Incremental diagnostic accuracy of computed tomography myocardial perfusion imaging over coronary angiography stratified by pre-test probability of coronary artery disease and severity of coronary artery calcification: The CORE320 study.
BACKGROUND
Myocardial CT perfusion (CTP) has been validated as an incremental diagnostic predictor over coronary computed tomography angiography (CTA) in assessing hemodynamically significant stenosis.


OBJECTIVE
To assess the diagnostic performance of CTA and CTP alone versus combined CTA-CTP stratified by Morise's pre-test probability and coronary artery calcium (CAC, Agatston) score.


METHODS
381 individuals (153 low/intermediate-risk for CAD, 83 high-risk, 145 known CAD) were further stratified based on CAC score cut-offs of 1-399 and ≥400. Area under the curve for receiver operating characteristics (AUC) was calculated to assess the diagnostic performance. Reference standards were QCA≥50% stenosis+corresponding SPECT summed stress score ≥1.


RESULTS
In both pre-test risk groups with an Agatston score of 1-399, AUCs of CTA-CTP were not significantly different than that from CTA alone. In the low/intermediate-risk group with CAC score 1-399, AUC for CTA-CTP (89) was higher than that for CTP (76, p=0.003) alone. In the same group with CAC score ≥400, AUCs were higher for CTA-CTP (97) than that for CTA (88, p=0.030) and CTP (83, p=0.033). In high risk/known CAD patients with CAC 1-399, diagnostic performance for CTA-CTP (77) was superior to CTP (71, p=0.037) alone. In the high risk/known CAD group with CAC score ≥400, AUCs for combined imaging were higher (86) than that for CTA (75, p<0.001) as well as CTP (78, p=0.020).


CONCLUSIONS
The incremental diagnostic accuracy of CTP over CTA persists in patients across severity spectra of pre-test probability of CAD and coronary artery calcification. In patients with severe coronary calcification (CAC score≥400), combined CTA-CTP has better diagnostic accuracy than CTA and CTP alone.
Cardiology Division, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA.
Ravi K
RK
Sharma
Cardiology Division, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA.
Armin
A
Arbab-Zadeh
Cardiology Division, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA.
Satoru
S
Kishi
National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
Marcus Y
MY
Chen
Cardiology Division, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA.
Tiago A
TA
Magalhães
Cardiology Division, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA.
Richard T
RT
George
Charité Medical School, Humboldt University, Berlin, Germany.
Marc
M
Dewey
Brigham and Women's Hospital, Boston, MA, USA.
Frank J
FJ
Rybicki
University of Copenhagen, Denmark.
Klaus F
KF
Kofoed
Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands.
Albert
A
de Roos
National Heart Center, Singapore, Singapore.
Swee Yaw
SY
Tan
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
Matthew
M
Matheson
Cardiology Division, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA.
Andrea
A
Vavere
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
Christopher
C
Cox
Beth Israel Deaconess Medical Center, Harvard University, Boston, MA, USA.
Melvin E
ME
Clouse
Cardiology Division, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA.
Julie M
JM
Miller
Cardiology Division, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA.
Jeffery A
JA
Brinker
National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
Andrew E
AE
Arai
Brigham and Women's Hospital, Boston, MA, USA.
Marcelo F
MF
Di Carli
Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil.
Carlos E
CE
Rochitte
Cardiology Division, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA. Electronic address: jlima@jhmi.edu.
Joao A C
JA
Lima
D000368:Aged; D000369:Aged, 80 and over; D017023:Coronary Angiography / Q000379:methods*; D003324:Coronary Artery Disease / Q000175:diagnosis*; D003331:Coronary Vessels / Q000000981:diagnostic imaging; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D061330:Multidetector Computed Tomography / Q000379:methods*; D055414:Myocardial Perfusion Imaging / Q000379:methods*; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012372:ROC Curve; D015203:Reproducibility of Results; D012720:Severity of Illness Index; D015899:Tomography, Emission-Computed, Single-Photon / Q000379:methods*; D061205:Vascular Calcification / Q000175:diagnosis*
Coronary calcium score; Coronary computed tomography angiography; Diagnostic accuracy; Myocardial computed tomography perfusion; Pre-test probability