Coronary Computed Tomographic Angiography
Publication Date: November 19, 2020
Last Updated: November 28, 2023
Recommendations
Evaluation of Stable Coronary Artery Disease: Coronary CTA in Native Vessels
| •It is appropriate to perform CTA as the first line test for evaluating patients with no known CAD who present with stable typical or atypical chest pain, or other symptoms which are thought to represent a possible anginal equivalent (e.g., dyspnea on exertion, jaw pain). |
| •It is appropriate to perform CTA as a first line test for evaluating patients with known CAD who present with stable typical or atypical chest pain, or other symptoms which are thought to represent a possible anginal equivalent (e.g., dyspnea on exertion, jaw pain). |
| •It is appropriate to perform coronary CTA following a non-conclusive functional test, in order to obtain more precision regarding diagnosis and prognosis, if such information will influence subsequent patient management. |
| •It is recommended to perform CTA as the first line test when considering evaluation for revascularization strategies using the ISCHEMIA Trial. |
| •It may be appropriate to perform CTA in selected asymptomatic high risk individuals, especially in those who have a higher likelihood of having a large amount of non-calcified plaque |
| •It is rarely appropriate to perform coronary CTA in very low risk symptomatic patients, e.g., <40 years of age with non-cardiac symptoms (chest wall pain, pleuritic chest pain). |
| •It is rarely appropriate to perform CTA in low- and intermediate risk asymptomatic patients. |
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Evaluation of Stable Coronary Artery Disease: Coronary CTA Post Revascularization
| •It is appropriate to perform coronary CTA in symptomatic patients with intracoronary stent diameter ≥3.0 mm. Measures to improve accuracy of stent imaging should be utilized, to include strict heart rate control (goal <60 bpm), iterative reconstruction, sharp kernel reconstruction, and mono-energetic reconstructions (when available). Protocols to optimize stent imaging should be developed and followed. |
| •It may be appropriate to perform coronary CTA in symptomatic patients with stents <3.0 mm, especially those known to have thin stent struts (<100 μm) in proximal, non-bifurcation locations. |
| •It is appropriate to perform CTA for evaluation of patients with prior CABG, particularly if graft patency is the primary objective. |
| •It is appropriate to perform CTA to visualize grafts and other structures prior to re-do cardiac surgery. |
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Evaluation of Stable Coronary Artery Disease: Coronary CTA with FFR or CTP
| •It may be appropriate to perform CT derived FFR and CT myocardial perfusion Imaging to evaluate the functional significance of intermediate stenoses on CTA (30–90% diameter stenosis) particularly in the setting of multivessel disease to help guide ICA referral and revascularization treatment planning. LM stenosis ≥50% and severe triple vessel disease should undergo invasive coronary angiography. |
| •Adding FFRCT and stress-CTP to CTA increases specificity, positive predictive value, and diagnostic accuracy over regular CTA. |
| •FFRCT and stress-CTP may be largely comparable in diagnostic utility. CTP is a potentially valuable alternative particularly when CT-FFR is technically difficult (e.g., suboptimal CTA quality, prior revascularization). |
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Evaluation of Stable Coronary Artery Disease: Coronary CTA in Other Conditions
| •It is appropriate to perform CTA for coronary artery evaluation prior to noncoronary cardiac surgery as an equivalent alternative to invasive angiography in selected patients, e.g., low-intermediate probability of CAD, younger patients with primarily non-degenerative valvular conditions. |
| •CTA may be considered an appropriate alternative to other noninvasive tests for evaluation of selected patients prior to noncardiac surgery. |
| •It is appropriate to perform CTA to exclude coronary artery disease in patients with suspected non-ischemic cardiomyopathy. |
| •It may be appropriate to perform late enhancement CT imaging to detect infiltrative heart disease or scar in selected patients who have non-ischemic or ischemic cardiomyopathy and who cannot undergo cardiac MRI. Such imaging may be performed if it has the potential to impact the diagnosis and/or treatment (e.g. planning for ablation therapy). |
| •It may be appropriate to perform CTA as an alternative to invasive coronary angiography for the screening of patients for coronary allograft vasculopathy in selected clinical practice settings. |
| •It is appropriate to perform CTA for the evaluation of coronary anomalies. |
| •It is appropriate to EKG gate aortic dissection and aneurysm CTA, as well as pulmonary embolus studies in men >45 years and women >55 years, and analyze and report the coronary arteries. |
| •CTA with a limited delayed image (60–90 sec) is an appropriate alternative to TEE when the primary aim is to exclude LA/LAA thrombus and in patients where the risks associated with TEE outweigh the benefits. In all situations CTA and TEE should be discussed with the patient in the setting of shared decision making. |
| •It may be appropriate to perform late enhancement CT imaging for the evaluation of myocardial viability in selected patients who cannot undergo cardiac MRI. Such imaging may be performed if it has the potential to impact the diagnosis and/or treatment (e.g. planning for revascularization). |
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Reporting on CTA: Coronary and Non Coronary Information
| •The CAD-RADs reporting is recommended. |
| •It is appropriate to report prior myocardial infarction when its features are evident on CTA. |
| •It is appropriate to report remote myocardial infarction when fatty metaplasia or calcification within an area of infarction are present. |
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Recommendation Grading
Overview
Title
Coronary Computed Tomographic Angiography
Authoring Organization
Society of Cardiovascular Computed Tomography
Publication Month/Year
November 19, 2020
Last Updated Month/Year
February 7, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Source Citation
Narula J, Chandrashekhar Y, Ahmadi A, Abbara S, Berman DS, Blankstein R, Leipsic J, Newby D, Nicol ED, Nieman K, Shaw L, Villines TC, Williams M, Hecht HS. SCCT 2021 Expert Consensus Document on Coronary Computed Tomographic Angiography: A Report of the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr. 2021 May-Jun;15(3):192-217. doi: 10.1016/j.jcct.2020.11.001. Epub 2020 Nov 20. PMID: 33303384; PMCID: PMC8713482.