Cardiac Computed

Tomography
Dyna Evalina Syahlul, BMedSci, SpJP
RSPAD Gatot Soebroto - DITKESAD

Introduction
CARDIAC CT AND SUSP.
CAD

Rapid and accurate

imaging of the
cardiovascular system,
including coronary
arteries, coronary
arterial wall, cardiac
valves, myocardium, and
associated structures

Diagnostic Tools in Stable Chest

Discomfort

Cardiac CT and Acute Chest Pain

Basic Principle

The detector array

consisting of narrow
channels for detection
of x-ray photons

Scan Modes

Contraindications to multi slice CT angiography

Absolute
Rapid heart rate, AF, frequent VES
Pregnancy
Extensive calcification
Unable to hold breath for 20 s
Contraindication to IV contras, beta-blocker or
nitrates
Relative
High BMI
Younger patient especialy if female due to
increase risk of excessive radiation

Prerequisites

The absolute requirements:

the ability to receive intravenous contrast

material
the ability to cooperate with breathing
instructions and to hold the breath for
approximately 10 to 20 seconds

Relative contraindications:
high or irregular heart rates (particularly atrial

fibrillation)
morbid obesity
severe coronary calcium

Contrast and Beta Blockers

Contraindications

Prerequisite

Scan quality is lower at higher heart rate

Heart rate control with target < 65
beats/min by administering:
metoprolol 25 to 100 mg orally 1 hour before

the scan) or intravenously (e.g., metoprolol 5

mg intravenously in repeated doses)

Nitroglycerin (400 to 800 g

sublingually): to increase coronary
artery diameter and to improve the
signal-to-noise ratio.

Patient Positioning

CT Cross-Sectional Anatomy (Axial)

@ the level of SVC and RVOT

CT Cross-Sectional Anatomy (Axial)

Display Mode

Clinical Indications

Detection of CAD in symptomatic patients

without known heart disease,
CAD risk assessment in asymptomatic
individuals
CAD detection in other cardiac conditions
Use of CT angiography after other test results
Use after revascularization
Evaluation of cardiac structure and function
Evaluation of intracardiac and extracardiac
structures

Coronary Artery Calcium Scanning

Used in asymptomatic patients to

refine their clinically predicted risk of
incident coronary heart disease
(CHD) beyond standard cardiac risk
factors
Proportional to the overall extent of
atherosclerosis
Low levels of radiation exposure (1 to
2 mSv)

Distribution of Coronary Calcium

Plaque Characteristics
NON CALCIFIED

MIXED

CALCIFIED

Coronary Calcium Scoring

Area = 15 mm2
Peak CT = 450
Score = 15 x 4 =
60

Area = 8 mm2
Peak CT = 290
Score = 8 x 2 =
16

Total Score =
Hn x-factor
(Agatston Scoring)

130-199

200-299

300-399

>400

Calcium Volume Scoring

1 - 10
Minimal
11 - 100
Mild
101 - 400
Moderate
>400
Severe

Calcium Score and Risk Stratification

A new form of cardiac

imaging

Non Invasive methods

Myocardial ischemia
4 slice 16 slice 64 slice ( 2004 ) 256 slice
64-row CT angiography has a sensitivity of 87%
to 99% and specificity of 93% to 96%, Negative
predictive value 99 %, PPV 78 %

Specificity will be reduced in:

severe coronary artery calcification (at

calcium scores above 400 to 1000)

obesity (due to excess image noise)

Pretest Probability of CAD by

Age, Sex, and Symptoms

ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010
Appropriate Use Criteria for Cardiac Computed Tomography,

Armin A, Zaheb. Stress testing and non-invasive coronary angiography in

patients with

Ventricular and Valvular Morphology

and Function

Estimation of EF, RWMA , and volumetric

analysis
Findings of prior myocardial infarction, e.g: wall
thinning, calcification, or fatty myocardial
replacement (indicated by negative HU densities
within the myocardium)
Atrial morphology and volume
Anatomic evaluation of cardiac valves and their
motion, both native and prosthetic valves (but it
lacks of physiologic valve flow evaluation )

Acute Aortic Syndromes and

Pulmonary Embolism

Aortic dissection: a sensitivity of 100% and a

specificity of 98%
Pulmonary embolism: a high, with a negative
predictive value of 99% in pretest likelihood

Emerging Applications
Chronic Myocardial Infarction

SUMMARY - INDICATIONS

SUMMARY - CONTRAINDICATIONS

APPROPRIATE USE CRITERIA C

ARDIAC CT SCAN

Thank You