Journal of the American College of Cardiology Vol. 48, No.

10, 2006
© 2006 by the American College of Cardiology Foundation ISSN 0735-1097/06/$32.00
Published by Elsevier Inc. doi:10.1016/j.jacc.2006.08.012

FOCUS ISSUE: CARDIAC IMAGING State-of-the-Art Paper

CLINICAL RESEARCH Non-Invasive Coronary Angiography

Computed Tomography Coronary Angiography

Stephan Achenbach, MD, FESC, FACC
Erlangen, Germany
Recent developments in computed tomography technology have made imaging of the
coronary arteries possible. All the same, the rapid motion and small dimensions of the
coronary vessels make coronary computed tomography angiography (coronary CTA) chal-
lenging. With the last generations of 16- and 64-slice computed tomography and adequate
patient preparation (which includes lowering of the heart rate), rates of sensitivity ranging
from 83% to 99% and specificity between 93% and 98% have been reported for the detection
of coronary artery stenoses in comparison with invasive coronary angiography. The high
negative predictive value (95% to 100%) found in these studies suggests that coronary CTA
may be a useful diagnostic technique to rule out the presence of coronary stenoses in selected
patients, especially those with a rather low pretest likelihood of disease. Imaging of coronary
artery bypass grafts is reliable, but clinical applications can be hampered by difficulties in
assessing the native coronary arteries in patients after undergoing bypass because of their
often-severe calcification. The detection of in-stent restenosis is made difficult by artifacts
caused by metal, especially in smaller stents. Finally, initial reports that coronary CTA
allows the detection and, to a certain extent, also the characterization and quantification
of noncalcified coronary arteriosclerotic plaque are interesting, but they currently do not
provide sufficient data to support clinical applications in the context of risk
stratification. (J Am Coll Cardiol 2006;48:1919 –28) © 2006 by the American College
of Cardiology Foundation

Computed tomography (CT) techniques have in the past
years been demonstrated to allow the visualization of coro-
nary arteries and especially of the coronary lumen. The small
dimensions of the coronary arteries, along with their rapid
motion, make imaging very challenging, and the temporal
and spatial resolution of CT had to be maximized to allow
the use of coronary CT angiography (coronary CTA).
Technical developments during the past several years—
especially the introduction of 64-slice CT scanners—and
growing experience concerning strategies for optimization
of image quality have made coronary CTA quite reliable for
some patient subgroups. However, coronary CTA is a new
imaging modality and remains a technically challenging one.
Various issues concerning scanner technology, image acqui-
sition and reconstruction, image interpretation, and poten-
tial clinical applications need to be carefully considered and,
in many fields, there are rapidly ongoing developments.
TECHNOLOGY OF CARDIAC CT
High temporal and spatial resolution are prerequisites for
imaging of the coronary arteries. Conventional CT, because of
the necessity of moving a heavy gantry with an X-ray tube and
a detector system around the patient, traditionally has been a
slow imaging modality. This encumbrance began to change
From the Department of Cardiology, University of Erlangen–Nürnberg, Erlangen,
Germany. Dr. Achenbach has received research grants and speaker honoraria from
Siemens Medical Systems and Bracco.
Manuscript received April 28, 2006; revised manuscript received June 2, 2006,
accepted June 6, 2006.
when 4-slice spiral (or “helical”) CT systems were introduced
around the year 2000. These systems provided a gantry
rotation time of approximately 0.5 s, and with dedicated image
reconstruction algorithms that required only data collected
during one-half rotation to reconstruct one image (1), a
temporal resolution of approximately 250 ms could be
achieved. In addition, simultaneous registration of the patient’s
electrocardiogram (ECG) permitted one to synchronize image
reconstruction with the cardiac phase. In this way, contiguous
cross-sectional images of the heart could be obtained, which all
showed the heart in the same cardiac phase. Initial reports on
visualization of the coronary artery lumen by 4-slice CT after
intravenous injection of contrast agent were published in the
year 2000 (2,3). All the same, because of the still relatively
limited temporal and spatial resolution as well as the long
duration of the required breath hold (as long as 40 s), the
datasets frequently were of insufficient quality for interpretation
(with approximately 30% of arteries classified as “unevaluable”)
(4,5), which prevented clinical applications.
However, the initial success in visualizing the coronary
arteries had triggered substantial interest in coronary
CTA, and rapid improvements in CT technology ensued,
aimed at permitting more reliable and accurate coronary
artery imaging. The gantry rotation speed was increased
to improve temporal resolution, slice collimation (thick-
ness) was decreased to improve spatial resolution, X-ray
tubes were strengthened to reduce image noise, and
scanners allowed to acquire data in more and more slices
simultaneously—from 4 to 8, 16, 32, 40, and 64 slices per
1920 Achenbach JACC Vol. 48, No. 10, 2006
Coronary CTA November 21, 2006:1919–28

Interestingly, recent publications show that industry is

Abbreviations and Acronyms
CT ⫽ computed tomography
CTA ⫽ computed tomography angiography
rotation (6 –28). Increasing the number of slices allows
one to cover a larger volume per rotation. It thus
decreases the overall duration of data acquisition and,
consequently, the duration of the breath hold and the
necessary amount of contrast agent. Currently, 64-slice
scanners with a gantry rotation times of 420 ms or shorter
can be considered “state-of-the-art” equipment for the visu-
alization of coronary arteries by CT.
However, it is important to note that the number of slices
alone is not the one and only parameter that will influence
image quality for coronary imaging. As mentioned previ-
ously, rotation speed, slice collimation, and tube output
determine the temporal and spatial resolution and the mere
number of slices only influences the overall duration of data
acquisition. With current 64-slice scanners, the necessary
breath hold is between 6 and 12 s and, thus, easy to perform.
Simply adding a few more slices to existing scanner designs
will therefore not lead to major improvements in the future.
pursuing different concepts for the further development of
cardiac CT. One approach is to increase the volume
coverage (number of slices) so dramatically that imaging of
the heart is possible in a single heart beat, which will make
cardiac imaging less vulnerable to arrhythmias. Such sys-
tems will typically have 256 slices of approximately 0.5-mm
collimation, and first results have been published (29,30).
Spatial and temporal resolution remain unchanged. Another
approach is to leave the number of slices at 64 but to combine
2 X-ray tubes and detectors in a single gantry, arranged at an
angle of 90°. With this approach (dual-source CT), only a
one-quarter rotation of the gantry is necessary to collect data
from 180° of projections; temporal resolution is therefore twice
as high as with a single X-ray tube and detector. It is expected
that this will substantially reduce problems caused by motion
artifact in clinical applications (31,32).
Data acquisition for coronary CTA. Most experienced
centers prepare patients for a coronary CTA study by lowering
the heart rate to ⬍65 or even ⬍60 beats/min— usually by
administering oral or intravenous beta-blockers. Also, it is
recommended to administer sublingual nitrates immediately
before scanning to dilate the coronary arteries which, in my
experience, substantially improves image quality.

Figure 1. Typical dataset as acquired by coronary computed tomography angiography (CTA) after intravenous injection of contrast agent (here: dual-source
CT with a temporal resolution of 83 ms). (A) Transaxial image (0.75-mm reconstructed slice thickness) at the level of the proximal left anterior descending
coronary artery. Cross sections of the proximal left anterior descending coronary artery (arrow) and left circumflex coronary artery (arrowhead) are visible.
(B) Transaxial image at the level of the right coronary artery ostium. Smaller arrow: right coronary artery; larger arrow: left anterior descending coronary
artery; arrowhead: left circumflex coronary artery. (C) Transaxial image at the midventricular level. Smaller arrow: right coronary artery; larger arrow: left
anterior descending coronary artery; arrowhead: left circumflex coronary artery. (D) Maximum intensity projections (here: 5-mm thickness in axial
orientation) can be used to visualize longer segments of the coronary arteries and the relationship of main and side branches. Here, the left main and
proximal left anterior descending (arrow) as well as left circumflex coronary artery (arrowhead) are displayed. (E) Another maximum intensity projection
(8-mm thickness) in a double-oblique plane that parallels the right interventricular groove is used to display the entire course of the right coronary artery
(arrows). (F) Curved multiplanar reconstruction (0.75-mm thickness) was used to visualize the right coronary artery (arrows). (G) Three-dimensional
display of the heart and coronary arteries. Smaller arrow: right coronary artery; larger arrow: left anterior descending coronary artery; arrowhead: left
circumflex coronary artery.
JACC Vol. 48, No. 10, 2006 Achenbach 1921
November 21, 2006:1919–28 Coronary CTA

Although details of data acquisition will vary depending on

scanner type, acquisition of a high-resolution “volume dataset”
that covers the entire heart constitutes the core of the scan
protocol. For this acquisition, between 50 to 120 ml of contrast
agent are injected intravenously and the patient needs to
perform a breath hold of 6 to 20 s (depending on the
scanner generation and dimensions of the heart). The
radiation exposure (effective dose) is estimated to be be-
tween 3 and 15 mSv, depending on the scan protocol
(33–36). Electrocardiogram-correlated tube current modu-
lation (reduction of tube current in systole) can reduce
radiation exposure by 30% to 50% (36 –38).
As mentioned previously, data acquired in projections of
approximately 180° are necessary to reconstruct a cross-
sectional image. These data can be obtained during one single
180° sweep of the CT gantry (and the temporal resolution
would then correspond to one-half the rotation time). In this
case, all the data used to reconstruct one image would stem
from the same heart beat. An alternative is to piece together
the 180° of data from several consecutive heart beats. The time
window of data used out of each cardiac cycle for image
reconstruction will then be shorter than one-half rotation of
the gantry (ideally, for example, it would correspond to
one-eighth rotation if data from four consecutive heart beats
were used). However, the effectiveness of these so-called
“multiphase” reconstruction algorithms depends on the rela-
tionship between heart rate, rotation time, and the speed with
which the patient table is advanced into the scanner (“pitch”),
and this relationship is not linear—the algorithms are more
effective for some heart rates than for others. Also, it is
important to note that the obtained images constitute an
average of several heart beats, which may reduce sharpness. Figure 2. Systolic (A) and diastolic (B) reconstruction of a “short axis”
The dataset obtained by coronary CTA will typically consist reformat to analyze left ventricular function. Such information can be
obtained as a byproduct of coronary computed tomography angiography
of approximately 250 to 350 transaxial cross-sectional images from the same dataset using largely automated processing tools.
(Fig. 1). Slice thickness usually is chosen to be between 0.5 and
1.0 mm, and images will be spaced at a distance less than their vessels. The right coronary artery, which displays the most
thickness so that consecutive images have some overlap. The rapid motion during the cardiac cycle, is most frequently
images are in most cases transferred to off-line workstations for affected. Severe calcifications of the coronary arteries may
further processing and evaluation. Two-dimensional forms of obscure the coronary artery lumen because of partial volume
image reconstruction, such as “multiplanar reconstructions” or effects. The high contrast also may aggravate the effect of
“maximum intensity projections,” can facilitate data interpre- motion artifacts, and calcification can therefore lead to false-
tation. Three-dimensional reconstructions are visually pleasing negative and false-positive findings of coronary stenoses (Fig.
but rarely helpful to evaluate the data (Fig. 1). Importantly, 3). It has been shown in several studies that the accuracy for
image data can be reconstructed at any desired time instant in detection of coronary stenoses is lower in the presence of severe
the cardiac cycle. Reconstruction of several data sets through- calcification (14,28,41,42). More importantly, it has been
out the cardiac cycle thus permits for dynamic visualization of convincingly shown that heart rate is predictive of image
cardiac function (Fig. 2). Analysis of left ventricular wall quality and that a low heart rate substantially improves image
motion can be obtained as a “byproduct” of coronary CTA and quality, rate of evaluable arteries, and accuracy for stenosis
has been shown to provide accurate assessment of global and detection (42– 47).
regional left ventricular function (39,40).
Image quality and artifacts. A regular heart rate is necessary
DETECTION OF CORONARY ARTERY STENOSES
for reliable imaging of the coronary arteries by computed
tomography. Furthermore, the limited temporal and spatial In experienced hands, a high sensitivity and specificity for
resolution of CT can lead to artifacts that may make the images the detection of hemodynamically relevant coronary artery
difficult or, in some situations, even impossible to evaluate. stenoses can be achieved by recent generations of 16-slice
Motion can lead to blurring of the contours of the coronary and 64-slice CT (Fig. 4). Table 1 lists the results of recent
1922 Achenbach JACC Vol. 48, No. 10, 2006
Coronary CTA November 21, 2006:1919–28

Figure 3. Artifacts typically encountered in computed tomography coronary angiography. (A) An obvious motion artifact is present at the level of the
mid-right coronary artery. A round cross section of the right coronary artery would be expected. Because of motion, the contour of the right coronary artery
is blurred (larger arrows). In addition, on both sides of a small side branch, areas of very low computed tomography attenuation can be noted (smaller
arrows). These artifacts also are caused by motion and typically are found adjacent to high-contrast structures (e.g., contrast-enhanced coronary arteries).
(B) Severe coronary calcification in the proximal left anterior descending coronary artery (arrows). Calcifications of this extent can in some cases render the
datasets unevaluable concerning the presence of coronary artery stenoses. (C) In some cases, the occurrence of a motion artifact is more subtle. The figure
displays transaxial images at the level of the mid-right coronary artery, just distal to the ostium of a right ventricular side branch (arrowhead). On the left,
the image was reconstructed at 70% of the cardiac cycle. A slight motion artifact is present (smaller arrow), which blurs the contour of a calcified plaque
in the arterial wall (larger arrow) and also causes a low-density structure, which might be mistaken for noncalcified plaque components. On the right, the
same image was reconstructed at 65% of the cardiac cycle. No motion artifact is present. The plaque is practically entirely calcified.

publications that analyzed the accuracy of stenosis detection
in consecutive patients referred for diagnostic coronary
angiography, using scanners with at least 16 slices. Most
studies comprised between 50 and 100 individuals, and the
patients were somewhat preselected (e.g., exclusion of all
patients with renal failure or arrhythmias, in many studies
exclusion of patients with previous known coronary artery
disease, exclusion of unstable patients, and selection bias
because patients had been referred for a clinically indicated
invasive coronary angiogram). Also, analysis usually was
limited to coronary segments of a diameter ⬎1.5 to 2.0 mm.
All the same, the studies show that at experienced sites and
with careful data acquisition and evaluation, sensitivities
ranging from 83% to 99% and specificities ranging from
93% to 98% can be achieved for the detection of hemody-
namically relevant stenoses. The rate of unevaluable coro-
nary artery segments was low (between 0% and 12%).
Remarkably, a very high negative predictive value (95% to
100%) was uniformly found. Although this result may partly
be secondary to the relatively low prevalence of coronary
stenoses in most studies, it indicates that in such patient
groups, modern CT scanners with adequate image acquisi-
tion protocols may be used to reliably rule out the presence
of significant coronary artery stenoses.
Clearly, coronary CTA has limitations and should not be
expected to widely replace invasive, catheter-based diagnos-
tic cardiac catheterization in the foreseeable future. Spatial
resolution limits the ability of CTA to provide exact,
quantitative measures of stenosis severity. In addition to
limitations caused by calcium and rapid coronary motion,
patients in atrial fibrillation or with other arrhythmias as
well as patients with contraindications to iodinated contrast
agent cannot be studied. As a purely anatomical imaging
modality, the hemodynamic consequence of coronary artery
stenoses cannot be assessed. Coronary CTA is furthermore
a purely diagnostic tool. As opposed to invasive coronary
angiography, there is no option for immediate intervention.
Patients whose clinical presentation suggests a very high
likelihood of having a stenosis (e.g., with absolutely typical
chest pain and an unambiguously positive stress test) will
thus most likely not benefit from so-called “noninvasive
angiography” of any kind. However, the high negative
predictive value may make the clinical application of coro-
nary CTA useful in patients who are considered for invasive
angiography because they are symptomatic but do not have
a high pretest likelihood of coronary stenoses: if CTA
clearly demonstrates normal coronary arteries, invasive an-
giography is not necessary. “Screening” applications of
coronary CTA in asymptomatic individuals currently are
not backed by clinical data. Although the use of coronary
CTA for the detection of prognostically significant coronary
lesions (e.g., main stem stenoses) in certain high-risk
populations such as patients with diabetes are conceivable,
the potential benefit remains to be proven in adequately
designed, prospective studies.
Bypass grafts. The imaging of venous bypass grafts is less
challenging than coronary arteries because they are larger
and they move less rapidly than the coronary vessels (Fig. 5).
Imaging of internal mammary artery grafts can in some
cases be more difficult because of artifacts caused by metal
clips placed alongside the bypass grafts. Several studies
performed using 16-slice CT have shown that occlusions
and stenoses of bypass grafts can be detected with very high
accuracy (48 –55) (Table 2). However, it has so far not been
shown that CT imaging permits assessment not only of the
bypass grafts but also of native coronary arteries distal to the
JACC Vol. 48, No. 10, 2006 Achenbach 1923
November 21, 2006:1919–28 Coronary CTA

Figure 4. Shown is a patient with a high-grade stenosis of the left anterior descending coronary artery. (A) Transaxial computed tomography image (0.75-mm
slice thickness) showing the stenosis, which involves the left anterior descending coronary artery and the relatively large diagonal branch. (B) In a 5-mm thick
maximum intensity projection (transaxial orientation), the stenosis is more readily seen (arrow). Again, it can be seen that the stenosis involves the ostium of the
left anterior descending coronary artery and a large diagnonal branch in this bifurcation. (C) Curved multiplanar reconstruction of the left anterior descending
coronary artery (larger arrow) shows the stenosis and the involvement of the side branch (smaller arrow). (D) Three-dimensional reconstruction (“volume
rendering technique”). The stenosis of the left anterior descending coronary artery proximal to the bifurcation is clearly visible (arrow). However, the limited spatial
resolution of the 3-dimensional reconstruction fails to demonstrate the presence of ostial stenoses of the 2 bifurcation branches. (E) Invasive coronary angiogram.

bypass grafts or arteries that have not received a bypass graft. calcify heavily and are frequently of small size (45,54). This
The coronary arteries may, in fact, be challenging to assess limits the clinical usefulness of coronary CTA in patients
by CT in patients after bypass surgery because they tend to who develop chest pain after bypass surgery because it

Table 1. Accuracy for Detection of Coronary Stenoses Using Coronary Computed Tomography Angiography With at Least 16 Slices
(Comparison With Invasive Coronary Angiography)
Collimation Gantry Rotation Sensitivity Specificity
Author n (Patients) (mm) (ms) (%) (%) NPV (%) n.e. (%)
Kuettner et al. (15) 124 16 ⫻ 0.75 375 85 98 96 7
Mollet et al. (16) 51 16 ⫻ 0.75 375 95 98 99 —
Martuscelli et al. (17) 64 16 ⫻ 0.625 500 89 98 98 —
Morgan-Hughes et al. (18) 58 16 ⫻ 0.625 500 83 97 97 2
Schujif et al. (19) 45 16 ⫻ 0.75 420 98 97 100 6
Hoffmann et al. (20) 103 16 ⫻ 0.75 420 95 98 99 6
Achenbach et al. (21) 50 16 ⫻ 0.75 375 94 96 99 4
Leschka et al. (22) 53 64 ⫻ 0.6 370 94 97 99 —
Raff et al. (23) 70 64 ⫻ 0.6 330 86 95 98 12
Leber et al. (24) 59 64 ⫻ 0.6 330 73 97 99 —
88* 97* 99* —
Mollet et al. (25) 52 64 ⫻ 0.6 330 99 95 99 2
Ropers et al. (26) 82 64 ⫻ 0.6 330 95 93 99 4
Fine et al. (27) 66 64 ⫻ 0.6 330 95 96 95 6
Studies performed by 16-slice scanners that did not use all 16 detector rows for data acquisition are not listed. *Analysis in proximal and mid-coronary segments.
n.e. ⫽ not evaluable; NPV ⫽ negative predictive value.
1924 Achenbach JACC Vol. 48, No. 10, 2006
Coronary CTA November 21, 2006:1919–28

Figure 5. Computed tomography angiography in a patient with 3 venous coronary artery bypass grafts. (A) Transaxial cross section showing the aortic
anastomosis and a cross section of the mid-segments of the venous graft to the left anterior descending coronary artery (arrows). In addition, a cross section
of the left circumflex graft is seen (arrowhead). (B) Transaxial 5-mm thick maximum intensity projection showing the aortic anastomosis of the right
coronary artery bypass graft (double arrows). In addition, a cross section of the left anterior descending graft (larger arrow) and of the left circumflex graft
(arrowhead) are visible. The proximal left coronary artery is seen, with a high-grade stenosis of the left main coronary artery proximal to the bifurcation
(smaller arrow). The coronary arteries are of narrow lumen and have substantial calcification. (C) Curved multiplanar reconstruction of the venous graft
to the right coronary artery (arrows). The double arrows indicate the anastomosis to the distal right coronary artery. (D) Three-dimensional reconstruction
showing bypass graft to left anterior descending (larger arrow), to left circumflex (arrowhead), and to right coronary artery (smaller arrow).

Table 2. Results of 16-Slice Computed Tomography Coronary Angiography for the Assessment of Bypass Grafts in Comparison
With Invasive Coronary Angiography
n (Patients) Procedure Sensitivity (%) Specificity (%) n.e. (%)
Nieman et al. (48) 24 Bypass occlusion 100 98 0–5
Bypass stenosis 60–83 88–90 5–10
Native coronary stenosis 79–89 72–75 31–34
Martuscelli et al. (49) 96 Bypass occlusion 100 100 9–12
Bypass stenosis 90 100 9–12
Schlosser et al. (50) 51 Bypass occlusion 100 100 12
Bypass stenosis 90 100 12
Chiurlia et al. (51) 51 Bypass occlusion 100 100 0
Bypass stenosis 96 100 0
Moore et al. (52) 50 Bypass occlusion 100 100 0
Bypass stenosis 100 99 0
Burgstahler et al. (53) 13 Bypass occlusion 100 100 5
Bypass stenosis 100 93 0
Salm et al. (54) 25 Bypass occlusion 100 100 8
Bypass stenosis 100 94 8
Stenosis in nongrafted vessels 100 89 24
Anders et al. (55) 32 Bypass occlusion 100 98 0
Bypass stenosis 85–88 90–82 16–22
In 2 of the studies, analysis of native coronary arteries was included. Although the accuracy for the detection of stenoses and occlusions in bypass grafts is uniformly high, reliable
assessment of native coronary arteries was not possible.
n.e. ⫽ not evaluable.
JACC Vol. 48, No. 10, 2006
November 21, 2006:1919–28
usually will be necessary to assess the status both of the
bypass grafts and of the native coronary arteries. Most likely,
64-slice CT will permit more complete and reliable assess-
ment of patients, but this remains to be proven.
Coronary artery stents. Because of artifacts caused by
metal, the visualization of the lumen within coronary artery
stents by multidetector CT is more challenging than the
assessment of the native coronary arteries (Fig. 6). Only a
small number of studies have evaluated the value of MDCT
to detect in-stent restenosis (56 – 61). In those studies, most
performed by 16-slice CT, the rate of evaluable stents was
low and, even in assessable stents, sensitivity for the detec-
tion of in-stent restenosis was only between 54% and 83%.
Next to the type of scanner used, several factors that
influence the accessibility of stents have been identified.
They include the type of stent, as shown in phantom studies
(61,62). Also, the available data suggest that stent diameter
plays a significant role. In the study by Schuijf et al. (57),
28% of stents with a diameter ⱕ3.0 mm, but only 10% of
Figure 6. Imaging of coronary artery stents. (A) A stent with a diameter
of 3.5 mm in a distal left main coronary artery, immediately proximal to
the bifurcation, is assessable by coronary computed tomography angiog-
raphy and shows absence of in-stent restenosis (arrow). (B) A stent with
a diameter of 3.5 mm in a right coronary artery shows artifacts within
the stent lumen and cannot be assessed by computed tomography.
Achenbach 1925
Coronary CTA
stents with a diameter of more than 3.0 mm were unevalu-
able. In a study by Gilard et al. (61), which included only
stents implanted in the left main coronary artery—with a
large mean diameter of 3.9 mm—all stents were assessable,
and all 4 restenoses were detectable by CT. In another
study by the same group, with 232 included stents—the
largest such study to date— 49% of stents with a diameter
ⱕ3.0 mm and 19% of stents with a diameter ⬎3.0 mm
could not be evaluated (56). Gaspar et al. (60) found that
with 40-slice CT, all of 111 stents were evaluable (with a
mean stent diameter of 3.3 mm), but only 72% of in-stent
restenoses were detected. The use of 64-slice scanners
may improve coronary stent visualization by CT (62,63),
but the ability of coronary CTA to replace invasive
angiography in unselected patients with previous coro-
nary stenting has not been demonstrated.
Imaging of coronary atherosclerotic plaque. Several pub-
lications have shown that, in addition to the detection of
coronary artery stenoses, multidetector CT also permits
the visualization of nonstenotic plaque, both calcified and
noncalcified (Fig. 7). Sensitivities for the detection of
plaque—whether calcified or noncalcified— have been
reported to be approximately 80% to 90% (64 – 68).
Again, patients were somewhat preselected in these
studies. Also, most studies did not evaluate the accuracy
for detection of single plaques, but of coronary segments
that contain plaque and, in many cases, the detection of
plaque was, in fact, driven by the detection of calcified
plaque, with substantially lower sensitivity to detect
purely noncalcified plaque (65,68). One study has dem-
onstrated that coronary CTA can analyze the extent of
remodeling in coronary atherosclerotic lesions (69). Ac-
cording to current knowledge, the ability of CT to
quantify the size and volume of plaque is limited
(65,68,70). Correlation coefficients for plaque area and
volume ranged from r ⫽ 0.55 to r ⫽ 0.80 (65,68,70). On
a per-segment basis, CTA underestimated the plaque
volume when compared with intravascular ultrasound in a
study performed by 16-slice CT (mean plaque volume per
segment of 24 ⫾ 35 mm3 in CT vs. 43 ⫾ 60 mm3 for
intravascular ultrasound, p ⬍ 0.001) (65). A more de-
tailed analysis performed using 64-slice CT showed that
there was a tendency to overestimate the volume of
calcified plaque (65.8 ⫾ 110.0 mm3 vs. 53.2 ⫾ 90.3 mm3,
p ⫽ 0.19), whereas the volume of noncalcified and
“mixed” plaque was systematically underestimated in CT
(59.8 ⫾ 76.6 mm3 vs. 67.7 ⫾ 67.9 mm3 and 47.7 ⫾ 87.5
mm3 vs. 57.5 ⫾ 99.4 mm3, p ⬍ 0.03) (68).
Similarly, initial observations have shown that, on
average, the CT attenuation within “fibrous” plaques
(mean attenuation values of 91 to 116 Hounsfield units)
is greater than within “lipid-rich” plaques (mean attenu-
ation values of 47 to 71 Hounsfield units) (66,68,70 –75).
However, the large variability of measured density values
within plaques (74) and the substantial influence of
contrast density within the coronary lumen on density
1926 Achenbach
Coronary CTA
Figure 7. Imaging of coronary atherosclerotic plaque. (A) Small, partly
calcified coronary atherosclerotic plaque in the very proximal segment of
the left anterior descending coronary artery (arrow). (B) In a patient with
severe coronary atherosclerosis, calcified (smaller arrow) and noncalcified
plaque (larger arrow) are visible in the mid-section of the left anterior
descending coronary artery.
values measured within plaques (76,77) currently do not
allow the use of CT for the classification of a single
coronary atherosclerotic plaque.
SUMMARY AND OUTLOOK
Computed tomography has gone through rapid develop-
ment during the past years, much of which was driven by
the desire to provide reliable and accurate coronary
angiography by CT. In fact, visualization of the coronary
arteries has become increasingly stable and, with recent
scanner generations, adequate patient selection, and ex-
perience in acquisition and interpretation of data, signifi-
cant coronary artery stenoses can be reliably ruled out by
multi-detector CT in some patient subgroups. Currently,
the use of coronary CTA does not constitute a broad
replacement for diagnostic coronary angiography, but avail-
able data indicate that, in certain clinical situations, it may
be an alternative for selected patients. The main area of
JACC Vol. 48, No. 10, 2006
November 21, 2006:1919–28
interest is currently the use of CT to rule out stenoses in
patients with possible coronary artery disease but a rather
low pretest likelihood of significant disease. This pertains
to “stable” patients but also potentially to patients who
present with acute chest pain, in whom coronary artery
disease may often not be very likely. The accurate
definition of the potential role of coronary CTA to rule
out disease in a clinical context, including analysis of
cost-effectiveness aspects and of the possibility of devel-
oping organizational structures that will provide for
“24/7” availability of competent data acquisition and
interpretation, will be necessary next steps that must be
pursued with high priority. Finally, more widespread
availability of 16- and 64-slice scanners as well as
subsequent scanner generations will lead to an increase in
sites that offer CT imaging of the heart, which creates
issues of education, training, and quality control.
Reprint requests and correspondence: Dr. Stephan Achenbach,
Department of Cardiology, University of Erlangen–Nürnberg,
Ulmenweg 18, 91054 Erlangen, Germany. E-mail: stephan.
achenbach@med2.med.uni-erlangen.de.
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