title: Noninvasive anatomical and functional assessment of coronary artery disease.
abstract: OBJECTIVE
  In suspected coronary artery disease (CAD), invasive coronary angiography (ICA) is traditionally the diagnostic tool of choice. However, patients often have no significant disease. Moreover, assessment of fractional flow reserve (FFR) has been shown to have prognostic implications. Recently, coronary computed tomography angiography (CTA) and cardiac magnetic resonance (CMR) myocardial perfusion imaging (CMR-Perf) have gained increasing attention through their accurate anatomical and functional assessment, respectively. We studied the added value of integrating these tests (CT+CMRint) in the diagnosis of CAD, with FFR as the reference standard.
  
  
  METHODS
  We included 101 patients consecutively referred for outpatient assessment of CAD who underwent CTA and CMR-Perf prior to ICA with FFR assessment. Lesions were considered positive by CT+CMRint only if positive in the two tests alone. The mean follow-up was 2.9±0.6 years.
  
  
  RESULTS
  All patients completed the study protocol without adverse effects. Forty-four patients had CAD by FFR. CTA had excellent sensitivity and negative predictive value (100%) but, as expected, its specificity and positive predictive value were lower (61% and 67%, respectively). Diagnostic accuracy by FFR was 78% for CTA, 88% for CMR-Perf and 92% for CT+CMRint. Regarding diagnostic accuracy, CT+CMRint showed statistically significant superiority (AUC=0.917, 95% CI 0.845-0.963) compared with CTA (AUC=0.807, 95% CI 0.716-0.879, p=0.0057) or CMR-Perf (AUC=0.882, 95% CI 0.802-0.938, p=0.0398) alone. Regarding prediction of revascularization, the integrated protocol maintained its superior performance.
  
  
  CONCLUSIONS
  CT+CMRint showed superior diagnostic accuracy and could thus lead to a considerable reduction in invasive procedures for CAD diagnosis, with less risk and greater patient comfort.
authors.affiliation: Cardiology Department, Hospital de Braga, Portugal. Electronic address: vglramos@gmail.com.
authors.forename: Vítor
authors.initials: V
authors.lastname: Ramos
authors.affiliation: Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal.
authors.forename: Nuno
authors.initials: N
authors.lastname: Bettencourt
authors.affiliation: Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Silva
authors.affiliation: Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal.
authors.forename: Nuno
authors.initials: N
authors.lastname: Ferreira
authors.affiliation: Division of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom.
authors.forename: Amedeo
authors.initials: A
authors.lastname: Chiribiri
authors.affiliation: Department of Cardiology and Pneumology and Heart Research Centre, Georg-August-University, Göttingen, Germany.
authors.forename: Andreas
authors.initials: A
authors.lastname: Schuster
authors.affiliation: Cardiology Department, Centro Hospitalar de S. João, Portugal; Faculty of Medicine, Porto University, Portugal.
authors.forename: Adelino
authors.initials: A
authors.lastname: Leite-Moreira
authors.affiliation: Cardiology Department, Centro Hospitalar de S. João, Portugal; Faculty of Medicine, Porto University, Portugal.
authors.forename: José
authors.initials: J
authors.lastname: Silva-Cardoso
authors.affiliation: Division of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom.
authors.forename: Eike
authors.initials: E
authors.lastname: Nagel
authors.affiliation: Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal.
authors.forename: Vasco
authors.initials: V
authors.lastname: Gama
mesh_terms: D000328:Adult; D000368:Aged; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging* / Q000503:physiopathology*; D005260:Female; D053805:Fractional Flow Reserve, Myocardial; D006801:Humans; D018810:Magnetic Resonance Angiography; D008297:Male; D008875:Middle Aged; D014057:Tomography, X-Ray Computed
keywords: Angio TC cardíaco; Avaliação integrada; Cardiac magnetic resonance myocardial perfusion imaging; Computed tomography angiography; Coronary artery disease; Doença coronária; Estudo de perfusão por ressonância magnética cardiovascular; Fractional flow reserve; Integrated assessment; Reserva fracional funcional