Cronicon O PEN A C C ESS EC CARDIOLOGY Short Communication Computed Tomography Coronary Angiography (CTCA) and its Non-invasive Role in Stable Coronary Artery Disease Han Naung Tun1,2* and Syed Haseeb Raza Naqvi3 1 Council on Clinical Practice, Clinical and Research Working Groups, European Society of Cardiology, France 2 National Representative of Heart Failure Specialist of Tomorrow for Myanmar in European Heart Failure Association, European Society of Cardiology, France 3 Department of Cardiac Electrophysiology, National Institute of Cardiovascular Diseases, Karachi, Pakistan *Corresponding Author: Han Naung Tun, Council on Clinical Practice, Clinical and Research Working Groups, European Society of Cardiology and National Representative of Heart Failure Specialist of Tomorrow for Myanmar in European Heart Failure Association, European Society of Cardiology, France. Received: September 30, 2019; Published: October 17, 2019 Coronary artery disease (CAD) is a pathological process characterized by atherosclerotic plaque accumulation in the epicardial arteries, whether obstructive or non-obstructive. This process can be modified by lifestyle adjustments, pharmacological therapies, and invasive interventions designed to achieve disease stabilization or regression. The dynamic nature of the CAD process results in various clinical presentations, which can be conveniently categorized as either acute coronary syndromes (ACS) or chronic coronary syndromes (CCS). CTCA uses computed tomography (CT) scanning to take images (angiograms) of the coronary arteries. It requires the use of rapid CT scanning techniques and can only be carried out in centers where the equipment is suitable and the medical/technology staffs are trained appropriately. Computed Tomography Coronary Angiography is the preferred test in patients with a lower range of clinical likelihood of CAD, no previous diagnosis of CAD, and characteristics associated with a high likelihood of good image quality. It detects subclinical coronary atherosclerosis but can also accurately rule out both anatomically and functionally significant CAD. Its higher accuracy values of CTCA when low clinical likelihood populations are subjected to examination [1]. Trials evaluating outcomes after coronary CTA to date have mostly included patients with a low clinical likelihood [2,3]. The non-invasive functional tests for ischaemia typically have better rule-in power. In outcome trials, functional imaging tests have been associated with fewer referrals for downstream ICA compared with a strategy relying on anatomical imaging [4,5]. Functional evalu- ation of ischaemia (either non-invasive or invasive) is required in most patients before revascularization decisions can be made. Therefore, non-invasive functional testing has now come to be preferred in patients at the higher end of the range of clinical likelihood if revascularization is likely or the patient has previously diagnosed CAD. If CAD is suspected in patients, but who have a very low clinical likelihood (≤ 5%) of CAD, should have other cardiac causes of chest pain excluded and their cardiovascular risk factors adjusted, based on a risk-score assessment. In patients with repeated, unprovoked attacks of anginal symptoms mainly at rest, vasospastic angina should be considered, diagnosed, and treated appropriately In addition to diagnostic accuracy and clinical likelihood, the selection of a non-invasive test depends on other patient characteristics, local expertise, and the availability of tests. Some diagnostic tests may perform better in some patients than others. For example, irregular heart rate and the presence of extensive coronary calcification are associated with increased likelihood of non-diagnostic image quality of CTCA and it is not recommended in such patients [1]. Stress echocardiography or SPECT perfusion imaging can be combined with Citation: Han Naung Tun., et al. “Computed Tomography Coronary Angiography (CTCA) and its Non-invasive Role in Stable Coronary Artery Disease”. EC Cardiology 6.11 (2019): 49-50. Computed Tomography Coronary Angiography (CTCA) and its Non-invasive Role in Stable Coronary Artery Disease 50 dynamic exercise testing, and may be preferred if additional information available from the exercise test, such as exercise tolerance or heart rate response to exercise, is considered important. Exercise ECG cannot be used for diagnostic purposes in the presence of ECG ab- normalities that prevent the evaluation of ischaemia. Risks related to different diagnostic tests need to be weighed against the benefits to the individual [6]. For example, exposure to ionizing radiation associated with CTCA and nuclear perfusion imaging needs to be taken into account, especially in young individuals [6]. Similarly, contraindications to pharmacological stressors and contrast agents (iodine-based contrast agents and gadolinium-based chelates) need to be taken into account. When testing is used appropriately, the clinical benefit from accurate diagnosis and therapy exceeds the projected risks of testing itself. European Society of Cardiology (ESC)’s chronic coronary syndrome guideline revised the role of CTCA in CCS is to first line considered non-invasive investigation in 2019 updated guideline. This recommendation is based on Diagnostic performance of computed tomography coronary angiography (from the Prospective National Multicenter Multivendor EVASCAN Study, SCOT- HEART Registry, Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry) CONFRIM Registry and Prospective Multicenter Imaging Study for Evaluation of Chest Pain - PROMISE Trial. If obstructive CAD cannot be excluded based on clinical evaluation alone, either non-invasive functional imaging or anatomical imaging using CTCA may be used as the initial test to rule-out or establish the diagnosis of CCS [1-3]. These all results of the registries and trials have provided valuable information about the usefulness of CCTA that is recommended to use as a first-line considered non-invasive tool in our clinical practice in Chronic Coronary Syndrome. Conflict of Interest None to declare. Bibliography 1. Gueret P., et al. “Diagnostic performance of computed tomography coronary angiography (from the prospective national multicenter multivendor EVASCAN study)”. American Journal of Cardiology 111.4 (2013): 471-478. 2. Douglas PS., et al. “Outcomes of anatomical versus functional testing for coronary artery disease”. New England Journal of Medicine 372 (2015): 1291-1300. 3. SCOT-HEART investigators. “CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOTHEART): an open-label, parallel-group, multicentre trial”. Lancet 385.99985 (2015): 2383-2391. 4. Greenwood JP., et al. “Effect of care guided by cardiovascular magnetic resonance, myocardial perfusion scintigraphy, or NICE guidelines on subsequent unnecessary angiography rates: the CE-MARC 2 randomized clinical trial”. Journal of the American Medical Association 316.10 (2016): 1051-1060. 5. Karthikeyan G., et al. “Functional compared to anatomical imaging in the initial evaluation of patients with suspected coronary artery disease: an international, multi-center, randomized controlled trial (IAEA-SPECT/CTA study)”. Journal of Nuclear Cardiology 24.2 (2017): 507-517. 6. Knuuti J., et al. “Risks and benefits of cardiac imaging: an analysis of risks related to imaging for coronary artery disease”. European Heart Journal 35.10 (2014): 633-638. Volume 6 Issue 11 November 2019 ©All rights reserved by Han Naung Tun., et al. Citation: Han Naung Tun., et al. “Computed Tomography Coronary Angiography (CTCA) and its Non-invasive Role in Stable Coronary Artery Disease”. EC Cardiology 6.11 (2019): 49-50.