Coronary dual source multi detector computed tomography in patients suspected of coronary artery disease: Prevalence of incidental extra-cardiac findings

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Abstract

Objectives

(1) To establish the prevalence of incidental extra-cardiac findings (ECFs) in coronary multi detector computed tomography (CCT) performed in a large, homogeneous cohort of patients suspected of coronary artery disease (CAD). (2) To examine whether any association can be established between ECFs and pretest risk as determined by conventional risk factors for CAD, the Diamond-Forrester risk model or coronary artery calcium scores. (3) To assess cost related to extra-cardiac examinations.

Design

Retrospective study of consecutive patients who had CCT performed. A large field of view was recreated from the non-enhanced CT scan and evaluated by a radiologist for incidental ECFs.

Subjects

Patients with chest pain referred to CTA by a cardiologist.

Results

In 1383 patients a total of 481 ECFs were indentified, 378 minor (meaning no follow-up was needed) and 103 major ECFs (ECF followed up clinically and/or with additional imaging), in a total of 393 (28%) patients. 85 (6%) patients had one major ECF and 9 (0.7%) patients had two major ECFs. In 19 (4 cases of malignancy) patients the major ECF had therapeutic consequences. Significant positive associations were found between age and smoking, respectively and the presence of ECFs. The cost estimate of saving one life from malignant disease based on ECF examinations is 40,190€.

Conclusion

Incidental extra-cardiac findings are common, sometimes revealing serious, even malignant disease. Diagnostic follow-up of major ECFs seems to be cost-effective in a Danish clinical setting. We recommend investigating a large field of view for incidental ECFs following CCT.

Introduction

In Western societies coronary artery disease (CAD) is one of the leading causes of morbidity and mortality. Coronary multislice computed tomography (CCT) is recommended in patients suspected of CAD with low to intermediate pretest probability of disease [1]. In contrast to other cardiac imaging techniques CCT inherently contain detailed information on the surrounding organs such as the lungs, mediastinum, the chest wall, columna and the upper abdomen, respectively. Numerous studies have investigated the prevalence of incidental extra-cardiac findings (ECFs) in CTA. However, most of these studies have been performed in either inhomogeneous or relatively small cohorts [2], [3], [4], [5], [6], [7], [8], [9]. Furthermore there has been a great deal of controversy on whether to analyze CCT scans for ECFs or not. The purpose of this study is threefold. (1) To establish the prevalence of incidental ECFs as identified by CCT in a large, homogeneous cohort of patients with chest pain suspected of CAD. (2) To investigate possible associations between conventional risk factors for CAD and pretest risk of CAD, respectively, and the occurrence of incidental ECFs. (3) To assess costs related to extra-cardiac examinations.

Section snippets

Study cohort

The study cohort comprised consecutive patients with chest pain referred for CCT on a suspicion of CAD. All CCT examinations were performed at the Department of Cardiology, Vejle Hospital in Denmark between February 2006 and July 2009. Patients were referred for CCT at the discretion of the treating cardiologist following a physical examination, blood samples, electrocardiogram (ECG), and echocardiography. Risk factors were derived through a structured interview and medical records. Smoking was

Results

During the study period 1410 patients with chest pain were scheduled for CCT. Twenty-seven patients were excluded from the CT investigation as they were unable to cooperate or because of pulse irregularities. Thus, 1383 patients form the basis of this study. Mean (±SD/range) follow-up time was 16 (7/6–28) months. In 91 (6.6%) patients, the enhanced scan was not accomplished due to high Agatston score. Patient characteristics for the entire cohort are presented in Table 1. A total of 481 ECFs,

Discussion

In this study hitherto comprising the largest cohort of symptomatic patients suspected of CAD, we found that 28% of the patients referred for CCT had one or more incidental extra-cardiac findings. In 7% of the patients the ECF resulted in additional downstream clinical evaluation or imaging investigation. Four (0.3%) patients were diagnosed with malignancy, of whom three were in a potentially curable stage of the disease. Previous reports (Table 6) indicate that ECFs in electron beam computed

Conclusion

This present study reaffirms that incidental extra-cardiac findings are common with a potential of revealing serious, and even malignant disease, and sometimes may explain patients symptoms. Both age and smoking are associated to the presence of ECFs. Diagnostic follow-up of major ECFs seems to be a cost-effective strategy in a Danish clinical setting. We recommend investigating a large field of view for incidental ECFs following CCT.

Conflict of interest

None.

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