Coronary artery disease
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The diagnosis of coronary artery disease is based on typical imaging criteria either by cardiac CT or invasive coronary angiography.
Coronary artery disease is asymptomatic in most of the population. When severe enough it can cause angina or an acute coronary syndrome including myocardial infarction. CAD may also present with heart failure or sudden cardiac death.
Coronary artery disease is primarily due to atherosclerosis, an inflammatory process that leads to atheroma development and remodeling/stenosis of the coronary arteries. Diameter stenosis of >50% or a cross-sectional area reduction of >75% can lead to angina. Thrombus formation after plaque disruption can lead to acute coronary syndrome 1,2.
non-modifiable: family history, age, male sex 1
There are a variety of techniques to image coronary artery disease including both anatomical and functional modalities. Coronary angiography has been the mainstay for many years, but in certain patient groups, it is being replaced by non-invasive imaging such as coronary CT angiography (cCTA).
There are several appropriate clinical indications for the performance of coronary CTA 8:
acute chest pain in patients with a low-to-intermediate pretest probability of coronary artery disease
assessment of congenital heart disease
coronary artery calcium scoring
patients with technically limited images from echocardiography or MRI
Haemodynamically significant stenoses are those >70% for all coronary arteries, except the left main coronary artery where >50% stenosis is considered significant 7. CTCA is also good at identifying lesion features that contribute to vulnerable plaque.
In a post hoc analysis of prospectively acquired data, a cutoff value > -70 HU of the perivascular fat attenuation index (FAI) around the proximal right coronary artery was found to be predictive of increased all-cause mortality 10.
The recently proposed SCCT grading scale for stenosis severity assesses the degree of luminal diameter stenosis 6:
0% = no visible stenosis
1-24% = minimal stenosis
25-49% = mild stenosis
50-69% = moderate stenosis
70-99% = severe stenosis
100% = occlusion