The Malaysian consensus statement on utilisation of cardiac CT
1 National Heart Association of Malaysia, Damansara Uptown, Petaling Jaya, Selangor, Malaysia
2 College of Radiology Malaysia, Department of
Biomedical Imaging, University Malaya Medical Centre, Kuala Lumpur, Malaysia
This statement is a result of a joint working group
between the College of Radiology, Academy of Medicine and the National Heart
Association of Malaysia.
Cardiovascular disease is a conglomerate of diseases that
affect the heart and the arterial system in the body. It remains the number one
cause of death in developed countries. In Malaysia, between the years 2000 and 2004,
20-25% of deaths in Government hospitals were due to cardiovascular disease
Coronary artery disease (CAD) is characterised by the
presence of atherosclerotic plaques in the coronary arteries. Coronary artery
calcification is part of the development of these atherosclerotic plaques.
These plaques progressively narrow the arterial lumen and hence impair blood
flow. The reduction in coronary artery flow may be asymptomatic or symptomatic,
may occur with or without exertion, and may culminate in a myocardial
infarction, depending on the severity of the obstruction and rapidity of
Various investigational modalities are available for the
detection of CAD. These include electrocardiography, echocardiography and
radionuclide imaging. Lately, there has been increasing awareness in newer
imaging techniques such as Computer Tomography (CT) and Magnetic Resonance
Imaging (MRI) in diagnosing CAD.
CT as an imaging modality has been around for more than
three decades. However, only in the last few years with the introduction of the
multislice computer tomography (MSCT), has it allowed adequate imaging and
interpretation of the status of the coronary arteries and its related
structures. It is a novel technique, in that it allows non-invasive visualisation
of the coronary artery lumen. Although the gold standard for diagnosing
obstructive coronary disease is still invasive coronary angiography, cardiac
CT, in certain clinical situations, may be an acceptable alternative [2, 3, 4,
5]. Coronary calcium, a marker of plaque burden, can also be quantified with
this method, and to a certain extent, plaque composition can be characterised
The growth and availability of MSCT services in Malaysia have been immense. Therefore, it is important for the local medical profession to
understand the requirements to obtain a minimum dataset for adequate
interpretation of the cardiac study, and most importantly patient selection,
preparation and safety. In order to make full use of this powerful imaging tool
in daily clinical practice to increase the diagnostic yield, its potential and
limitations have to be understood. This document aims to outline the
requirements for cardiac CT, current indications, safety, reporting and
training issues in Malaysia. The committee understands that CT technology and
applications are evolving rapidly, and it is only pertinent that this document
will be constantly revised to parallel the developments.
Rationale of Cardiac CT
Comprehensive cardiac assessment requires information on
coronary vascular anatomy, cardiac morphology, function, perfusion, metabolism
and tissue characterisation. At the moment, no single imaging modality is able
to successfully achieve accurate global assessment of the heart, which is a
difficult organ to image because of its rapid, complex, cyclical, variable
rate-dependent motion and its small vessels.
Cross-sectional CT imaging of the coronary arteries was
first performed with the electron beam CT in 1984. However, low spatial resolution
and high image noise limited the image quality. Since 1998, with the
introduction of the 4-slice mechanical CT scanners and subsequently 16- and
64-slice CT scanners with higher spatial and temporal resolutions, accurate
visualisation of the coronary arteries, cardiac anatomy as well as functional
imaging are possible. At the time of writing, the evolving CT technology has
presented us with various new developments, including dual source CT scanners
as well as 320-slice CT scanners (which boast greater anatomical coverage and
shorter scan time).
Invasive imaging techniques, especially selective
conventional coronary angiography, will remain vital in planning and
guiding catheter-based and surgical treatment of significantly
stenotic coronary lesions. However, because coronary angiography is
associated with a small but not negligible risk of complications (inherent in
invasive procedures), inconvenience to patients and significant costs, coronary
CT angiography (CTA) is an attractive alternative to invasive selective
coronary angiography, with the potential to reduce the number of purely
diagnostic angiograms. In particular, patients with intermediate likelihood of
CAD may benefit from coronary CTA .
Cardiac CT is usually performed as a two-part examination
� first, the coronary artery calcium score, and secondly, the coronary artery
The calcium score measures the amount of calcified plaques
in the coronary arteries as a surrogate marker for atherosclerotic disease. The
majority of published studies have reported that the total amount of coronary
calcium (usually expressed as the Agatston score) predicts coronary disease
events beyond standard risk factors. Calcium score is useful given a negative
CT test as atherosclerotic disease is less likely (negative predictive value
96-100%). In addition, intermediate risk patients (10-20% 10-year Framingham
Risk Score) may benefit from a calcium score by refining clinical risk
prediction and selecting patients for more aggressive risk factor modification
and pharmacological intervention [8, 9].
Coronary CTA has been shown to be accurate in the
detection and quantification of haemodynamically significant stenosis. Several
studies have shown that the overall sensitivity is between 95% and 99%, and
specificity 93-96% for detection of coronary artery stenosis [10-12].
Sensitivity, specificity, and the negative predictive value
(NPV) of 64-slice MSCT per patient are approximately 97%, 79%, and 96%,
respectively . In addition, coronary CTA is able to display non-calcified
plaque and vascular remodelling with good correlation with intravascular
The dataset obtained during the contrast-enhanced coronary
scans can also be processed to obtain functional information of the heart.
This document represents a joint effort between the
National Heart Association of Malaysia and the College of Radiology (Malaysia) to:
- Present a summary of existing medical literature and data on cardiac CT.
As this is an emerging technology, there are still areas of uncertain
significance which are being explored in current studies. The appropriate and
optimal application of this technology must be individually tailored to each
patient taking into account risks, benefits, cost effectiveness and
availability of alternative technology.
- Make suggestions regarding the training of physicians wishing to
participate in this field. The current criteria are formulated based on
prevailing practices and conditions in Malaysia with reference to accepted
standard clinical practices worldwide.
Requirements of Cardiac CT
Imaging of the heart using CT demands exact performance
requirements from the scanner. These requirements include:
(a) Minimisation of cardiac motion artifacts
This is the most critical aspect of cardiac imaging. The
coronary arteries go through a series of complex movements during the cardiac
cycle. Therefore, in order to image the coronary artery successfully, a scanner
with a high temporal resolution is needed. One method of achieving this is by
reducing the gantry rotation time . The 4-slice CT scanners have rotation
times of 0.5 sec. Newer scanners have gantry rotation times of 0.42 sec or
less. Currently a 64-slice CT scanner has a temporal resolution of 165 msec.
Furthermore, the artifacts from cardiac motion can be
further suppressed by imaging during the quiescent phase of the cardiac cycle
. This can be achieved by synchronising the image acquisition and image
reconstruction with the ECG signal of the patient. This is done by using
cardiac gating mechanism during scanning. Two ECG gating techniques are
employed namely prospective ECG triggering and retrospective ECG triggering.
Another method that can be employed to improve the
temporal resolution is to combine projection data from consecutive cardiac
cycles . This is called multi-segment reconstruction and provides a
significant improvement in the temporal resolution by combining data from as
many as four cardiac cycles. However, this technique relies heavily on the
regularity of the heart rate for its success .
(b) Minimisation of respiratory artifacts
Cardiac CT scans are performed during a single breath-hold
to minimise motion from respiration. In order to achieve this, the acquisition
time for the total coverage of the heart has to be short. The acquisition time
for cardiac scans using the 4-slice CT scanners ranged between 33 and 40 sec.
With the introduction of 16-slice CT scanners, the acquisition time was reduced
to less than 20 sec. Further reduction in acquisition time (of less than 10 sec)
was achieved with the 64-slice CT scanners, further reducing the occurrence of
involuntary motion artifacts from respiration and movements of the patients.
(c) High spatial resolution
The epicardial coronary arteries are small with diameters
ranging from 5 mm proximally to less than 1 mm distally. Imaging of these small
structures requires high spatial resolution. With the introduction of the
16-slice CT scanners, the presence of submillimetre detector widths has
provided significant improvement in the in-plane (x-y) resolution. The current
64-slice CT scanners have detector widths ranging between 0.5 and 0.625 mm
(d) Adequate and uniform contrast enhancement
Poor vessel opacification is one of the factors that
affect the image quality of the CT examination and renders distal vessels to be
non-evaluable. Therefore, contrast injection protocol must be tailored to
optimise contrast-to-noise ratio and to obtain uniform contrast enhancement.
This is achieved by using contrast delivery techniques such as the automatic
bolus tracking or the test bolus technique. Contrast needs to be administered
via a powered contrast medium injector.
(e) Employment of radiation dose-reduction techniques
Managing radiation dose to the patient during a cardiac CT
scan is a primary concern. Various methods for dose-reduction are available.
During the scan, the tube current (mA) can be modulated to be optimum at time
of the targeted phase acquisition (usually diastolic). At other times, the tube
current is kept at a nominal level. Using this technique, a dose saving of
about 45% can be achieved, depending on the heart rate during the acquisition
(f) Management of large volume of image data
Cardiac CT using submillimetre detector thickness results
in a large amount of image data to be reconstructed and interpreted. This
provides a challenge to the clinician in management of these data. CT scanners
currently need to be equipped with software, which enable these data to be
visualised in the native axial images, multiplanar reconstruction (MPR),
maximum intensity projection (MIP) as well as 3D volume rendering images. In
order to do this, powerful workstations are needed for image reconstructions
and evaluation. Software for measurement including quantitative manual and
semiautomatic tools is useful for further analysis of coronary artery stenosis
In view of the above requirements, it is the
recommendation of the committee that the acceptable imaging systems that can be
utilised for cardiac imaging include a minimum of a 16-slice MSCT,
electron-beam CT or the dual-source CT scanner. At the very minimum, a 4-slice
CT scanner is required for calcium scoring.
Indications of coronary CTA
As coronary CTA is a relatively new imaging modality,
there is limited clinical evidence available for many indications and case
scenarios for which coronary CTA may be useful. The committee has proposed an
�Appropriateness Criteria� championed by the American College of Cardiology
Foundation  which blends scientific evidence and practical experience by
engaging a diverse technical panel to rate each indication as appropriate or
inappropriate application of coronary CTA. In formulating a consensus, these
authors are greatly aided by the report of the American College of Cardiology
Foundation Quality Strategic Directions Committee Appropriateness Criteria
Working Group that included the American College of Radiology, Society of
Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic
Resonance, American Society of Nuclear Cardiology, North American Society for
Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and
Society of Interventional Radiology .
- An appropriate imaging study is one in which the expected
incremental information, combined with clinical judgment, exceed the expected
negative consequences by a sufficiently wide margin for a specific indication
that the procedure is generally considered acceptable care and a reasonable
approach for that indication (negative consequences include the risks of
radiation or contrast exposure and test inaccuracies).
- An inappropriate test for that indication means that cardiac CTA
is not generally acceptable and is not a reasonable approach for that
- In many instances, cardiac CTA may be regarded as generally acceptable
or a reasonable approach for that indication but would require more research
and/or patient information to classify that indication definitively. Examples
of such indications are detection of CAD in patients with acute chest pain but
without typical ECG or cardiac enzyme changes; patients with typical chest pain
and previous bypass graft or coronary stenting procedure; and screening for CAD
in the asymptomatic high-risk population; and evaluation of left ventricular
function in clinical heart failure patients with technically limited images
In deliberating the appropriateness of cardiac CTA, the
committee evaluated only clinical evidence from cardiac CTA imaging using slice
collimations of less than 1.0 mm for the detection of haemodynamically
significant coronary artery stenosis � usually accepted as 50% luminal stenosis
or greater . Any local data that is more relevant to the Malaysian
population were also included [18, 19]. The indications are for coronary imaging
and calcium scoring unless otherwise specified. Provided that image quality is
adequate, evaluation is performed by cardiac CTA level 2 or 3 trained doctors
(see under Section: Training), and the patients are properly chosen and
prepared for the study. Cardiac CTA has been investigated and reported for the
- Detection of haemodynamically significant coronary artery disease in a
heterogeneous group of patients.
- Coronary stent and bypass graft patency.
1. Detection of CAD in patients with:
- Chest pain and intermediate pre-test probability of CAD  and:
- not suitable for exercise treadmill test (ETT);
- un-interpretable or equivocal functional tests (ETT, perfusion or stress
- no ischaemic ECG changes and negative serial enzymes.
- Asymptomatic and low-to-moderate cardiovascular risk  but positive
- Cardiomyopathy to exclude coronary disease.
2. Structure and Function Evaluation
- Suspected coronary anomalies;
- Assessment of complex congenital heart disease;
- Evaluation of intra-cardiac masses and pericardial diseases in patients
- technically limited images echo, MRI or TEE;
- Evaluation of pulmonary vein anatomy prior to radiofrequency ablation
- Coronary vein mapping prior to placement of biventricular pacemaker.
1. Detection of CAD in patients with:
- Typical cardiac chest pain and high pre-test probability;
- Acute chest pain, high pre-test probability demonstrating ischaemic ECG
changes and/or positive cardiac enzymes;
- Evidence of moderate-to-severe ischaemic on functional tests (ETT,
perfusion, stress echo).
2. Asymptomatic patients/population with:
- Low-to-moderate CV risk score for screening;
- High CV risk but CCTA or conventional angiography was normal up to 2
3. Asymptomatic patients/population without inducible ischaemia on
functional tests for:
- Evaluation of bypass grafts;
- Evaluation of coronary stents.
Indications for Calcium score
Recent publications suggest calcium scoring provides
additional prognostic information to traditional risk scoring methods. Calcium
scoring is appropriate for patients deemed at medium risk for cardiovascular
events based on risk factor models. The presence of calcium and the
incremental levels of coronary artery calcium score denote higher levels of
risk and hence, guide the aggressiveness of preventive therapies and target
goals. This is because there are no well-defined boundaries of risk levels but
instead a risk continuum relationship similar to hypertension. Calcium scoring
has been shown to be independently predictive of cardiovascular risk and adds
incremental prognostic information to the conventional risk factor scoring
Reporting of Cardiac CTA
The documentation of a CTA report should include the
- Patient demographics
- Reporting physician(s)
- Type of examination
- Indication for CT angiography
- CT hardware and acquisition protocols (scanning and contrast)
- Need for beta-blocker or any adjunctive medications and dosage used
- Adequacy of image quality
- Contrast used and amount
- Complication(s) if any
The CTA volume dataset must be examined in multiple
reconstruction protocols including axial, multiplanar, and maximum intensity
projection (MIP) .
Axial images are the most valuable in evaluation of the
coronary arteries [7, 26]. Advanced post-processing tools e.g.
3D-Volume-rendered techniques, MIP are most accurate when viewed together with
the axial data.
Proper window width and level or appropriate kernel should
be used to visualise structure of interest or excessive calcification, if
Every segment of the coronary tree needs to be examined
and documented using established nomenclature. This paper proposes one model of
the coronary tree segmentation (Figure 1). This would allow cross-referencing
with findings during catheter angiography. It also provides standardisation in
the reporting which is crucial for clinical trials and communication. Presence
of non-assessable segments should be noted.
In reporting the coronary arteries, dominance, presence of
variants and anomalies should be noted. Description of plaques should include
segmental location, extent of disease, attenuation characteristics, degree of stenosis
and presence of vessel remodelling.
Stenosis quantification is based on referencing to
adjacent segment�s luminal calibre rather than vessel luminal wall to outer
wall diameter. Vessel cross-sectional and longitudinal views should be used for
estimation . Stenosis quantification can be performed by visual estimate
and/or electronic callipers. Lesion severity are usually categorised as mild,
moderate, severe or occluded which corresponds to stenotic severities of
<50%, 50-70%, >70% and 100% narrowing. Plaque attenuation characteristics
may be described e.g. calcified, non-calcified or mixed. Special features e.g.
plaque ulceration, vessel dissection, and thrombus may sometimes be seen.
Additional information may be reported by experts if
optimal images are available e.g. cardiac chambers (size, morphology),
myocardium (thinning, contour change or attenuation difference), pericardium
(masses, thickness, calcification, effusion) and extra-cardiac structures.
Information on cardiac function and valve structures, and
function may be obtained with other post-processing methods if needed.
Bypass graft assessment
Volume-rendering technique (VRT) displays good
3D-orientation of the grafts and the target anastomostic sites [2, 27]. Venous
grafts are well visualised by CTA owing to its larger size and lack of
mobility. Graft disease and stenosis are reported in a manner similar to native
coronary arteries. Presence of surgical clips and often dense calcification in
native vessels of post-CABG patients may give rise to artifacts that make
assessment rather challenging.
Limited reports are currently available on stent
evaluation with MSCT . The accuracy of assessment is influenced by the type
and size of stents. Owing to the high attenuation from stent material,
appropriate window width and level or kernels should be chosen. Intrastent
filling defects owing to in-stent restenosis (ISR) / occlusion should be noted.
Adequacy of stent expansion may explain the reason for restenosis.
Radiation protection in Cardiac CT
The major drawback of imaging of the heart using
multislice MSCT is the high radiation dose. The effective dose for coronary
angiography using EBCT ranges from 1.5 to 2.0 mSv while a similar examination
using 4-slice MSCT ranges from 6 to 13 mSv . Recent MSCT multicentre
studies have documented higher radiation doses of up to 30 mSv in day-to-day
practice. However, with dose reduction techniques such as ECG-dependent dose
modulation as mentioned before, dose saving of about 45% can be achieved. In a
study by Hausleiter et al., the use of ECG-dependent dose modulator resulted in
a significant reduction in the effective dose estimate from 10.6 � 1.2 to 6.4 �
0.9 (using 16-slice MSCT scanner) and 14.8 � 1.8 to 9.4 � 1.0 mSv (using
64-slice MSCT scanner) . The new �step and shoot� technique available in
some systems today allows a 50-80% dose reduction .
It is imperative then that the principles of radiation
exposure namely justification, limitation and ALARA (As Low As Reasonably Achievable)
should be upheld at all times. Therefore, in view of the considerable radiation
doses, it is the recommendation of the committee that:
- The decision to expose a patient to cardiac CT has to be made by
physicians aware of the radiation risks that will be incurred by the patient.
At the time of writing, CT coronary artery angiography is not considered as a
screening procedure and each patient should have justifiable indications to
undergo the procedure. The use of MSCT for calcium scoring for risk
stratification purposes are acceptable in clinical practice.
- The use of dose-reduction techniques should be employed whenever
possible. Effective dose during cardiac CT should ideally not exceed 13 mSv
. Special care should be taken when imaging children and young female (as
the breast would be included in the scanning field).
Safety issues in Cardiac CT
Safety issues in cardiac CT involve issues regarding
radiation, intravenous contrast administration and administration of
β-blockers and nitrates.
Issues regarding radiation have been mentioned before. It
is important that all personnel involved in cardiac CT are aware of radiation
risks and undergo basic training in radiation effects and radiation protection.
Risks with contrast media administration include adverse
reactions to the contrast, its nephrotoxic properties and risk of
extravasation. The supervising physician should be able to identify patients
with increased risk of developing adverse reactions or in which contrast media
is contraindicated. Patients with renal failure should also be identified. The
physician should be well versed in treating and managing contrast media
β-blockers are currently the preferred method to
reduce heart rate. Supervising physicians should be aware of the dosage, action
and the contraindications of β-blockers.
Training in Cardiac CT
CT is an important imaging modality for the detection and
characterisation of cardiac disease; therefore it is crucial that physicians
who supervise and interpret cardiac CT should have appropriate competency,
experience and expertise .
Competencies are divided into:
- Criteria for performing calcium scoring exclusively only.
- Criteria for interpreting cardiac CT
- level 1 competency
- level 2 competency
- level 3 competency
1. Criteria for performing calcium scoring exclusively only
Any physicians such as cardiologists and radiologists who
are certified from the acceptable body/board and have undergone training which
includes cardiac anatomy and experience with training in interpretation of
cross-sectional imaging are qualified to interpret coronary artery calcium
2. Criteria for interpreting cardiac CT
Physicians should have adequate knowledge and
understanding of the anatomy, physiology and pathophysiology of the cardiac
systems for cardiac CT interpretation.
a) Level 1 competency
This is defined as the minimal introductory training for
familiarity with CCTA but is not sufficient for independent interpretation of
the CCTA studies [33, 34]. The trainee should have been actively involved in
CCTA interpretation under the direction and supervision of a qualified level 2
or 3 mentor.
The trainee should undergo mentored interpretation of at
least 25 cases of CCTA with contrast (of which a minimum of 10 cases should be
in correlation with conventional coronary angiography). Studies may be taken
from an established teaching file or previous CCT cases. Trainees are required
to provide proof of training (e.g. verified log book, letter of certification
by a qualified level 2 or 3 mentor).
b) Level 2 competency
This is defined as the minimum level of training for a
doctor to independently perform and interpret CCTA [33, 34]. This is intended
for individuals who wish to practise or be actively involved with CCTA. The
doctors at this level should have sufficient training to interpret the CT
examination accurately and independently.
The trainee should undergo mentored interpretation of at
least 75 cases of CCTA, of which the trainee must perform at least 15 cases
under supervision of a qualified level 2 or 3 mentor. A minimum of 25 should be
correlated with coronary angiography. Studies may be taken from an established teaching
file or previous CCTA cases.
The trainee should also undergo training in advanced
anatomy, contrast administration, principles of 3-dimensional imaging/post-processing,
principles of radiation protection and its hazards to patients and personnel,
and appropriate post-procedural patient monitoring.
Trainees are required to provide proof of training (e.g.
verified log book, certificate of attendance, letter of certification by a
qualified level 2 or 3 mentor)
c) Level 3 competency
This represents the highest level of expertise that would
enable an individual to serve as a director of a cardiac CT centre [33, 34].
This person would also be directly responsible for quality control and training
This requires a further minimum cumulative training period
of 6 months after completion of level 2 training. Trainee should interpret at
least 150 cases of CCTA. The cases reflect the broad range of pathology
expected in cardiac imaging. The trainee must be involved in performing at
least 75 cases and ongoing participation in quality assurance and safety
programmes as well as be involved in research activities. Studies may be taken
from an established teaching file or previous CCTA cases.
Trainees are required to provide proof of training (e.g. verified
log book, certificate of attendance, and letter of certification by a qualified
level 3 mentor)
Training requirements for radiographers
CT radiographers should possess a diploma in radiography,
or any equivalent radiography qualifications recognised by the Ministry of
Health Malaysia or Society of Radiographers Malaysia.
It is encouraged that the radiographers performing the
cardiac CT have advanced certification in at least post-basic CT. The
radiographers must also be able to prepare, position, ensure patient safety,
monitor the patient, apply the contrast injection and scanning protocol as
prescribed by supervising doctors. They should also perform regular quality
control testing .
If the radiographer does not have an advanced
certification in CT, a minimum of 3 months full-time CT training is required
under the supervision of a suitably trained CT radiographer and radiologist
before being allowed to operate a CT scanner independently. Radiographers are
encouraged to keep a log book of the number of CT cases performed.
The radiographer should also have adequate Continuous
Professional Development (CPD) on CCTA-related topics (at least attend one
conference / workshop / course every 2 years).
CT scanners should not be operated by any person without
the above stated qualifications e.g. medical physicists, technicians, research
staff, post-doctorate fellows, nurses and any other non-radiological qualified
Intravenous contrast materials can be administered by
radiographers and nurses under the direction of supervising doctors, if the
practice is in compliance with institutional regulations.
Extracardiac findings of coronary CTA
CT scans performed for cardiac evaluation includes
visualisation of extracardiac structures within its scan range. The importance
of this is two-fold. Firstly, some of the risk factors for CAD such as smoking,
male sex, and age overlap with the risk factors for other chest diseases such
as bronchial carcinoma .
Secondly, chest pain is not unique to cardiac disease, and
may be a result of other chest pathology [36, 37].
With the same raw data, at no additional radiation
exposure to the patient, reconstructions of the images into a larger field of
view allow visualisation of the lung and chest wall at the level of scan.
Dedicated coronary artery CT focused on the heart displays 35.5% of total chest
volume, while images reconstructed at maximal field of view visualises 70.3%
Studies have shown that cardiac CT demonstrated a significant
number of previously unknown extracardiac findings, some of which had an
immediate impact on workup, follow-up or both. The incidence of extracardiac
findings ranged from 7.8 to 58.1% [37, 38]. The extracardiac findings that
required some form of therapy was 3 to 5% [35, 37]. These included pulmonary
embolism, bronchogenic carcinoma, liver tumours and congenital anomalies.
Evaluation of extracardiac structures should be performed by a radiologist.
However, cardiac scans have a small field of view
restricted to the heart which precludes a complete evaluation of the thorax.
Therefore both patients and referring physicians have to understand that the
focus of the cardiac CT is for the detection of cardiac diseases.
Figure 1 Modified 17-segment of the AHA reporting system .
Table 1 Pre-test Probability of Coronary Artery Disease by Age, Gender and Symptoms (Reproduced from ACC/AHA 2002 Guideline Update for Exercise Testing) .
Annual Report: Number of discharges and deaths due to circulatory system by age and sex. Malaysia: Information and Documentation System Unit, Ministry of Health Malaysia, 2004.
Achenbach S. Computed tomography coronary angiography. J Am Coll Cardiol 2006; 48(10):1919-28.
Nieman K, Cademartiri F, Lemos PA et al. Reliable noninvasive coronary angiography with fast submillimeter multislice spiral computed tomography. Circulation 2002; 106(16):2051-4.
Raff GL, Gallagher MJ, O'Neill WW et al. Diagnostic accuracy of noninvasive coronary angiography using 64-slice spiral computed tomography. J Am Coll Cardiol 2005; 46(3):552-7.
Achenbach S, Ropers D, Kuettner A et al. Contrast-enhanced coronary artery visualization by dual-source computed tomography--initial experience. Eur J Radiol 2006; 57(3):331-5.
Leber AW, Becker A, Knez A et al. Accuracy of 64-slice computed tomography to classify and quantify plaque volumes in the proximal coronary system: a comparative study using intravascular ultrasound. J Am Coll Cardiol 2006; 47(3):672-7.
Hoffmann U, Ferencik M, Cury RC et al. Coronary CT angiography. J Nucl Med 2006; 47(5):797-806.
Budoff MJ, Achenbach S, Blumenthal RS et al. Assessment 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 Clinical Cardiology. Circulation 2006; 114(16):1761-91.
Greenland P, Bonow RO, Brundage BH et al. ACCF/AHA 2007 clinical expert consensus document on coronary artery calcium scoring by computed tomography in global cardiovascular risk assessment and in evaluation of patients with chest pain: a report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCF/AHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) developed in collaboration with the Society of Atherosclerosis Imaging and Prevention and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol 2007; 49(3):378-402.
Mollet NR, Cademartiri F, van Mieghem CA et al. High-resolution spiral computed tomography coronary angiography in patients referred for diagnostic conventional coronary angiography. Circulation 2005; 112(15):2318-23.
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; 97(3):343-8.
Fine JJ, Hopkins CB, Ruff N et al. Comparison of accuracy of 64-slice cardiovascular computed tomography with coronary angiography in patients with suspected coronary artery disease. Am J Cardiol 2006; 97(2):173-4.
Nikolaou K, Knez A, Rist C et al. Accuracy of 64-MDCT in the diagnosis of ischemic heart disease. AJR Am J Roentgenol 2006; 187(1):111-7.
Vembar M, Walker MJ, Johnson PC. Cardiac imaging using multislice computed tomography scanners: technical considerations. Coron Artery Dis 2006; 17(2):115-23.
Flohr TG, Schaller S, Stierstorfer K et al. Multi-detector row CT systems and image-reconstruction techniques. Radiology 2005; 235(3):756-73.
Patel MR, Spertus JA, Brindis RG et al. ACCF proposed method for evaluating the appropriateness of cardiovascular imaging. J Am Coll Cardiol 2005; 46(8):1606-13.
Hendel RC, Patel MR, Kramer CM et al. 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 Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology. J Am Coll Cardiol 2006; 48(7):1475-97.
Ong TK, Chin SP, Liew CK et al. Accuracy of 64-row multidetector computed tomography in detecting coronary artery disease in 134 symptomatic patients: influence of calcification. Am Heart J 2006; 151(6):1323.e1-6.
Sim KH, Ong TK, Chin SP et al. Computed Tomography Scan for Cardiac Intervention. Indian Heart J 2007; 59:B25-32.
Gibbons RJ, Balady GJ, Bricker JT et al. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol 2002; 40(8):1531-40.
Grundy SM, Pasternak R, Greenland P et al. AHA/ACC scientific statement: Assessment of cardiovascular risk by use of multiple-risk-factor assessment equations: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology. J Am Coll Cardiol 1999; 34(4):1348-59.
Agatston AS, Janowitz WR, Hildner FJ et al. Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol 1990; 15(4):827-32.
Detrano R, Guerci AD, Carr JJ et al. Coronary calcium as a predictor of coronary events in four racial or ethnic groups. N Engl J Med 2008; 358(13):1336-45.
Budoff MJ, Shaw LJ, Liu ST et al. Long-term prognosis associated with coronary calcification: observations from a registry of 25,253 patients. J Am Coll Cardiol 2007; 49(18):1860-70.
Cury RC, Ferencik M, Achenbach S et al. Accuracy of 16-slice multi-detector CT to quantify the degree of coronary artery stenosis: assessment of cross-sectional and longitudinal vessel reconstructions. Eur J Radiol 2006; 57(3):345-50.
Achenbach S. Coronary CT angiography: A cardiologist�s perspective. Suppl to Appl Radiol 2005; (22-32).
Soon KH, Kelly AM, Cox N et al. Non-invasive multislice computed tomography coronary angiography for imaging coronary arteries, stents and bypass grafts. Intern Med J 2006; 36(1):43-50.
Austen WG, Edwards JE, Frye RL et al. A reporting system on patients evaluated for coronary artery disease. Report of the Ad Hoc Committee for Grading of Coronary Artery Disease, Council on Cardiovascular Surgery, American Heart Association. Circulation 1975; 51(4 Suppl):5-40.
Hunold P, Vogt FM, Schmermund A et al. Radiation exposure during cardiac CT: effective doses at multi-detector row CT and electron-beam CT. Radiology 2003; 226(1):145-52.
Hausleiter J, Meyer T, Hadamitzky M et al. Radiation dose estimates from cardiac multislice computed tomography in daily practice: impact of different scanning protocols on effective dose estimates. Circulation 2006; 113(10):1305-10.
Hsieh J, Londt J, Vass M et al. Step-and-shoot data acquisition and reconstruction for cardiac x-ray computed tomography. Med Phys 2006; 33(11):4236-48.
Weinreb JC, Larson PA, Woodard PK et al. American College of Radiology clinical statement on noninvasive cardiac imaging. Radiology 2005; 235(3):723-7.
College of Physicians and College of Radiologists Joint Writing Committee, Thye HK, Han KB et al. Guidelines on cardiac CT in Singapore (2006). Ann Acad Med Singapore 2006; 35(4):287-96.
Budoff MJ, Achenbach S, Fayad Z et al. Task Force 12: training in advanced cardiovascular imaging (computed tomography): endorsed by the American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Atherosclerosis Imaging and Prevention, and Society of Cardiovascular Computed Tomography. J Am Coll Cardiol 2006; 47(4):915-20.
Haller S, Kaiser C, Buser P et al. Coronary artery imaging with contrast-enhanced MDCT: extracardiac findings. AJR Am J Roentgenol 2006; 187(1):105-10.
Romey A, Ross MA, Gallagher M et al. Non-cardiac findings by multislice computed tomographic angiography aid patient diagnosis. Acad Emerg Med 2006; 13(Suppl 1):S189-90.
Onuma Y, Tanabe K, Nakazawa G et al. Noncardiac findings in cardiac imaging with multidetector computed tomography. J Am Coll Cardiol 2006; 48(2):402-6.
Horton KM, Post WS, Blumenthal RS et al. Prevalence of significant noncardiac findings on electron-beam computed tomography coronary artery calcium screening examinations. Circulation 2002; 106(5):532-4.
|Received 21 August 2008; accepted 22 August 2008
Correspondence: Department of Biomedical Imaging, University of Malaya Medical Centre, 59100 Kuala Lumpur, Malaysia. Tel.: +603-79492069; Fax: +603-79581973; E-mail: firstname.lastname@example.org (Yang Faridah Abdul Aziz).
Please cite as: Sim KH, Abdul Aziz YF, Chin SP, Chong FL, Choo GH, Chew D, Ho ELM, Chia H, Yusoff MR, Ng KH, Syed Abu Bakar SM, Tan KH, Musa Z,
The Malaysian consensus statement on utilisation of cardiac CT, Biomed Imaging Interv J 2008; 4(4):e41