Radiology Section - Contrast Enhanced Computed Tomographic Angiography (CTA) for Coronary Artery Evaluation

IMPORTANT REMINDER

Regence Medical Policies are developed to provide guidance for members and providers regarding coverage in accordance with contract terms. Benefit determinations are based in all cases on the applicable contract language. To the extent there may be any conflict between the Medical Policy and contract language, the contract language takes precedence.

PLEASE NOTE: Contracts exclude from coverage, among other things, services or procedures that are considered investigational or cosmetic. Providers may bill members for services or procedures that are considered investigational or cosmetic. Providers are encouraged to inform members before rendering such services that the members are likely to be financially responsible for the cost of these services.

DESCRIPTION

Contrast-enhanced computed tomographic angiography (CTA) is a noninvasive imaging study that requires the use of intravenously administered contrast material and high-resolution, high-speed CT machinery to obtain detailed images of the coronary blood vessels. Very short image acquisition times are necessary to avoid blurring artifacts from the rapid motion of the beating heart. Rapid scanning is also helpful so that the volume of cardiac images can be obtained during breath-holding.

The various computed tomographic (CT) imaging devices used to assess coronary arteries include but are not limited to electron beam CT (also known as ultrafast CT) and helical CTs including multi-detector row CT (MDCT) and multi-slice CT (MSCT).

CTA has several important limitations. The presence of dense arterial calcification or an intracoronary stent can produce significant beam-hardening artifacts and may preclude a satisfactory study. The presence of an uncontrolled rapid heart rate or arrhythmia hinders the ability to obtain diagnostically satisfactory images. Evaluation of the distal coronary arteries is generally more difficult than visualization of the proximal and midsegment coronary arteries due to greater cardiac motion and the smaller caliber of coronary vessels in distal locations.

The effect of radiation exposure from CTA is not clearly understood and estimates of excess cancer risk have varied. The radiation delivered with 64-row MDCT is typically 8 to 20 mSv. CCA delivers about 4 to 8 mSv. Electrocardiographically (ECG)-controlled modulation of the x-ray beam during the cardiac cycle can reduce radiation exposure up to 50% by reducing exposure during nonimaging phases of the cardiac cycle. The EBCT using ECG triggering delivers the lowest dose (approximately 0.7 to 1.1 mSv with 3-mm sections).

POLICY/CRITERIA

Note:  This policy only addresses the use of CTA in the evaluation of coronary arteries and does not address the use of CTA for evaluation of cardiac structure and function (e.g. cardiac masses, emergent evaluations of aortic dissection, suspected pulmonary embolism, and structural morphology.)

The use of electron beam CT or helical CT to detect coronary artery calcification is addressed in a separate policy, Radiology 6, Computed Tomography to Detect Coronary Artery Calcification.

1. Anomalous Coronary Artery Mapping

   Contrast-enhanced computed tomographic angiography (CTA) for evaluation of congenital anomalous (native) coronary arteries in symptomatic patients may be considered medically necessary.

2. Evaluation of Coronary Artery Disease and all other indications

Contrast-enhanced computed tomographic angiography (CTA) of the coronary arteries is considered investigational for all other indications, including but not limited to the diagnosis and screening of coronary artery disease (CAD) including but not limited to:

1. Evaluation of chest pain in any setting, including but not limited to the emergency room or other hospital setting
2. Diagnosis of CAD in coronary artery bypass grafts
3. Diagnosis of CAD after percutaneous stent placement
4. Delineation of coronary artery anatomy prior to a cardiovascular procedure
5. Monitoring plaque density to evaluate treatment effect

POSITION STATEMENT ^[1]

• Contrast-enhanced computed tomographic angiography (CTA) appears to effectively determine the origin and course of coronary arteries in cases when conventional angiography is unsuccessful.
• It is uncertain if CTA can reliably diagnose the presence or severity of coronary artery disease (CAD) in patients with acute or chronic chest pain in any setting (eg, emergency department, hospital, clinic).
• Evidence is insufficient to determine whether a CTA diagnostic strategy provides greater benefits and/or lesser harms than comparative approaches for the evaluation of CAD.
• Currently, the “gold standard” for evaluating the presence and severity of CAD is invasive coronary angiography.  Other tests used to diagnose CAD in low to intermediate risk patients include the exercise treadmill test (ETT), the nuclear stress test, and stress echocardiography. How CTA should be used in the context of these other diagnostic protocols has not been well defined.
• In patients who are found to need invasive treatment, an intervention can be done efficiently at the time of angiography, thus avoiding the need for both CTA and angiography.  High risk patients are more likely to require intervention, but which high risk patient has not been well established.

Effectiveness

Mapping congenital anomalous coronary arteries

Several studies have shown that CTA may be able to map the origin and direction of anomalous arteries when conventional angiography cannot. ^[2-6] Anomalous coronary arteries are an uncommon finding at angiography, occurring in approximately 1% of coronary angiograms completed for evaluation of chest pain. Given the incidence and severity of this rare condition, the present level of evidence is sufficient to support the use of CTA for the presurgical mapping of anomalous coronary arteries when conventional angiography is unsuccessful or equivocal.

Validity of CTA for the Diagnosis or Screening of CAD

The majority of studies examining sensitivity, specificity, and positive and negative predictive values of CTA have significant limitations that do not allow conclusions to be made about the effectiveness of this test for evaluation of CAD in symptomatic or asymptomatic patients. ^[6-42] Limitations include one or more of the following:

• Inadequate Study Power  

Studies were not adequately powered to prove equivalence between CTA and conventional angiography. Sample sizes were not determined in advance.

• Potential Bias
  
  

  CTA for diagnosis of CAD has largely been evaluated in preselected, high risk patients who were scheduled for angiography.  The ability of CTA to diagnose and prevent angiography in patients with a low to intermediate risk, for which CTA use is proposed, is still unknown. Safety and efficacy for the low to intermediate risk population may be different than for those patients already scheduled for angiography.
  
  Subjects of some studies were convenience samples, limited to patients who agreed to be in the study, subjects scheduled for elective surgery, or availability of the research staff. These patient selection methods do not address selection bias.
  
  Diagnostic performance was analyzed and reported per vessel or per segment rather than per patient in some studies. While vessel or segment-based analyses might be useful in determining treatment decisions about single vessels, decisions about whether to undergo invasive angiography are not made on a vessel-by-vessel basis, but based on all cardiac vessels in the patient as a whole.
  
  Reporting was limited to evaluable coronary artery segments only, with up to 12% of these segments being excluded from analysis. In patients with bypass grafts or stents, evaluation was unreliable or impossible in 13-26% of the segments due to vascular clips or calcification artifacts.   Exclusion of these segments from analysis could confound sensitivity and specificity results. For example, in a meta-analysis in which patients from 14 studies were pooled, sensitivity and specificity fell from 90% and 91% to 79% and 81%, respectively when nonassessable segments were included in the analysis. ^[37]  

Results for the technical validity of CTA, including the sensitivity, specificity, and positive and negative predictive values are inconsistent between studies ranging from a sensitivity of 86% to 100% and a specificity of 49% to 100%.

In patients with in-stent restenosis, measurements of diameter were smaller on MDCT by 16% to 27% compared with conventional angiography. It is not known how this difference might influence clinical management of the patient.

Clinical Utility Of CTA for the Diagnosis and Treatment of CAD

The clinical utility of CTA depends on how the results of the study can be used to benefit patient management.  The available evidence has not demonstrated that CTA can improve patient outcomes to a greater extent than currently available tests for the following reasons:

There is only one randomized controlled clinical trial that addresses the use of CTA in a clinical setting. This trial evaluated the ability CTA compared to standard nuclear stress testing to assess the severity and extent of coronary stenosis in symptomatic patients treated in the emergency room. ^[43] This study had significant flaws and failed to demonstrate that CTA was superior to nuclear stress testing for the following reasons:

• There was no clearly defined primary end point stated in advance
•  Although the study authors concluded the interventions were equivalent, the study was not sufficiently powered to support this conclusion.
• 94.7% of patients evaluated with nuclear stress testing were able to be discharged to home compared to only 67% of subjects who were discharged directly home due to CTA findings alone. 
• For intermediate stenosis or for non-diagnostic CTA, a stress test was performed in addition to CTA, resulting in a second radiation exposure in 24% of the MSCT arm.
• 4% of the MSCT arm required a third radiation exposure.

Other studies evaluating the clinical utility of this test include non-randomized case series with the following limitations: ^[44-51]

• Within the emergency department, the accuracy of the diagnosis was not dependent on CTA.  Final diagnosis and treatment planning were dependent on the combination of clinical data, radionuclide testing, coronary angiography, and stress echocardiography.
• No alternative strategy for making a diagnosis was specifically defined.
• Within the setting of bypass graft assessment, no information is provided about patient symptoms or how the evidence of graft occlusion affected patient management.
• One large case series reported CTA decreased the rate of normal conventional cardiac angiography by 4.7% during a two-year period which was statistically significant, but of modest magnitude. In the same setting, accuracy achieved was less than desirable with a false-negative rate of 10%. ^[52]

In summary, larger studies are needed to evaluate low- to intermediate- risk patients and to compare how clinical management of these patients is impacted with the use of CTA.

Clinical Utility of CTA for Monitoring Response to Treatment or Lifestyle Changes

Current evidence is insufficient to establish clinical utility for the use of CTA in monitoring the effects of treatment and lifestyle changes in patients with or at risk of developing CAD.  CTA has been used in some studies as a tool to measure both plaque density and lumen size. There are currently no studies comparing health outcomes following treatment planning with versus without plaque density monitoring.

Safety

There are significant safety considerations with use of CTA for the evaluation of coronary arteries including the following:

• CTA has as much as 2-3 times the level of radiation exposure compared to conventional angiography; improved technology is decreasing this radiation exposure. Projected lifetime cancer risks from radiation exposure with CTA vary, and appear to be higher for younger patients and for women. Prospective outcomes data is lacking.  
• False positive or false negative results may lead to unnecessary treatments or conversely, to inaction when treatment is warranted
• The presence of dense arterial calcifications or an intracoronary stent can interfere with imaging quality and lead to the need for repeat testing
• The benefits and harms of evaluation of frequent (up to 68%) incidental findings are not known. ^[53-61]
• The use of beta blockers, required for MSCT to slow the heart rate, may present a risk under certain clinical situations.
• The use of high contrast medium may impair renal function under certain clinical situations.

Updated appropriateness criteria have recently been published for both CTA and cardiac magnetic resonance imaging (CMRI). ^[62] These criteria were developed using a consensus process that compared the expected benefit of the test with the expected negative consequences. Although a number of scenarios were judged as appropriate for use of CTA in evaluating coronary arteries, an evidence-based review process was not required to make decisions about expected benefits or harms.

REFERENCES

1. BlueCross BlueShield Association Medical Policy Reference Manual "Contrast-Enhanced Computed Tomography Angiography (CTA) for Coronary Artery Evaluation." Policy No. 6.01.43
2. Berbarie RF, Dockery WD, Johnson KB, Rosenthal RL, Stoler RC, Schussler JM. Use of multislice computed tomographic coronary angiography for the diagnosis of anomalous coronary arteries. Am J Cardiol. 2006 Aug 1;98(3):402-6.  PMID: 16860032
3. Datta J, White CS, Gilkeson RC, et al. Anomalous coronary arteries in adults: depiction at multi-detector row CT angiography. Radiology. 2005 Jun;235(3):812-8.  PMID: 15833984
4. Schmitt R, Froehner S, Brunn J, et al. Congenital anomalies of the coronary arteries: imaging with contrast-enhanced, multidetector computed tomography. Eur Radiol. 2005 Jun;15(6):1110-21.  PMID: 15756551
5. Memisoglu E, Hobikoglu G, Tepe MS, Norgaz T, Bilsel T. Congenital coronary anomalies in adults: comparison of anatomic course visualization by catheter angiography and electron beam CT. Catheter Cardiovasc Interv. 2005 Sep;66(1):34-42.  PMID: 16097013
6. TEC Assessment 2005. "Contrast-enhanced cardiac computed tomography angiography for coronary artery evaluation." BlueCross BlueShield Association Technology Evaluation Center, Vol. 20, Tab 4.
7. TEC Assessment 2006. "Contrast-Enhanced Cardiac Computed Tomographic Angiography in the Diagnosis of Coronary Artery Stenosis or for Evaluation of Acute Chest Pain." BlueCross BlueShield Association Technology Evaluation Center, Vol. 21, Tab 5.
8. Lim MC, Wong TW, Yaneza LO, De Larrazabal C, Lau JK, Boey HK. Non-invasive detection of significant coronary artery disease with multi-section computed tomography angiography in patients with suspected coronary artery disease. Clin Radiol. 2006 Feb;61(2):174-80.  PMID: 16439223
9. Leber AW, Knez A, von Ziegler F, et al. Quantification of obstructive and nonobstructive coronary lesions by 64-slice computed tomography: a comparative study with quantitative coronary angiography and intravascular ultrasound. J Am Coll Cardiol. 2005 Jul 5;46(1):147-54.  PMID: 15992649
10. Pugliese F, Mollet NR, Runza G, et al. Diagnostic accuracy of non-invasive 64-slice CT coronary angiography in patients with stable angina pectoris. Eur Radiol. 2006 Mar;16(3):575-82.  PMID: 16292649
11. Leschka S, Alkadhi H, Plass A, et al. Accuracy of MSCT coronary angiography with 64-slice technology: first experience. Eur Heart J. 2005 Aug;26(15):1482-7.  PMID: 15840624
12. Mollet NR, Cademartiri F, Krestin GP, et al. Improved diagnostic accuracy with 16-row multi-slice computed tomography coronary angiography. J Am Coll Cardiol. 2005 Jan 4;45(1):128-32.  PMID: 15629386
13. Raff GL, Gallagher MJ, O'Neill WW, Goldstein JA. Diagnostic accuracy of noninvasive coronary angiography using 64-slice spiral computed tomography. J Am Coll Cardiol. 2005 Aug 2;46(3):552-7.  PMID: 16053973
14. Ropers D, Rixe J, Anders K, et al. Usefulness of multidetector row spiral computed tomography with 64- x 0.6-mm collimation and 330-ms rotation for the noninvasive detection of significant coronary artery stenoses. Am J Cardiol. 2006 Feb 1;97(3):343-8.  PMID: 16442393
15. Garcia MJ, Lessick J, Hoffmann MH. Accuracy of 16-row multidetector computed tomography for the assessment of coronary artery stenosis. JAMA. 2006 Jul 26;296(4):403-11.  PMID: 16868298
16. Hamon M, Biondi-Zoccai GG, Malagutti P, Agostoni P, Morello R, Valgimigli M. Diagnostic performance of multislice spiral computed tomography of coronary arteries as compared with conventional invasive coronary angiography: a meta-analysis. J Am Coll Cardiol. 2006 Nov 7;48(9):1896-910.  PMID: 17084268
17. Scheffel H, Alkadhi H, Plass A, et al. Accuracy of dual-source CT coronary angiography: First experience in a high pre-test probability population without heart rate control. Eur Radiol. 2006 Dec;16(12):2739-47.  PMID: 17031451
18. Hamon M, Morello R, Riddell JW. Coronary arteries: diagnostic performance of 16- versus 64-section spiral CT compared with invasive coronary angiography--meta-analysis. Radiology. 2007 Dec;245(3):720-31.  PMID: 17951354
19. Vanhoenacker PK, Heijenbrok-Kal MH, Van Heste R, et al. Diagnostic performance of multidetector CT angiography for assessment of coronary artery disease: meta-analysis. Radiology. 2007 Aug;244(2):419-28.  PMID: 17641365
20. Sun Z, Jiang W. Diagnostic value of multislice computed tomography angiography in coronary artery disease: a meta-analysis. Eur J Radiol. 2006 Nov;60(2):279-86.  PMID: 16887313
21. Jones CM, Athanasiou T, Dunne N, et al. Multi-detector computed tomography in coronary artery bypass graft assessment: a meta-analysis. Ann Thorac Surg. 2007 Jan;83(1):341-8.  PMID: 17184705
22. Jabara R, Chronos N, Klein L, et al. Comparison of multidetector 64-slice computed tomographic angiography to coronary angiography to assess the patency of coronary artery bypass grafts. Am J Cardiol. 2007 Jun 1;99(11):1529-34.  PMID: 17531575
23. Hong C, Chrysant GS, Woodard PK, Bae KT. Coronary artery stent patency assessed with in-stent contrast enhancement measured at multi-detector row CT angiography: initial experience. Radiology. 2004 Oct;233(1):286-91.  PMID: 15304660
24. Lu B, Dai R, Bai H, et al. Detection and analysis of intracoronary artery stent after PTCA using contrast-enhanced three-dimensional electron beam tomography. J Invasive Cardiol. 2000 Jan;12(1):1-6.  PMID: 10731255
25. Hamon M, Champ-Rigot L, Morello R, Riddell JW. Diagnostic accuracy of in-stent coronary restenosis detection with multislice spiral computed tomography: a meta-analysis. Eur Radiol. 2008 Feb;18(2):217-25.  PMID: 17763854
26. Carbone I, Francone M, Algeri E, et al. Non-invasive evaluation of coronary artery stent patency with retrospectively ECG-gated 64-slice CT angiography. Eur Radiol. 2008 Feb;18(2):234-43.  PMID: 17929024
27. Maintz D, Grude M, Fallenberg EM, Heindel W, Fischbach R. Assessment of coronary arterial stents by multislice-CT angiography. Acta Radiol. 2003 Nov;44(6):597-603.  PMID: 14616203
28. Kwon BJ, Jung C, Sheen SH, Cho JH, Han MH. CT angiography of stented carotid arteries: comparison with Doppler ultrasonography. J Endovasc Ther. 2007 Aug;14(4):489-97.  PMID: 17696623
29. Das KM, El-Menyar AA, Salam AM, et al. Contrast-enhanced 64-section coronary multidetector CT angiography versus conventional coronary angiography for stent assessment. Radiology. 2007 Nov;245(2):424-32.  PMID: 17890354
30. Muhlenbruch G, Mahnken AH, Das M, et al. Evaluation of aortocoronary bypass stents with cardiac MDCT compared with conventional catheter angiography. AJR Am J Roentgenol. 2007 Feb;188(2):361-9.  PMID: 17242243
31. Gerber TC, Sheedy PF, Bell MR, et al. Evaluation of the coronary venous system using electron beam computed tomography. Int J Cardiovasc Imaging. 2001 Feb;17(1):65-75.  PMID: 11495511
32. Scheffel H, Leschka S, Plass A, et al. Accuracy of 64-slice computed tomography for the preoperative detection of coronary artery disease in patients with chronic aortic regurgitation. Am J Cardiol. 2007 Aug 15;100(4):701-6.  PMID: 17697832
33. Meijboom WB, Mollet NR, Van Mieghem CA, et al. Pre-operative computed tomography coronary angiography to detect significant coronary artery disease in patients referred for cardiac valve surgery. J Am Coll Cardiol. 2006 Oct 17;48(8):1658-65.  PMID: 17045904
34. Budoff MJ, Dowe D, Jollis JG, et al. Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial. J Am Coll Cardiol. 2008 Nov 18;52(21):1724-32.  PMID: 19007693
35. Miller JM, Rochitte CE, Dewey M, et al. Diagnostic performance of coronary angiography by 64-row CT. N Engl J Med. 2008 Nov 27;359(22):2324-36.  PMID: 19038879
36. Meijboom WB, Meijs MF, Schuijf JD, et al. Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study. J Am Coll Cardiol. 2008 Dec 16;52(25):2135-44.  PMID: 19095130
37. Sun Z, Almutairi AM. Diagnostic accuracy of 64 multislice CT angiography in the assessment of coronary in-stent restenosis: a meta-analysis. Eur J Radiol. 2010 Feb;73(2):266-73.  PMID: 19056191
38. Sun Z, Davidson R, Lin CH. Multi-detector row CT angiography in the assessment of coronary in-stent restenosis: a systematic review. Eur J Radiol. 2009 Mar;69(3):489-95.  PMID: 18162351
39. Marano R, De Cobelli F, Floriani I, et al. Italian multicenter, prospective study to evaluate the negative predictive value of 16- and 64-slice MDCT imaging in patients scheduled for coronary angiography (NIMISCAD-Non Invasive Multicenter Italian Study for Coronary Artery Disease). Eur Radiol. 2009 May;19(5):1114-23.  PMID: 19089430
40. Fazel P, Peterman MA, Schussler JM. Three-year outcomes and cost analysis in patients receiving 64-slice computed tomographic coronary angiography for chest pain. Am J Cardiol. 2009 Aug 15;104(4):498-500.  PMID: 19660601
41. Hoffmann U, Bamberg F, Chae CU, et al. Coronary computed tomography angiography for early triage of patients with acute chest pain: the ROMICAT (Rule Out Myocardial Infarction using Computer Assisted Tomography) trial. J Am Coll Cardiol. 2009 May 5;53(18):1642-50.  PMID: 19406338
42. Weustink AC, Mollet NR, Neefjes LA, et al. Diagnostic accuracy and clinical utility of noninvasive testing for coronary artery disease. Ann Intern Med. 2010 May 18;152(10):630-9.  PMID: 20479028
43. Goldstein JA, Gallagher MJ, O'Neill WW, Ross MA, O'Neil BJ, Raff GL. A randomized controlled trial of multi-slice coronary computed tomography for evaluation of acute chest pain. J Am Coll Cardiol. 2007 Feb 27;49(8):863-71.  PMID: 17320744
44. Sato Y, Matsumoto N, Ichikawa M, et al. Efficacy of multislice computed tomography for the detection of acute coronary syndrome in the emergency department. Circ J. 2005 Sep;69(9):1047-51.  PMID: 16127184
45. White CS, Kuo D, Kelemen M, et al. Chest pain evaluation in the emergency department: can MDCT provide a comprehensive evaluation? AJR Am J Roentgenol. 2005 Aug;185(2):533-40.  PMID: 16037533
46. Hollander JE, Litt HI, Chase M, Brown AM, Kim W, Baxt WG. Computed tomography coronary angiography for rapid disposition of low-risk emergency department patients with chest pain syndromes. Acad Emerg Med. 2007 Feb;14(2):112-6.  PMID: 17267528
47. Gallagher MJ, Ross MA, Raff GL, Goldstein JA, O'Neill WW, O'Neil B. The diagnostic accuracy of 64-slice computed tomography coronary angiography compared with stress nuclear imaging in emergency department low-risk chest pain patients. Ann Emerg Med. 2007 Feb;49(2):125-36.  PMID: 16978738
48. Rubinshtein R, Halon DA, Gaspar T, et al. Impact of 64-slice cardiac computed tomographic angiography on clinical decision-making in emergency department patients with chest pain of possible myocardial ischemic origin. Am J Cardiol. 2007 Nov 15;100(10):1522-6.  PMID: 17996512
49. Schlosser T, Konorza T, Hunold P, Kuhl H, Schmermund A, Barkhausen J. Noninvasive visualization of coronary artery bypass grafts using 16-detector row computed tomography. J Am Coll Cardiol. 2004 Sep 15;44(6):1224-9.  PMID: 15364323
50. Anand DV, Lim E, Lipkin D, Lahiri A. Evaluation of graft patency by computed tomographic angiography in symptom-free post-coronary artery bypass surgery patients. J Nucl Cardiol. 2008 Mar-Apr;15(2):201-8.  PMID: 18371591
51. von Kiedrowski H, Wiemer M, Franzke K, et al. Non-invasive coronary angiography: the clinical value of multi-slice computed tomography in the assessment of patients with prior coronary bypass surgery. Evaluating grafts and native vessels. Int J Cardiovasc Imaging. 2009 Feb;25(2):161-70.  PMID: 18759133
52. Matsumoto N, Sato Y, Yoda S, et al. Prognostic value of non-obstructive CT low-dense coronary artery plaques detected by multislice computed tomography. Circ J. 2007 Dec;71(12):1898-903.  PMID: 18037743
53. Aglan I, Jodocy D, Hiehs S, et al. Clinical relevance and scope of accidental extracoronary findings in coronary computed tomography angiography: a cardiac versus thoracic FOV study. Eur J Radiol. 2010 Apr;74(1):166-74.  PMID: 19268514
54. Kirsch J, Araoz PA, Steinberg FB, Fletcher JG, McCollough CH, Williamson EE. Prevalence and significance of incidental extracardiac findings at 64-multidetector coronary CTA. J Thorac Imaging. 2007 Nov;22(4):330-4.  PMID: 18043387
55. Koonce J, Schoepf JU, Nguyen SA, Northam MC, Ravenel JG. Extra-cardiac findings at cardiac CT: experience with 1,764 patients. Eur Radiol. 2009 Mar;19(3):570-6.  PMID: 18925400
56. Kawano Y, Tamura A, Goto Y, Shinozaki K, Zaizen H, Kadota J. Incidental detection of cancers and other non-cardiac abnormalities on coronary multislice computed tomography. Am J Cardiol. 2007 Jun 1;99(11):1608-9.  PMID: 17531590
57. Husmann L, Tatsugami F, Aepli U, et al. Prevalence of noncardiac findings on low dose 64-slice computed tomography used for attenuation correction in myocardial perfusion imaging with SPECT. Int J Cardiovasc Imaging. 2009 Dec;25(8):859-65.  PMID: 19662511
58. Lazoura O, Vassiou K, Kanavou T, Vlychou M, Arvanitis DL, Fezoulidis IV. Incidental non-cardiac findings of a coronary angiography with a 128-slice multi-detector CT scanner: should we only concentrate on the heart? Korean J Radiol. 2010 Jan-Feb;11(1):60-8.  PMID: 20046496
59. Machaalany J, Yam Y, Ruddy TD, et al. Potential clinical and economic consequences of noncardiac incidental findings on cardiac computed tomography. J Am Coll Cardiol. 2009 Oct 13;54(16):1533-41.  PMID: 19815125
60. Lehman SJ, Abbara S, Cury RC, et al. Significance of cardiac computed tomography incidental findings in acute chest pain. Am J Med. 2009 Jun;122(6):543-9.  PMID: 19486717
61. Johnson KM, Dennis JM, Dowe DA. Extracardiac findings on coronary CT angiograms: Limited versus complete image review. AJR Am J Roentgenol. 2010 Jul;195(1):143-8.  PMID: 20566808
62. Taylor AJ, Cerqueira M, Hodgson JM, et al. ACCF/SCCT/ACR/AHA/ASE/ ASNC/NASCI/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol. 2010 Nov 23;56(22):1864-94.  PMID: 21087721

CROSS REFERENCES

Computed Tomography to Detect Coronary Artery Calcification, Regence Medical Policy Manual, Radiology, Policy No. 6

Ultrasonographic Measurement of Carotid and Femoral Artery Intima-Media Thickness as an Assessment of Atherosclerosis, Regence Medical Policy Manual, Radiology, Policy No. 37

Radiology Section Table of Contents