Korean J Radiol.  2018 Oct;19(5):905-915. 10.3348/kjr.2018.19.5.905.

Diagnostic Accuracy of Electrocardiogram-Gated Thoracic Computed Tomography Angiography without Heart Rate Control for Detection of Significant Coronary Artery Stenosis in Patients with Acute Ischemic Stroke: A Comparative Study

Affiliations
  • 1Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Korea. ksm9723@yahoo.co.kr
  • 2Department of Cardiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Korea.
  • 3Department of Neurology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Korea.

Abstract


OBJECTIVE
To compare the diagnostic performance of electrocardiogram (ECG)-gated thoracic computed tomography angiography (TCTA) without heart rate (HR) control in ischemic stroke patients with coronary CTA (CCTA) in non-stroke patients for detection of significant coronary artery stenosis.
MATERIALS AND METHODS
From September 2009 through August 2014, we retrospectively enrolled 138 consecutive patients diagnosed with acute ischemic stroke who had undergone ECG-gated TCTA and conventional coronary angiography (CCA). Over the same period, we selected 167 non-stroke patients with suspected or known coronary artery disease who had undergone CCTA and CCA. With CCA as the reference standard, the diagnostic performance of TCTA and CCTA for identification of significant coronary stenosis (diameter reduction ≥ 50%) was calculated.
RESULTS
There was no significant difference in baseline characteristics between TCTA (n = 132) and CCTA (n = 164), except for the higher prevalence of atrial fibrillation in the stroke group. There was significant difference (p < 0.001) between TCTA and CCTA in average HR (68 ± 12 vs. 61 ± 10 beats per minute) and image quality score (1.3 ± 0.6 vs. 1.2 ± 0.6). Significant coronary stenosis was identified in 101 (77%) patients, 179 (45%) vessels, and 293 (15%) segments of stroke patients, and in 136 (83%) patients, 259 (53%) vessels, and 404 (16%) segments of non-stroke patients. Diagnostic performance on a per-vessel and per-patient basis was similar in both TCTA and CCTA groups. There was only significant difference in area under receiver-operating characteristic curve between TCTA and CCTA groups (0.79 vs. 0.87, p < 0.001) on per-segment basis.
CONCLUSION
Electrocardiogram-gated TCTA without HR control facilitates the identification of significant coronary stenosis in patients with ischemic stroke.

Keyword

Atherosclerosis; Coronary artery disease; Coronary angiography; Computed tomography; Stroke

MeSH Terms

Angiography*
Atherosclerosis
Atrial Fibrillation
Coronary Angiography
Coronary Artery Disease
Coronary Stenosis*
Coronary Vessels*
Electrocardiography
Heart Rate*
Heart*
Humans
Prevalence
Retrospective Studies
Stroke*

Figure

  • Fig. 1 Protocol for TCTA.After coronary calcium scan, TCTA was acquired from aortic arch to inferior border of heart to detect significant coronary stenosis and high-risk sources of cardiogenic embolism, and to evaluate aortic plaques. Three minutes after TCTA, late-phase CT was acquired from left atrium to middle of left ventricle to distinguish between slow flow and thrombus in LAA without additional use of iodinated contrast medium. ECG = electrocardiogram, LAA = left atrial appendage, TCTA = thoracic computed tomography angiography

  • Fig. 2 Images in 70-year-old man with acute ischemic stroke.Patient manifested hypertension, diabetes mellitus and atrial fibrillation. A. ECG obtained during TCTA examination showed atrial fibrillation and ventricular premature contraction. ECG-based tube current modulation was switched off in this patient. B. Curved multi-planar reformatted image shows approximately insignificant stenosis (arrowhead) via mixed calcified and non-calcified plaques and poor contrast enhancement (arrow) in PL. C. Curved multi-planar reformatted image shows poor contrast enhancement in middle segment of LAD (arrows), corresponding to non-evaluable segment. D. Curved multi-planar reformatted image shows poor contrast enhancement or diffuse obstruction in OM1 (arrows). Patient was diagnosed with 3-vessel disease by TCTA findings. E. Early-phase TCTA demonstrates triangular-shape filling defects within LAA (arrows). F. Delayed imaging reveals complete in-filling of appendage confirming that defect was secondary to circulatory stasis rather than thrombus. G. Oblique sagittal reconstruction image of aortic arch shows 3.5-mm-thick atheroma (arrow) of proximal aortic arch with hypoattenuating component. H–J. Conventional coronary angiography images showed no significant stenoses in early-branching PL (arrow, H) and middle LAD (arrow, I) whereas subtotal occlusion without collateral flow in OM1 (arrow, J). LAD = left anterior descending coronary artery, OM1 = first obtuse marginal artery, PL = posterolateral branch


Reference

1. Bonita R. Epidemiology of stroke. Lancet. 1992; 339:342–344. PMID: 1346420.
Article
2. Ayala C, Greenlund KJ, Croft JB, Keenan NL, Donehoo RS, Giles WH, et al. Racial/ethnic disparities in mortality by stroke subtype in the United States, 1995-1998. Am J Epidemiol. 2001; 154:1057–1063. PMID: 11724723.
Article
3. Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in acute stroke treatment. Stroke. 1993; 24:35–41. PMID: 7678184.
Article
4. Kolominsky-Rabas PL, Weber M, Gefeller O, Neundoerfer B, Heuschmann PU. Epidemiology of ischemic stroke subtypes according to TOAST criteria: incidence, recurrence, and long-term survival in ischemic stroke subtypes: a population-based study. Stroke. 2001; 32:2735–2740. PMID: 11739965.
5. Doufekias E, Segal AZ, Kizer JR. Cardiogenic and aortogenic brain embolism. J Am Coll Cardiol. 2008; 51:1049–1059. PMID: 18342221.
Article
6. Hur J, Choi BW. Cardiac CT imaging for ischemic stroke: current and evolving clinical applications. Radiology. 2017; 283:14–28. PMID: 28318443.
Article
7. Hur J, Kim YJ, Lee HJ, Ha JW, Heo JH, Choi EY, et al. Cardiac computed tomographic angiography for detection of cardiac sources of embolism in stroke patients. Stroke. 2009; 40:2073–2078. PMID: 19372451.
Article
8. Hur J, Kim YJ, Lee HJ, Nam JE, Hong YJ, Kim HY, et al. Cardioembolic stroke: dual-energy cardiac CT for differentiation of left atrial appendage thrombus and circulatory stasis. Radiology. 2012; 263:688–695. PMID: 22495682.
Article
9. Calvet D, Touzé E, Varenne O, Sablayrolles JL, Weber S, Mas JL. Prevalence of asymptomatic coronary artery disease in ischemic stroke patients: the PRECORIS study. Circulation. 2010; 121:1623–1629. PMID: 20351236.
10. Amarenco P, Lavallée PC, Labreuche J, Ducrocq G, Juliard JM, Feldman L, et al. Prevalence of coronary atherosclerosis in patients with cerebral infarction. Stroke. 2011; 42:22–29. PMID: 21088246.
Article
11. Yoo J, Yang JH, Choi BW, Kim YD, Nam HS, Choi HY, et al. The frequency and risk of preclinical coronary artery disease detected using multichannel cardiac computed tomography in patients with ischemic stroke. Cerebrovasc Dis. 2012; 33:286–294. PMID: 22286013.
Article
12. Brønnum-Hansen H, Davidsen M, Thorvaldsen P. Danish MONICA Study Group. Long-term survival and causes of death after stroke. Stroke. 2001; 32:2131–2136. PMID: 11546907.
Article
13. Hartmann A, Rundek T, Mast H, Paik MC, Boden-Albala B, Mohr JP, et al. Mortality and causes of death after first ischemic stroke: the Northern Manhattan Stroke Study. Neurology. 2001; 57:2000–2005. PMID: 11739816.
Article
14. Hur J, Lee KH, Hong SR, Suh YJ, Hong YJ, Lee HJ, et al. Prognostic value of coronary computed tomography angiography in stroke patients. Atherosclerosis. 2015; 238:271–277. PMID: 25544177.
Article
15. Meijboom WB, Meijs MF, Schuijf JD, Cramer MJ, Mollet NR, van Mieghem CA, et al. Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study. J Am Coll Cardiol. 2008; 52:2135–2144. PMID: 19095130.
16. Yoon YE, Lim TH. Current roles and future applications of cardiac CT: risk stratification of coronary artery disease. Korean J Radiol. 2014; 15:4–11. PMID: 24497786.
Article
17. ASCI Practice Guideline Working Group. Beck KS, Kim JA, Choe YH, Hian SK, Hoe J, et al. 2017 multimodality appropriate use criteria for noninvasive cardiac imaging: expert consensus of the Asian society of cardiovascular imaging. Korean J Radiol. 2017; 18:871–880. PMID: 29089819.
Article
18. Lee K, Hur J, Hong SR, Suh YJ, Im DJ, Kim YJ, et al. Predictors of recurrent stroke in patients with ischemic stroke: comparison study between transesophageal echocardiography and cardiac CT. Radiology. 2015; 276:381–389. PMID: 25692312.
Article
19. Raff GL, Chinnaiyan KM, Share DA, Goraya TY, Kazerooni EA, Moscucci M, et al. Advanced Cardiovascular Imaging Consortium Co-Investigators. Radiation dose from cardiac computed tomography before and after implementation of radiation dose-reduction techniques. JAMA. 2009; 301:2340–2234. PMID: 19509381.
Article
20. Austen WG, Edwards JE, Frye RL, Gensini GG, Gott VL, Griffith LS, et al. A reporting system on patients evaluated for coronary artery disease. Report of the Ad Hoc Committee for grading of coronary artery disease, Council on Cardiovascular Surgery, American Heart Association. Circulation. 1975; 51(4 Suppl):5–40. PMID: 1116248.
Article
21. Choi BH, Ko SM, Hwang HK, Song MG, Shin JK, Kang WS, et al. Detection of left atrial thrombus in patients with mitral stenosis and atrial fibrillation: retrospective comparison of two-phase computed tomography, transoesophageal echocardiography and surgical findings. Eur Radiol. 2013; 23:2944–2953. PMID: 23821020.
Article
22. Hausleiter J, Meyer T, Hermann F, Hadamitzky M, Krebs M, Gerber TC, et al. Estimated radiation dose associated with cardiac CT angiography. JAMA. 2009; 301:500–507. PMID: 19190314.
Article
23. Adams RJ, Chimowitz MI, Alpert JS, Awad IA, Cerqueria MD, Fayad P, et al. Coronary risk evaluation in patients with transient ischemic attack and ischemic stroke: a scientific statement for healthcare professionals from the Stroke Council and the Council on Clinical Cardiology of the American Heart Association/American Stroke Association. Stroke. 2003; 34:2310–2322. PMID: 12958318.
24. Cujec B, Polasek P, Voll C, Shuaib A. Transesophageal echocardiography in the detection of potential cardiac source of embolism in stroke patients. Stroke. 1991; 22:727–733. PMID: 2057970.
Article
25. Leung DY, Black IW, Cranney GB, Walsh WF, Grimm RA, Stewart WJ, et al. Selection of patients for transesophageal echocardiography after stroke and systemic embolic events. Role of transthoracic echocardiography. Stroke. 1995; 26:1820–1182. PMID: 7570732.
26. Pepi M, Evangelista A, Nihoyannopoulos P, Flachskampf FA, Athanassopoulos G, Colonna P, et al. Recommendations for echocardiography use in the diagnosis and management of cardiac sources of embolism: European Association of Echocardiography (EAE) (a registered branch of the ESC). Eur J Echocardiogr. 2010; 11:461–476. PMID: 20702884.
Article
27. Fazio GP, Redberg RF, Winslow T, Schiller NB. Transesophageal echocardiographically detected atherosclerotic aortic plaque is a marker for coronary artery disease. J Am Coll Cardiol. 1993; 21:144–150. PMID: 8417055.
Article
28. Hur J, Kim YJ, Lee HJ, Ha JW, Heo JH, Choi EY, et al. Left atrial appendage thrombi in stroke patients: detection with two-phase cardiac CT angiography versus transesophageal echocardiography. Radiology. 2009; 251:683–690. PMID: 19366905.
Article
29. Halpern EJ. Triple-rule-out CT angiography for evaluation of acute chest pain and possible acute coronary syndrome. Radiology. 2009; 252:332–345. PMID: 19703877.
Article
30. Burris AC 2nd, Boura JA, Raff GL, Chinnaiyan KM. Triple rule out versus coronary CT angiography in patients with acute chest pain: results from the ACIC consortium. JACC Cardiovasc Imaging. 2015; 8:817–825. PMID: 26093928.
31. Shapiro MD, Dodd JD, Kalva S, Wittram C, Hsu J, Nasir K, et al. A comprehensive electrocardiogram-gated 64-slice multidetector computed tomography imaging protocol to visualize the coronary arteries, thoracic aorta, and pulmonary vasculature in a single breath hold. J Comput Assist Tomogr. 2009; 33:225–232. PMID: 19346850.
Article
32. Ropers U, Ropers D, Pflederer T, Anders K, Kuettner A, Stilianakis NI, et al. Influence of heart rate on the diagnostic accuracy of dual-source computed tomography coronary angiography. J Am Coll Cardiol. 2007; 50:2393–2398. PMID: 18154964.
Article
33. Primak AN, McCollough CH, Bruesewitz MR, Zhang J, Fletcher JG. Relationship between noise, dose, and pitch in cardiac multi-detector row CT. Radiographics. 2006; 26:1785–1794. PMID: 17102050.
Article
34. Feuchtner GM, Jodocy D, Klauser A, Haberfellner B, Aglan I, Spoeck A, et al. Radiation dose reduction by using 100-kV tube voltage in cardiac 64-slice computed tomography: a comparative study. Eur J Radiol. 2010; 75:e51–e56. PMID: 19671491.
Article
35. Lell M, Hinkmann F, Anders K, Deak P, Kalender WA, Uder M, et al. High-pitch electrocardiogram-triggered computed tomography of the chest: initial results. Invest Radiol. 2009; 44:728–733. PMID: 19809339.
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