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Computed tomography coronary angiography (CTCA) has evolved as a non-invasive imaging technology that can be used as an alternative first-line diagnostic test in symptomatic patients with low to intermediate likelihood of coronary artery disease (CAD).1 Nevertheless, it has not (yet) fulfilled initial expectations that it would be able to replace conventional invasive coronary angiography because CTCA tends to overestimate the severity of the coronary stenosis, resulting in a number of patients with false-positive outcomes that is too high. This is mainly caused by the blooming effect of calcified lesions in combination with the still too limited spatial resolution of CTCA as compared with invasive coronary angiography. CTCA provides, additional to luminography, comprehensive assessment of the anatomical manifestations of coronary atherosclerosis, including the distribution (proximal, mid and distal) and extent (one-, two-, three-vessel disease, left main disease) of CAD, the presence of ‘positive remodelling’ of the vessel and a, rather crude, assessment of the coronary plaque components (calcified, non-calcified and mixed) according to Schuijf et al.2
CTCA is considered a reliable technique providing high-quality images at low radiation exposure. It is now timely to explore the full potential of CTCA, ranging from its diagnostic ability to rule-in or rule-out CAD, to its prognostic potential in symptomatic patients and asymptomatic individuals and, finally, to assess the cost effectiveness with clinical outcomes as primary end points.
Prognostic value of CTCA in symptomatic patients
In symptomatic patients CTCA can non-invasively identify patients at high risk of major adverse cardiac events (MACE), and a negative CTCA is significantly related …