%, 90%, 96%, 99%, 69%, 95% and 10.4 ± 5.4 mSv, respectively. Multivariate analysis showed that prospective ECG-gating (− 8.8 mSv CI95% − 13.4 to − 4.3 mSv, p = 0.001), dual-source (− 3.7 mSv CI95% − 7.9 to 0 mSv, p = 0.05) and BMI-adapted scanning protocols (− 4.5 mSv CI95% − 8.7 to − 2.7 mSv, p = 0.03) were independent predictors of ED reduction. In patients with low heart rate, the best compromise between ED, Fe and Ac (2.5 mSv, 97% and 98%, respectively) was obtained combining prospective ECG-gating and BMI-adapted scanning protocols, while in patients with high heart rate the strategy associated with the best results (10 mSv, 98% and 97%, respectively) was the use of dual-source MDCT with retrospective ECG gating and modulation dose.
In conclusion, careful selection of CT scanning protocols according to the patient's characteristics is critical for keeping the radiation exposure “as low as reasonably achievable” (ALARA) without impairing Fe and Ac.
Cardiac disease evaluation and management among kidney and liver transplantation candidates: A scientific statement from the American Heart Association and the American College of Cardiology Foundation
2012, Journal of the American College of Cardiology
Citation Excerpt :
Other studies report poor correlation between coronary artery calcium scores and the likelihood of angiographic CAD in patients with advanced kidney disease (129–131), a finding that may reflect the high burden of medial vascular calcification in ESRD compared with the intimal calcification seen in the non-ESRD population (132). Cardiac CT angiography (64–320 slice and dual source) is a highly sensitive tool for evaluating symptomatic patients with low to intermediate pretest probability of obstructive CAD (133,134). However, this modality has not been studied in patients with significant kidney disease, and its accuracy may be limited in this population because of a high burden of calcified coronary atherosclerosis.

View all citing articles on Scopus

View full text

Coronary artery diseaseComparison of Diagnostic Accuracy of 64-Slice Computed Tomography Coronary Angiography in Women Versus Men With Angina Pectoris

Section snippets

Methods

Results

Discussion

Accuracy of MSCT coronary angiography with 64-slice technology: first experience

Eur Heart J

Diagnostic accuracy of noninvasive coronary angiography using 64-slice spiral computed tomography

J Am Coll Cardiol

Quantification of obstructive and nonobstructive coronary lesions by 64-slice computed tomography: a comparative study with quantitative coronary angiography and intravascular ultrasound

J Am Coll Cardiol

High-resolution spiral computed tomography coronary angiography in patients referred for diagnostic conventional coronary angiography

Circulation

Usefulness of multidetector row spiral computed tomography with 64- × 0.6-mm collimation and 330-ms rotation for the noninvasive detection of significant coronary artery stenoses

Am J Cardiol

Diagnostic accuracy of 64-slice multislice computed tomography in the noninvasive evaluation of significant coronary artery disease

Am J Cardiol

Accuracy of 64-MDCT in the diagnosis of ischemic heart disease

AJR

Comparison of accuracy of 64-slice cardiovascular computed tomography with coronary angiography in patients with suspected coronary artery disease

Am J Cardiol

Diagnostic accuracy of 64-slice computed tomography for detecting angiographically significant coronary artery stenosis in an unselected consecutive patient population: comparison with conventional invasive angiography

Circ J

Coronary artery disease
Comparison of Diagnostic Accuracy of 64-Slice Computed Tomography Coronary Angiography in Women Versus Men With Angina Pectoris