CARDIAC COMPUTED TOMOGRAPHY
Provides high-resolution images of cardiac structures (including the pericardium and cardiac masses) and detects coronary calcification in atherosclerosis with high sensitivity. CT angiography (CTA) delineates abnormalities of the great vessels, including aortic aneurysms and dissection, and pulmonary embolism. Multislice spiral CT provides high-resolution images of coronary anatomy. It is most useful in evaluation of suspected coronary anatomic anomalies and to exclude high-grade coronary stenoses in pts with chest pain and intermediate pretest probability of coronary artery disease. Its greatest accuracy is in detection of left main and proximal LAD and circumflex disease. CTA is also helpful in assessing the patency of bypass grafts.
Table 114-2 summarizes key diagnostic features of the noninvasive imaging modalities. Figure 114-3 provides an algorithm for diagnostic imaging assessment of suspected CAD.
| ECHOCARDIOGRAPHY | NUCLEAR IMAGING | COMPUTED TOMOGRAPHY | MAGNETIC RESONANCE IMAGING | |
|---|---|---|---|---|
| LV size/function | Initial modality of choice Low cost, portable Provides ancillary structural and hemodynamic information | Available from gated SPECT stress imaging | Excellent resolution, but high cost | Excellent resolution, but high cost |
| Valve disease | Initial modality of choice Valve motion, stenosis, regurgitation Doppler hemodynamics | Assesses eligibility for TAVR | Visualize valve motion Delineate abnormal flow | |
| Pericardial disease | Pericardial effusion Doppler in tamponade, constriction | Identifies pericardial thickening | Identifies pericardial thickening, inflammation, fibrosis | |
| Aortic disease | TEE: rapid diagnosis of acute dissection | Image entire aorta Aortic aneurysms Aortic dissection | Image entire aorta Aortic aneurysms | |
| Cardiac masses | TTE—large intracardiac thrombi/masses | Extracardiac masses | Extracardiac masses | |
| TEE—smaller intracardiac masses | Myocardial masses | Myocardial masses |
Abbreviations: SPECT, single-photon emission CT; TAVR, transcatheter aortic valve replacement; TEE, transesophageal echocardiography; TTE, transthoracic echocardiogram.
FIGURE 114-3
Flow diagram for selection of stress testing in a pt with chest pain. LBBB, left bundle branch block; Prev MI, previous myocardial infarction; Nuc, SPECT nuclear imaging study; Pharm nuc, pharmacologic nuclear imaging (adenosine, regadenoson, dipyridamole); PPM, permanent pacemaker.
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