CAD detection in patients with intermediate-high pre-test probability: low-dose CT delayed enhancement detects ischemic myocardial scar with moderate accuracy but does not improve performance of a stress-rest CT perfusion protocol

Abstract

Objectives: This study sought to compare computed tomography delayed enhancement (CTDE) against cardiac magnetic resonance (CMR) late gadolinium enhancement (LGE) for detection of ischemic scar and to test the additive value of CTDE as part of a comprehensive multidetector computed tomography (MDCT) stress-rest protocol including computed tomography perfusion (CTP) and computed tomography angiography (CTA) for the diagnosis of significant coronary artery disease (CAD).

Background: CTDE has been recently described as a promising tool for noninvasive detection of myocardial scar, similarly to CMR-LGE techniques. Despite its theoretical potential as an adjunctive tool to improve MDCT accuracy for detection of CAD, its clinical performance has not been validated.

Methods: One hundred five symptomatic patients with suspected CAD (age 62.0 ± 8.0 years, 67% men) underwent MDCT, CMR, and x-ray invasive coronary angiography. The MDCT protocol consisted of calcium scoring, stress CTP under adenosine 140 μg/kg/min, rest CTP + CTA, and a low-dose radiation prospective scan for detection of CTDE. CMR-LGE was used as the reference standard for assessment of scar. Functionally significant CAD was defined as the presence of ≥90% stenosis/occlusion or fractional flow reserve measurements ≤0.80 in vessels >2 mm.

Results: CTDE had good accuracy (90%) for ischemic scar detection with low sensitivity (53%) but excellent specificity (98%). Positive and negative predictive values were 82% and 91%, respectively. On a patient-based model, MDCT protocol without integration of CTDE results had a sensitivity, specificity, and positive and negative predictive values of 90%, 81%, 80%, and 90%, respectively, for the detection of functionally significant CAD. Addition of CTDE results did not improve MDCT performance (90%, 77%, 77%, and 90%, respectively).

Conclusions: CTDE has moderate accuracy for detection of ischemic scar in patients with suspected CAD. Integration of CTDE into a comprehensive MDCT protocol including stress-rest CTP and CTA does not improve MDCT accuracy for detection of significant CAD in intermediate-to-high pre-test probability populations.

Keywords: CAD; CI; CMR; CTA; CTDE; CTP; FFR; LGE; MDCT; QCA; ROC; XA; cardiac magnetic resonance; computed tomography angiography; computed tomography delayed enhancement; computed tomography perfusion; confidence interval; coronary artery disease; delayed enhancement; fractional flow reserve; late gadolinium enhancement; multidetector computed tomography; quantitative coronary angiography; receiver-operating characteristic; tomography; x-ray invasive coronary angiography.