title: Combined coronary angiography and myocardial perfusion by computed tomography in the identification of flow-limiting stenosis - The CORE320 study: An integrated analysis of CT coronary angiography and myocardial perfusion.
abstract: BACKGROUND
  The combination of coronary CT angiography (CTA) and myocardial CT perfusion (CTP) is gaining increasing acceptance, but a standardized approach to be implemented in the clinical setting is necessary.
  
  
  OBJECTIVE
  To investigate the accuracy of a combined coronary CTA and myocardial CTP comprehensive protocol compared to coronary CTA alone, using a combination of invasive coronary angiography and single photon emission CT as reference.
  
  
  METHODS
  Three hundred eighty-one patients included in the CORE320 trial were analyzed in this study. Flow-limiting stenosis was defined as the presence of ≥50% stenosis by invasive coronary angiography with a related perfusion defect by single photon emission CT. The combined CTA + CTP definition of disease was the presence of a ≥50% stenosis with a related perfusion defect. All data sets were analyzed by 2 experienced readers, aligning anatomic findings by CTA with perfusion defects by CTP.
  
  
  RESULTS
  Mean patient age was 62 ± 6 years (66% male), 27% with prior history of myocardial infarction. In a per-patient analysis, sensitivity for CTA alone was 93%, specificity was 54%, positive predictive value was 55%, negative predictive value was 93%, and overall accuracy was 69%. After combining CTA and CTP, sensitivity was 78%, specificity was 73%, negative predictive value was 64%, positive predictive value was 0.85%, and overall accuracy was 75%. In a per-vessel analysis, overall accuracy of CTA alone was 73% compared to 79% for the combination of CTA and CTP (P < .0001 for difference).
  
  
  CONCLUSIONS
  Combining coronary CTA and myocardial CTP findings through a comprehensive protocol is feasible. Although sensitivity is lower, specificity and overall accuracy are higher than assessment by coronary CTA when compared against a reference standard of stenosis with an associated perfusion defect.
authors.affiliation: Department of Cardiology, Cardiology Division, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Blalock 524D1, 600 North Wolfe Street, Baltimore, MD 21287, USA; Department of Cardiology, Heart Institute (InCor), University of São Paulo Medical School, Brazil; Department of Radiology, Division of Cardiovascular CT/MR, Heart Hospital (HCOR), São Paulo, Sao Paulo, Brazil.
authors.forename: Tiago A
authors.initials: TA
authors.lastname: Magalhães
authors.affiliation: Department of Cardiology, Cardiology Division, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Blalock 524D1, 600 North Wolfe Street, Baltimore, MD 21287, USA.
authors.forename: Satoru
authors.initials: S
authors.lastname: Kishi
authors.affiliation: Department of Cardiology, Cardiology Division, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Blalock 524D1, 600 North Wolfe Street, Baltimore, MD 21287, USA.
authors.forename: Richard T
authors.initials: RT
authors.lastname: George
authors.affiliation: Department of Cardiology, Cardiology Division, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Blalock 524D1, 600 North Wolfe Street, Baltimore, MD 21287, USA.
authors.forename: Armin
authors.initials: A
authors.lastname: Arbab-Zadeh
authors.affiliation: Department of Cardiology, Cardiology Division, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Blalock 524D1, 600 North Wolfe Street, Baltimore, MD 21287, USA.
authors.forename: Andrea L
authors.initials: AL
authors.lastname: Vavere
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Christopher
authors.initials: C
authors.lastname: Cox
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Matthew B
authors.initials: MB
authors.lastname: Matheson
authors.affiliation: Department of Cardiology, Cardiology Division, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Blalock 524D1, 600 North Wolfe Street, Baltimore, MD 21287, USA.
authors.forename: Julie M
authors.initials: JM
authors.lastname: Miller
authors.affiliation: Department of Cardiology, Cardiology Division, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Blalock 524D1, 600 North Wolfe Street, Baltimore, MD 21287, USA.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Brinker
authors.affiliation: Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
authors.forename: Marcelo
authors.initials: M
authors.lastname: Di Carli
authors.affiliation: Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
authors.forename: Frank J
authors.initials: FJ
authors.lastname: Rybicki
authors.affiliation: Department of Cardiology, Heart Institute (InCor), University of São Paulo Medical School, Brazil; Department of Radiology, Division of Cardiovascular CT/MR, Heart Hospital (HCOR), São Paulo, Sao Paulo, Brazil.
authors.forename: Carlos E
authors.initials: CE
authors.lastname: Rochitte
authors.affiliation: Department of Radiology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA, USA.
authors.forename: Melvin E
authors.initials: ME
authors.lastname: Clouse
authors.affiliation: Department of Cardiology, Cardiology Division, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Blalock 524D1, 600 North Wolfe Street, Baltimore, MD 21287, USA. Electronic address: jlima@jhmi.edu.
authors.forename: João A C
authors.initials: JA
authors.lastname: Lima
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017023:Coronary Angiography / Q000379:methods*; D003326:Coronary Circulation; D023921:Coronary Stenosis / Q000000981:diagnostic imaging* / Q000503:physiopathology; D003331:Coronary Vessels / Q000000981:diagnostic imaging* / Q000503:physiopathology; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D055414:Myocardial Perfusion Imaging / Q000379:methods*; D011237:Predictive Value of Tests; D011446:Prospective Studies; D011857:Radiographic Image Interpretation, Computer-Assisted; D015203:Reproducibility of Results; D012720:Severity of Illness Index; D015899:Tomography, Emission-Computed, Single-Photon; D014057:Tomography, X-Ray Computed / Q000379:methods*
keywords: Coronary CT angiography; Hybrid imaging; Multislice CT; Myocardial CT perfusion; Myocardial perfusion imaging