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.
TABLE 114-2: Selection of Imaging Tests
 ECHOCARDIOGRAPHYNUCLEAR IMAGINGCOMPUTED TOMOGRAPHYMAGNETIC RESONANCE IMAGING
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
hmom20_ch114_f003.png
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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