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.

TABLE 114-2: Selection of Imaging Tests
LV size/function

Initial modality of choice

Low cost, portable

Provides ancillary structural and hemodynamic information

Available from gated SPECT stress imagingExcellent resolution, but high costExcellent 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 thickeningIdentifies pericardial thickening, inflammation, fibrosis
Aortic diseaseTEE: rapid diagnosis of acute dissection 

Image entire aorta

Aortic aneurysms

Aortic dissection

Image entire aorta

Aortic aneurysms

Cardiac massesTTE—large intracardiac thrombi/masses Extracardiac massesExtracardiac masses
 TEE—smaller intracardiac masses Myocardial massesMyocardial 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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