An Opportunity to Seize From Low Hanging Fruits: Capitalising on Incidentally Reported Coronary Artery Calcification.

AIM: We investigated the prevalence of incidental coronary artery calcifications (CAC) from non-electrocardiogram (ECG)-gated computed tomography (CT) chest (both contrast and non-contrast) for inpatients. We also assessed for downstream investigation and statin prescription from the inpatient teams. Incidental CAC are frequent findings on non-ECG-gated CT chest. It is associated with adverse prognosis in multiple patient cohorts. METHOD: All non-ECG-gated CT chest done as inpatients from a single centre referred from 1 January 2022 to 31 December 2022 with reported incidental CAC were reviewed for inclusion. Patients who had a history of known coronary artery disease, history of coronary stent or bypass, and presence of cardiac devices were excluded. RESULTS: Total of 123 patients were included, making the prevalence 6.2% (123/1,980). The median age is 76 years (interquartile range 69-85) and predominantly male at 54.5%. The majority of CT chest done were contrasted scans (91.1%). Only 26.8% of CAC were reported on severity with visual quantification, with 7.3% each reported for both moderate and severe CAC. Only 2.4% of CAC were reported in the conclusion of the CT report. Most of these patients were asymptomatic (34.1%). A total of 20.3% of patients had further tests done. Inpatient hospital mortality was 8.1%. About 23.6% and 34.1% of patients were on aspirin and statin therapy respectively at baseline. There was only 1 patient (1.2%) who was prescribed with new statin therapy on discharge. CONCLUSION: Incidental CAC is prevalent in inpatient settings and remains under-recognised by ordering clinicians, with low prescription rate of statin therapy. Practice-changing measures to standardise reporting of incidental CAC is needed to identify patients with subclinical coronary disease and initiate preventive interventions.

Coronary artery calcium assessment on non-gated chest CT to optimize pre-operative cardiac screening in liver transplantation.

BACKGROUND: Guidelines recommend standard pre-operative cardiac screening in all liver transplantation (LT) recipients, despite the relatively low prevalence of obstructive coronary artery disease. Most LT recipients often have non-gated computed tomography (CT) performed of the chest and abdomen. This study evaluated the ability of coronary artery calcification (CAC) assessment on consecutively available scans, to identify a selection of low-risk patients, in whom further cardiac imaging can be safely withheld. METHODS: LT recipients with prior non-gated CT chest-abdomen were included. CAC was visually scored on a semi-quantitative ordinal scale. Stress myocardial perfusion, coronary CT angiography (CCTA) and invasive coronary angiography (ICA) were used as golden standard. The sensitivity and specificity of CAC to exclude and predict obstructive CAD were assessed. In addition, peri- and postoperative mortality and cardiac events were analyzed. RESULTS: 149 LT recipients (ranged 31-71 years) were included. In 75% of patients, no CAC and mild CAC could rule out obstructive CAD on CCTA and ICA with 100% certainty. The threshold of mild CAC had a sensitivity of 100% for both CCTA and ICA and a specificity of 91% and 68%, respectively. None of the patients with no or mild calcifications experienced peri- and post-operative cardiac events or died of cardiac causes. CONCLUSION: Visual evaluation of CAC on prior non-gated CT can accurately and safely exclude obstructive CAD in LT recipients. Incorporation of these already available data can optimize cardiac screening, by safely withholding or correctly allocating dedicated cardiac imaging in LT recipients. Thereby, reducing patients' test burden and save health care expenses.

Coronary calcifications as assessed on routine non-gated chest CT; a gatekeeper to tailor downstream additional imaging in patients with stable chest pain.

Background and aims: Currently applied methods for risk-assessment in coronary artery disease (CAD) often overestimate patients' risk for obstructive CAD. To enhance risk estimation, assessment of coronary artery calcium (CAC) can be applied. In 10 % of patients presenting with stable chest pain a previous non-gated computed tomography (CT) has been performed, suitable for CAC-assessment. This study is the first to investigate the clinical utility of CAC-assessment on non-gated CT for risk-assessment of obstructive CAD in symptomatic patients. Methods: For this analysis, all patients referred for coronary computed tomography angiography (CCTA), in whom a previous non-gated chest CT was performed were included. The extent of CAC was assessed on chest CT and ordinally scored. CAD was assessed on CCTA and obstructive CAD defined as stenosis of ≥70 %. Patients were stratified according to CAC-severity and percentages of patients with obstructive CAD were compared between the CAC groups. Results: In total, 170 patients of 32-88 years were included and 35 % were male. The percentage of obstructive CAD between the CAC groups differed significantly (p < 0.01). A calcium score of 0 ruled out obstructive CAD irrespective of sex, pre-test probability, type of complaints and number of risk factors with a 100 % certainty. Furthermore, a mild CAC score ruled out obstructive CAD in patients with low - intermediate PTP or non-anginal complaints with 100 % certainty. Conclusion: When available, CAC on non-gated chest CT can accurately rule out obstructive CAD and can therefore function as a radiation-free and cost-free gatekeeper for additional imaging in patients presenting with stable chest pain.

The Clear Value of Coronary Artery Calcification Evaluation on Non-Gated Chest Computed Tomography for Cardiac Risk Stratification.

To enhance risk stratification in patients suspected of coronary artery disease, the assessment of coronary artery calcium (CAC) could be incorporated, especially when CAC can be readily assessed on previously performed non-gated chest computed tomography (CT). Guidelines recommend reporting on patients' extent of CAC on these non-cardiac directed exams and various studies have shown the diagnostic and prognostic value. However, this method is still little applied, and no current consensus exists in clinical practice. This review aims to point out the clinical utility of different kinds of CAC assessment on non-gated CTs. It demonstrates that these scans indeed represent a merely untapped and underestimated resource for risk stratification in patients with stable chest pain or an increased risk of cardiovascular events. To our knowledge, this is the first review to describe the clinical utility of different kinds of visual CAC evaluation on non-gated unenhanced chest CT. Various methods of CAC assessment on non-gated CT are discussed and compared in terms of diagnostic and prognostic value. Furthermore, the application of these non-gated CT scans in the general practice of cardiology is discussed. The clinical utility of coronary calcium assessed on non-gated chest CT, according to the current literature, is evident. This resource of information for cardiac risk stratification needs no specific requirements for scan protocol, and is radiation-free and cost-free. However, some gaps in research remain. In conclusion, the integration of CAC on non-gated chest CT in general cardiology should be promoted and research on this method should be encouraged.

Evaluation of Clinical Applicability of Coronary Artery Calcium Assessment on Non-Gated Chest Computed Tomography, Compared With the Classic Agatston Score on Cardiac Computed Tomography.

Given current pretest probability (PTP) estimations tend to overestimate patients' risk for obstructive coronary artery disease, evaluation of patients' coronary artery calcium (CAC) is more precise. The value of CAC assessment with the Agatston score on cardiac computed tomography (CT) for risk estimation has been well indicated in patients with stable chest pain. CAC can be equally well assessed on routine non-gated chest CT, which is often available. This study aims to determine the clinical applicability of CAC assessment on non-gated CT in patients with stable chest pain compared with the classic Agatston score on gated CT. Consecutive patients referred for evaluation of the Agatston score, who had a previously performed non-gated chest CT for evaluation of noncardiac diseases, were included. CAC on non-gated CT was ordinally scored. Subsequently, patients were stratified according to CAC severity and PTP. The agreement and correlation between the classic Agatston score and CAC on non-gated CT were evaluated. The discriminative power for risk reclassification of both CAC assessment methods was assessed. Invasive coronary angiography was used as the gold standard, when available. A total of 140 patients aged between 30 and 88 years were included. The agreement between ordinally scored CAC and the Agatston score was excellent (κ = 0.82) and the correlation strong (r = 0.94). Most patients (80%) with an intermediate PTP had no or mild CAC on non-gated CT. They were reclassified at low risk with 100% accuracy compared with invasive coronary angiography. Similarly, 86% of patients had an Agatston score <300. These patients were reclassified with 98% accuracy. In patients with high PTP, the accuracy remained substantial and comparable, 94% and 89%, respectively. In conclusion, we believe this is the first study to assess the clinical applicability of CAC on non-gated CT in patients with stable chest pain, compared with the classic Agatston score. The agreement between methods was excellent and the correlation strong. Furthermore, CAC assessment on non-gated CT could reclassify patients' risk for obstructive coronary artery disease as accurately as could the classic Agatston score.

Impact of non-gated computed tomography on the timing of invasive strategy of patients with non-ST-elevation acute coronary syndrome.

Background: This study aimed to examine the clinical role of non-gated computed tomography (CT) in ruling out fatal chest pain in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS), with a focus on the time of arrival at the hospital to coronary angiography (CAG) and peak creatine kinase (CK) levels. Methods: We retrospectively examined 196 NSTE-ACS patients who were admitted with urgently diagnosed NSTE-ACS and underwent percutaneous coronary intervention between March 2019 and October 2022. The patients were divided into three groups, namely, non-CT group, CT and defect- group, and CT and defect+ group, based on whether they underwent a CT scan and the presence or absence of perfusion defects on the CT image. Results: After the initial admission for NSTE-ACS, 40 patients (20.4%) underwent non-gated CT prior to CAG. Among these 40 patients, 27 had a perfusion defect on the CT scan. The incidence of contrast-induced nephropathy was not different among the three groups. The CT and defect+ group had a shorter arrival-to-CAG time than that of the non-CT group. In NSTE-ACS patients with elevated CK levels, the CT and defect+ group had lower peak CK levels than those in the non-CT group. Conclusion: NSTE-ACS patients with perfusion defects on non-gated CT had a shorter time from arrival to CAG, which might be associated with a lower peak CK. Non-gated CT might be useful for early diagnosis and early revascularization in the clinical setting of NSTE-ACS.

Incidental, non-gated thoracic CT angiographic detection of proximal right coronary artery total occlusion associated with acute myocardial infarction.

Herein, we present a case of a right coronary artery proximal occlusion and acute myocardial infarction with absence of the reverse attenuation gradient sign that was incidentally identified in the emergency room with non-gated computed tomography angiography of the aorta performed to rule out aortic dissection. This case highlights the importance of assessing the heart and coronary arteries even on non-gated computed tomography angiography.

High-pitch non-gated scans on the second and third generation dual-source CT scanners: comparison of coronary image quality.

OBJECTIVE: To examine differences in image quality of the coronary arteries when performing high-pitch non-electrocardiography (ECG)-gated scans on the second-generation (2G) and third-generation (3G) dual-source CT scanners. METHODS: We retrospectively examined patients with high-pitch non-ECG-gated CT angiography (CTA) of the chest or chest/abdomen/pelvis. Outpatient scans from 59 patients in the 3G high-pitch group and 53 patients in the 2G high-pitch group were included. Two blinded cardiac imagers independently scored the coronary image quality using a 4-point Likert scale (from completely diagnostic to completely non-diagnostic) and evaluated the presence of coronary artery disease. RESULTS: Diagnostic image quality of the coronaries in high-pitch CTA exams using 3G scanner was improved compared to 2G scanner, both on a per-vessel basis (45-94% versus 23-86%) and on a per-study basis (34% versus 14%). The 3G group showed a statistically significant improvement in image quality when evaluating the left main coronary, right coronary, and overall coronary arteries. Coronary artery disease was detected in 65% of high-pitch scans. Radiation doses in terms of CTDIvol and DLP were lower for 3G high-pitch scans (7.5 mGy and 491 mGy∗cm) compared to 2G high-pitch scans (14.8 mGy and 911 mGy∗cm). CONCLUSIONS: We found a higher proportion of diagnostic image quality of the coronary arteries in high-pitch non-ECG-gated CTA exams using a 3G dual-source CT scanner, compared to 2G. In scans with diagnostic image quality, underlying coronary artery disease may be confidently diagnosed and should prompt considerations for further management in the appropriate clinical setting.