Cardiopulmonar y Imaging • Original Research

Bischoff et al.

Comparison of Sequential and

Sequential Versus Helical Mode for Coronary CTA

Cardiopulmonary Imaging
Original Research
Helical Scanning for Radiation
Dose and Image Quality: Results
of the Prospective Multicenter
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Study on Radiation Dose Estimates

of Cardiac CT Angiography
(PROTECTION) I Study
Bernhard Bischoff 1 OBJECTIVE. Concerns have been raised about the radiation exposure of coronary CT
Franziska Hein1 angiography (CTA). Recently, a prospective ECG-triggered sequential coronary CTA tech-
Tanja Meyer 1 nique was developed to reduce exposure to ionizing radiation. The purpose of this analysis
Markus Krebs1 was to determine the impact of a sequential scanning technique on image quality and radia-
Martin Hadamitzky 1 tion dose in a prespecified subgroup analysis of the Prospective Multicenter Study on Radia-
tion Dose Estimates of Cardiac CT Angiography I (PROTECTION I) Study when compared
Stefan Martinoff 2
with a standard helical scanning technique.
Albert Schömig1 MATERIALS AND METHODS. This analysis comprises 685 64-MDCT coronary an-
Jörg Hausleiter 1 giography studies of 47 international study sites in which the image quality was assessed by an
Bischoff B, Hein F, Meyer T, et al. experienced coronary CTA investigator using a 4-point score (1 = nondiagnostic, 4 = excellent
image quality). Image quality was analyzed in all patients studied with the sequential scanning
mode (n = 99) and in randomly selected patients of the population studied with the helical ac-
quisition mode (n = 586). Radiation dose estimates were derived from the dose–length product
(DLP) and a conversion coefficient for the chest (0.014 mSv × mGy–1 × cm–1).
RESULTS. Although the sequential scanning mode significantly reduced radiation dose
estimates by 68% from 11.2 mSv for the helical mode to 3.6 mSv for the sequential mode (p <
0.001), the median diagnostic image quality scores were comparable in both groups. The me-
dian diagnostic score for both scanning modes was 3.5 (interquartile range: sequential vs he-
lical mode, 3.25–3.75 vs 3.0–3.75, respectively; p = 0.62).
CONCLUSION. The results of the PROTECTION I Study suggest that the prospective
ECG-triggered sequential coronary CTA technique significantly reduces radiation dose with-
out impairing image quality when compared with the standard retrospective helical data ac-
quisition in patients with a low and stable heart rate.

Keywords: coronary artery disease, CT, prospective
triggering, sequential scanning
DOI:10.2214/AJR.09.3543
Received August 25, 2009; accepted after revision
December 5, 2009.
1
Klinik für Herz und Kreislauferkrankungen, Deutsches
Herzzentrum Munchen, Lazarettstrasse 36, Munich,
Bavaria 80636, Germany. Address correspondence to J.
Hausleiter (hausleiter@dhm.mhn.de).
2 Dose Estimates of Cardiac CT Angiogra-
Institut für Radiologie und Nuklearmedizin, Deutsches
Herzzentrum München, Klinik an der TU München,
Munich, Germany.
AJR 2010; 194:1495–1499
0361–803X/10/1946–1495
© American Roentgen Ray Society
W
ith improvements in the tempo-
ral and spatial resolution of CT,
coronary CT angiography (CTA)
has become a common diagnos-
tic technique in clinical practice, particular-
ly for the examination of patients with an
intermediate pretest probability for obstruc-
tive coronary artery disease [1–3]. Never-
theless, there remains concern regarding
the exposure to ionizing radiation and its
potential hazards. The international Pro-
spective Multicenter Study on Radiation
phy I (PROTECTION I) Study analyzed the
extent of coronary CTA radiation dose esti-
mates and the impact of different strategies
to reduce dose in clinical practice [4]. The
study showed that effective radiation expo-
sure usually adds up to doses between 8 and
18 mSv when performing 64-MDCT coro-
nary angiography depending on the CT sys-
tem, the scanning technique, and patient-
dependent factors [4]. For this reason,
several dose-saving scanning techniques
and algorithms have been developed.
Usually, coronary CTA is performed us-
ing the retrospective ECG-gated helical
scanning technique [1]. When compared
with this helical image acquisition, the pro-
spective ECG-triggered sequential scanning
mode yields a considerable reduction of radi-
ation dose. Originally, the prospective scan-
ning algorithm was predominantly used for
unenhanced calcium scoring. Recently, this
scanning technique has been reintroduced
into contrast-enhanced coronary CTA [5].
When applying the prospective ECG-trig-
gered sequential scanning algorithm, image
acquisition is performed only during a short
predefined time period in the R-R interval,

AJR:194, June 2010 1495


requiring a low and stable heart rate. Small
single-center studies have indicated that in
comparison with retrospective ECG-gat-
ed helical scanning, sequential scanning al-
lows a significant reduction of the radiation
dose without impairing image quality in ad-
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equately selected patients [6, 7]. The aim of
this analysis was to compare the sequential
scanning mode and the standard helical im-
age acquisition in a large prospective multi-
center and multivendor study with respect to
image quality and radiation dose.
Material and Methods
Study Protocol
The methods of the observational PROTEC-
TION I Study have been described in detail else-
where [4]. In brief, 50 international study sites
provided image data and scanning protocols of
1,965 consecutive patients undergoing coronary
CTA during 1 month. All data were collected and
analyzed in a central coronary CTA core labora-
tory. All patients underwent coronary CTA for vi-
sualization of coronary arteries or bypass grafts,
combined examination of the coronary and pul-
monary arteries in patients with chest pain, or vi-
sualization of the cardiac anatomy before or after
electrophysiologic procedures. The current anal-
ysis comprised only the examinations performed
for visualization of the coronary arteries with a
64-MDCT system (n = 1,544 studies; sequential
coronary CTA: n = 99; helical coronary CTA: n =
1,445). Of these patients, we included all patients
scanned with a sequential scanning technique (n =
99, 100%) and a large group of randomly selected
patients examined with helical CT (n = 586, 41%)
in the current analysis. In these patients, image
quality grading was performed. Because of the
large number of patients, it was not practicable to
obtain image quality in all patients examined with
helical CT; therefore, a subgroup of these patients
was randomly selected for image quality grading.
The scanning protocol including the selection
of the scanning mode was at the discretion of the
performing physician. The study was approved by
the ethics committee, and all patients gave writ-
ten informed consent as required at the individual
study sites.
Image Quality
To obtain objective indexes of image quality,
the image noise, signal intensity, signal-to-noise
ratio, and contrast-to-noise ratio were obtained for
all coronary CTA examinations. The image noise
was defined as the averaged SDs of the CT attenu-
ation values (in Hounsfield units) inside two large
regions of interest (ROIs) in the proximal seg-
ments of the left and right coronary arteries. The
1496
Bischoff et al.
signal intensity was derived from the mean attenu- of 3 was defined as good and was assigned when
ation values measured in the same two ROIs. The artifacts, caused by motion, image noise, coro-
signal-to-noise ratio was calculated as the mean nary calcifications, or low contrast, did not inter-
CT attenuation values of the left and right coro- fere with assessment concerning the presence of
nary arteries divided by image noise. The con- luminal stenosis and the presence of calcified and
trast-to-noise ratio was defined as the difference noncalcified coronary atherosclerotic plaque. A
between the mean CT attenuation values of the score of 4, defined as excellent, indicated a com-
proximal coronary arteries and the mean density plete absence of motion artifacts, strong attenua-
of the left ventricular wall, which was divided by tion of vessel lumen, and clear delineation of ves-
image noise. sel walls and ability to assess luminal stenosis as
An experienced coronary CTA core labora- well as plaque characteristics.
tory reader, who was blinded to coronary CTA All coronary CTA examinations with at least
acquisition details, determined image quality one coronary artery with nondiagnostic image
on a per-vessel basis. Image quality was deter- quality (image quality score = 1) were rated
mined by a score describing image quality of the nondiagnostic.
four main coronary arteries—left main, left an-
terior descending, left circumflex, and right cor- Estimation of Radiation Dose
onary arteries—based on a 4-point grading sys- The collected parameters relevant to radiation
tem. A score of 1 was defined as nondiagnostic dose included the volume CT dose index (CTDIvol)
and meant that impaired image quality preclud- and dose–length product (DLP), both of which
ed appropriate evaluation of the coronary arteries were obtained from the CT scanning protocol of
due to severe motion artifacts, extensive coronary each coronary CTA study. The DLP was the pri-
calcifications, severe image noise, or insufficient mary study outcome parameter. For estimation of
contrast. A score of 2, defined as adequate, indi- the effective dose, the product of the DLP and an
cated that image quality was reduced because of organ weighting factor for the chest as the investi-
artifacts due to motion, image noise, or low con- gated anatomic region (k = 0.014 mSv × (mGy ×
trast attenuation but that image quality was still cm) –1 averaged between male and female models)
sufficient to rule out significant stenosis. A score was calculated as proposed by the European
TABLE 1: Patient and Scanning Characteristics
Sequential
Characteristics Helical Mode Mode p
Patient characteristics
No. of patients 586 99
Height, m 1.70 (1.64–1.78) 1.72 (1.65–1.80) 0.175
Weight, kg 76.0 (66.0–86.0) 75.0 (65.8–87.0) 0.781
Body mass index, kg/m2 26.2 (23.8–28.4) 25.8 (23.3–27.8) 0.188
Heart rate, bpm 61 (55–69) 56 (52–61) < 0.001
Sinus rhythm, no. (%) 568 (96.9) 98 (99.0) 0.248
Scanning characteristics
Scan length, mm 129 (118–143) 139 (139–139) < 0.001
Tube voltage, kV 120 (120–120) 120 (120–120) 0.08
CT scanner < 0.001
GE Healthcare 64-MDCT, a no. (%) 96 (16.4) 87 (87.9)
Philips Healthcare 64-MDCT,b no. (%) 28 (4.8) 11 (11.1)
Siemens Healthcare single-source 64-MDCT,c no. (%) 96 (16.4) 0 (0)
Siemens Healthcare dual-source 64-MDCT, d no. (%) 334 (57.0) 1 (1.0)
Toshiba 64-MDCT,e no. (%) 32 (5.5) 0 (0)
Note—Unless noted otherwise, data are presented as median (interquartile range).
aLightSpeed VCT.
bBrilliance 64.
cSomatom Sensation.
dSomatom Definition.
eAquilon 64.
AJR:194, June 2010
 Sequential Versus Helical Mode for Coronary CTA

Working Group for Guidelines on Quality Criteria TABLE 2: Quantitative Image Quality Parameters
in CT [8]. Median Value (Interquartile Range)
Image Quality Parameters Helical Mode Sequential Mode p
Statistical Analysis
For selection of patients for the helical CT Image noise (HU) 20 (17–24) 22 (19–27) 0.005
group, a random selection was performed using Signal intensity (HU) 365 (308–428) 388 (342–451) 0.003
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SPSS software (version 16.0.1, SPSS). To allow a

Signal-to-noise ratio 17.7 (14.3–22.1) 18.2 (14.4–21.5) 0.955
sufficient size of the control group, approximately
Contrast-to-noise ratio 13.0 (10.0–16.6) 13.3 (10.3–16.2) 0.775
40% of all helical coronary CTAs were selected,
resulting in a control group of 40.5% of all pa-
tients examined with helical CT. All parameters
of the sequential scanning protocol were com- p < 0.001 4
pared with the standard helical image acquisition. 2,000
Continuous variables were expressed as medians

Dose−Length Product (mGy × cm)

Image Quality Score (Grade)

(interquartile range [IQR]) and were compared us-
ing the Wilcoxon’s rank sum test. Categoric vari-
ables were expressed as frequencies or percentag-
3
es. The chi-square test was used to test differences
in the frequency of categoric variables. A p value
1,000
of < 0.05 was considered statistically significant.
All statistical analyses were performed using SPSS
software (version 16.0.1).
2
Results
A total of 685 patients undergoing 64- p < 0.622
MDCT coronary angiography at 47 study 0

sites were included in this analysis. Prospec-
tive ECG-triggered sequential image acqui-
sition was performed in 99 patients, whereas
586 patients were examined using retrospec-
tive ECG-gated helical scanning. Sequen-
tial image acquisition was used in five of the
47 study sites. Table 1 summarizes patient
and scanning characteristics, respective-
ly, of both groups. The frequency of sinus
rhythm, height, weight, and body mass index
were comparable in both groups. Heart rate
was significantly lower in patients scanned
with the sequential mode than those exam-
ined with the standard helical mode (56 vs
61 beats per minute [bpm], respectively; p <
0.001). Furthermore, there was a significant
difference regarding scanning length be-
tween both groups (139 and 129 mm for se-
quential and helical scanning mode, respec-
tively; p < 0.001).
When retrospective ECG-gated image ac-
quisition was used, the median CTDIvol add-
ed up to 49.8 mGy (IQR, 36.3–68.7 mGy).
In contrast, in patients examined with the se-
quential scanning technique, the median CT-
DIvol was significantly reduced to 18.4 mGy
(IQR, 15.8–24.0 mGy) (p < 0.001). Further-
more, sequential image acquisition led to a
significantly reduced DLP when compared
with standard helical scanning (median DLP
[IQR], 259 mGy × cm [234–337 mGy × cm]
vs 801 mGy × cm [563–1,091 mGy × cm],
respectively; p < 0.001), resulting in a 68%
Helical
Fig. 1—Box-and-whisker plots.
A and B, Box-and-whisker plots show dose–length product (A) and image quality score (B) for coronary CT
angiography examinations using either helical or sequential scanning mode. Horizontal line in each box shows
median and top and bottom lines of boxes show interquartile range (IQR). Whiskers show lowest value still
within 1.5 IQR of lower or upper quartile.
reduction of estimated radiation dose. This
difference translates to a median estimat-
ed radiation dose of 3.6 mSv (IQR, 3.3–4.7
mSv) versus 11.2 mSv (IQR, 7.9–15.3 mSv)
for sequential versus helical scanning tech-
nique, respectively.
Table 2 displays the quantitative image
quality data including image noise, signal-
to-noise ratio, and contrast-to-noise ratio
derived on scanning mode. With sequential
scanning, image noise and signal intensity
significantly increased by 9% and 6%, re-
spectively. Consequently, the derived signal-
and contrast-to-noise ratios did not differ sig-
nificantly between both groups.
Despite the reduction in radiation dose,
there was no significant difference between
groups regarding the image quality score
(median score [IQR] for sequential vs helical
mode, 3.50 [3.25–3.75] vs 3.50 [3.00–3.75],
respectively; p = 0.622). Figure 1 displays the
68% reduction of radiation dose and compa-
rable image quality in both groups. Whereas
the image quality achieved using sequential
coronary CTA was rated diagnostic in 93%
Sequential Helical Sequential
A B
of the patients, only 89% of the patients ex-
amined with conventional helical CT had di-
agnostic examinations (p = 0.245)
Figure 2 displays the image quality of two
coronary CTA examinations acquired with ei-
ther the sequential or helical scanning mode.
Discussion
In recent years, coronary CTA has evolved
as a useful noninvasive imaging technique
with a very high diagnostic accuracy for the
detection of obstructive coronary artery dis-
ease [9–11]. In addition, coronary CTA has
been shown to have a prognostic impact in
the evaluation of patients with chest pain
symptoms [12, 13]. However, the exposure to
ionizing radiation associated with coronary
CTA has raised concerns. Consequently, sev-
eral radiation dose–saving techniques have
been developed for coronary CTA to obtain
diagnostic coronary CTA images with the
lowest possible radiation dose.
The international PROTECTION I Study,
which is a prospective multicenter survey study
that focuses on radiation dose of coronary CTA

AJR:194, June 2010 1497


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Fig. 2—55-year-old man who underwent coronary CT angiography for visualization of coronary arrteries (A–C)
and 67-year-old man who underwent coronary CT angiography for visualization of coronary arteries (D–F).
A–F, Curved-planar maximum-intensity-projection CT angiograms of left descending artery (A and D), left
circumflex artery (B and E), and right coronary artery (C and F) obtained using sequential scanning mode (A–C)
and helical scanning mode (D–F) are shown for comparison with regard to image quality.
in daily practice, revealed a median radiation
dose of 12 mSv (IQR, 8–18 mSv) for coro-
nary CTA [4]. Furthermore, in this study sev-
eral independent predictors for the extent of
coronary CTA radiation exposure have been
identified. Among these factors, the prospec-
tive ECG-triggered sequential scanning pro-
tocol was a very strong independent predictor
of a reduced exposure to ionizing radiation.
However, the impact of the reduced dose
on image quality and the level of diagnos-
tic confidence are unknown. Therefore, the
current study investigates the impact of a se-
quential image acquisition in coronary CTA
on image quality and radiation dose in more
detail in a prespecified subgroup analysis of
the PROTECTION I Study.
The current analysis shows a 68% reduc-
tion in coronary CTA radiation dose for the
prospective ECG-triggered sequential scan-
ning technique in patients with a low and sta-
ble heart rate when compared with the stan-
dard helical scanning technique. Taking the
significantly longer scanning length in pa-
tients undergoing sequential scanning (139
and 129 mm for sequential and helical scan-
ning mode, respectively) into account, the
1498
Bischoff et al.
effect of applying the prospective ECG-trig-
gered sequential scanning mode on radiation
dose would be even higher. The differences
in scanning length between the helical and
sequential scanning mode may be explained
by differences in scan range definition.
Whereas scan range can be defined accurate-
ly to a millimeter in conventional helical CT,
it must be a multiple of scan coverage less
the overlapping zones in sequential scans.
Therefore, in some cases the scan range must
be larger in sequential scans than one would
have defined it in conventional helical CT.
Despite this tremendous reduction in ra-
diation dose, image quality was compara-
ble in both groups. Accordingly, the image
quality score did not differ significantly be-
tween both scanning modes. In this analy-
sis, the prospective ECG-triggered sequen-
tial scanning technique even showed a trend
to a higher rate of diagnostic coronary CTA
examinations than the conventional helical
coronary CTA technique (93% vs 89%, re-
spectively; p = 0.245). However, this analy-
sis due to the study design provides no data
about how many repeated scans were ob-
tained when image quality was nondiagnos-
tic. The relatively high rate of nondiagnostic
image quality may be explained by the unse-
lected study collective of the PROTECTION
I Study and the strict image quality rating in
the central core laboratory.
In concordance with the results of the cur-
rent analysis, Hein et al. [14] recently report-
ed a 63% reduction of radiation dose for se-
quential image acquisition in comparison
with standard helical image acquisition in pa-
tients examined using a dual-source CT sys-
tem. Similar to our analysis, image quality
did not differ significantly between both study
groups. A radiation dose reduction of even
77% without deterioration of image quality
was reported by Shuman et al. [7] who ret-
rospectively analyzed coronary CTA studies
of 100 matched patients either scanned with
helical (n = 50) or sequential (n = 50) mode.
Hirai et al. [6] performed both helical and se-
quential image acquisitions in 60 patients with
a heart rate below 75 bpm. When compared
with the helical scanning mode, the prospec-
tive ECG-triggered image acquisition led to
a 79% reduction of calculated effective dose
while maintaining image quality and the abil-
ity to assess for luminal stenosis.
Despite its enormous potential for radiation
dose reduction and high image quality, the
prospective ECG-triggered sequential scan-
ning mode has limitations. Using the sequen-
tial scanning mode, image acquisition usually
is performed during a short predefined period
during mid-to-late diastole, allowing only a
small reconstruction window. In patients with
higher heart rates and thus increased coronary
artery motion, coronary CTA acquired during
diastole often suffers from motion artifacts.
Therefore, the prospective ECG-triggered se-
quential scanning mode is recommended for
only patients with lower heart rates. In con-
trast, standard helical CT with ECG-depen-
dent tube current modulation and with a wide
time window of the full tube current also al-
lows image reconstruction in late systole,
where coronary artery motion in patients with
high heart rates is least and thus less motion
artifacts occur [15, 16].
In patients with lower heart rates, prospec-
tive ECG-triggered sequential scanning tech-
nique should be used more often. In the PRO-
TECTION I Study, only 5% of all patients
were examined using the sequential scanning
technique. Applying a threshold of 63 bpm—
as suggested by Husmann et al. [17]—below
which sequential image acquisition can be
performed with good image quality, 56% of
the PROTECTION I Study population would
have qualified for the sequential scanning
AJR:194, June 2010
 Sequential Versus Helical Mode for Coronary CTA
technique. This points out the enormous po-
tential of this dose-saving algorithm. There are
two main reasons for the low rate of sequential
scanning in the PROTECTION I Study: First,
many CT systems used in the study did not
allow sequential scanning during the study
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period. Second, many examiners may not
have been familiar with the sequential scan
algorithm and may have feared a potential
loss of diagnostic image information.
The sequential scanning technique can
be combined with other dose-saving strate-
gies. For example, an approach could be the
combination of prospective ECG-triggered
sequential image acquisition and a reduced
tube voltage of 100 kV in nonobese patients
with a slow and stable sinus rhythm. By com-
bining these radiation dose reduction tech-
niques, an estimated radiation dose of even
below 2 mSv can be obtained [18].
Limitations
The PROTECTION I Study was an ob-
servational study and therefore the scan-
ning protocol including the selection of the
scanning mode was at the discretion of the
performing physician. This nonrandomized
study design creates a potential selection
bias. The radiation dose associated with cor-
onary calcium scoring, which is performed
in some institutions before coronary CTA,
was not obtained in the current study. There-
fore, in this analysis only radiation dose as-
sociated with coronary CTA was taken into
account. In the PROTECTION I Study, only
patients with low heart rates were examined
using the sequential scanning mode. There-
fore, the diagnostic performance of ECG-
triggered sequential image acquisition could
not be evaluated in patients with higher heart
rates. The mean heart rate in the group who
underwent helical coronary CTA was signifi-
cantly higher than that of patients examined
with the sequential scanning technique. This
difference in heart rate may have caused an
image quality bias in favor of the sequential
coronary CTA group.
Besides heart rate, heart rate variability
significantly influences image quality of the
sequential scanning mode. Unfortunately,
heart rate variability was not recorded in the
PROTECTION I Study, so the effect of heart
rate variability on image quality could not
be assessed in the current analysis. Further-
more, invasive angiography results were not
obtained routinely in all patients; for this rea-
son, the diagnostic accuracy of the sequential
scanning mode could not be investigated.
AJR:194, June 2010
Summary
The results of this study show that, com-
pared with the standard helical image ac-
quisition, the prospective ECG-triggered se-
quential coronary CTA scanning technique
significantly reduces radiation dose without
impairing image quality in appropriately se-
lected patients.
References
1. Budoff MJ, Achenbach S, Blumenthal RS, et al. As-
sessment of coronary artery disease by cardiac
computed tomography: a scientific statement from
the American Heart Association Committee on
Cardiovascular Imaging and Intervention, Council
on Cardiovascular Radiology and Intervention, and
Committee on Cardiac Imaging, Council on Clini-
cal Cardiology. Circulation 2006; 114:1761–1791
2. Fox K, Garcia MA, Ardissino D, et al.; The Task
Force on the Management of Stable Angina Pec-
toris of the European Society of Cardiology.
Guidelines on the management of stable angina
pectoris: executive summary—the Task Force on
the Management of Stable Angina Pectoris of the
European Society of Cardiology. Eur Heart J
2006; 27:1341–1381
3. Hendel RC, Patel MR, Kramer CM, et al.; Ameri-
can College of Cardiology Foundation Quality
Strategic Directions Committee Appropriateness
Criteria Working Group; American College of
Radiology; Society of Cardiovascular Computed
Tomography; Society for Cardiovascular Mag-
netic Resonance; American Society of Nuclear
Cardiology; North American Society for Cardiac
Imaging; Society for Cardiovascular Angiogra-
phy and Interventions; Society of Interventional
Radiology. ACCF/ACR/SCCT/SCMR/ASNC/
NASCI/SCAI/SIR 2006 appropriateness criteria
for cardiac computed tomography and cardiac
magnetic resonance imaging: a report of the
American College of Cardiology Foundation
Quality Strategic Directions Committee Appro-
priateness Criteria Working Group, American
College of Radiology, Society of Cardiovascular
Computed Tomography, Society for Cardiovascu-
lar Magnetic Resonance, American Society of
Nuclear Cardiology, North American Society for
Cardiac Imaging, Society for Cardiovascular An-
giography and Interventions, and Society of Inter-
ventional Radiology. J Am Coll Cardiol 2006;
48:1475–1497
4. Hausleiter J, Meyer T, Hermann F, et al. Estimated
radiation dose associated with cardiac CT angiog-
raphy. JAMA 2009; 301:500–507
5. Hsieh J, Londt J, Vass M, Li J, Tang X, Okerlund
D. Step-and-shoot data acquisition and recon-
struction for cardiac x-ray computed tomography.
Med Phys 2006; 33:4236–4248
6. Hirai N, Horiguchi J, Fujioka C, et al. Prospective
versus retrospective ECG-gated 64-detector coro-
nary CT angiography: assessment of image qual-
ity, stenosis, and radiation dose. Radiology 2008;
248:424–430
7. Shuman WP, Branch KR, May JM, et al. Prospec-
tive versus retrospective ECG gating for 64-detec-
tor CT of the coronary arteries: comparison of
image quality and patient radiation dose. Radiol-
ogy 2008; 248:431–437
8. Menzel H, Schibilla H, Teunen D. European
guidelines for quality criteria for computed to-
mography. European Commission, 2000: publica-
tion no. EUR 16262 EN
9. Dewey M, Rutsch W, Schnapauff D, Teige F,
Hamm B. Coronary artery stenosis quantification
using multislice computed tomography. Invest
Radiol 2007; 42:78–84
10. Leber AW, Knez A, von Ziegler F, et al. Quantifi-
cation of obstructive and nonobstructive coronary
lesions by 64-slice computed tomography: a com-
parative study with quantitative coronary angiog-
raphy and intravascular ultrasound. J Am Coll
Cardiol 2005; 46:147–154
11. Raff GL, Gallagher MJ, O’Neill WW, Goldstein
JA. Diagnostic accuracy of noninvasive coronary
angiography using 64-slice spiral computed to-
mography. J Am Coll Cardiol 2005; 46:552–557
12. Hadamitzky M, Freißmuth B, Meyer T, et al.
Prognostic value of coronary computed tomo-
graphic angiography for prediction of cardiac
events in patients with suspected coronary artery
disease. JACC Cardiovasc Imaging 2009; 2:404–
411
13. Min JK, Shaw LJ, Devereux RB, et al. Prognostic
value of multidetector coronary computed tomo-
graphic angiography for prediction of all-cause
mortality. J Am Coll Cardiol 2007; 50:1161–1170
14. Hein F, Meyer, T, Hadamitzky M, et al. Prospec-
tive ECG-triggered sequential scan protocol for
coronary dual-source CT angiography: initial ex-
perience. Int J Cardiovasc Imaging (in press)
15. Herzog C, Arning-Erb M, Zangos S, et al. Multi-
detector row CT coronary angiography: influence
of reconstruction technique and heart rate on im-
age quality. Radiology 2006; 238:75–86
16. Seifarth H, Wienbeck S, Püsken M, et al. Optimal
systolic and diastolic reconstruction windows for
coronary CT angiography using dual-source CT.
AJR 2007; 189:1317–1323
17. Husmann L, Valenta I, Gaemperli O, et al. Feasi-
bility of low-dose coronary CT angiography: first
experience with prospective ECG-gating. Eur
Heart J 2008; 29:191–197
18. Scheffel H, Alkadhi H, Leschka S, et al. Low-
dose CT coronary angiography in the step-and-
shoot mode: diagnostic performance. Heart 2008;
94:1132–1137
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