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Thinking outside the box: clinical and economic implications of extracardiac findings on cardiac computed tomography angiography
  1. Edward Hulten1,2,
  2. Venkatesh L Murthy3
  1. 1 Department of Medicine, Cardiology Service, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
  2. 2 Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
  3. 3 Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
  1. Correspondence to Dr Edward Hulten, Department of Medicine, Cardiology Service, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA; eddiehulten{at}

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Kelion et al 1 report a cross-sectional study of the incidence of non-cardiac incidental findings on 4340 clinically indicated coronary CT angiography (CCTA). The first and most significant finding is that 15.8% of CCTA examinations contained an incidental finding, although 23.6% were previously known (12.1% newly recognised incidental findings). A large proportion of these findings, 43%, were pulmonary nodules or cysts of unclear clinical significance. While these incidentals would not otherwise have been diagnosed by screening criteria, their identification often does impose a burden on patients and medical systems without prognostic benefit.

Second, most incidentals, but not all, could be identified on a cardiac field of view (FOV) image, without a need for a wide FOV reconstruction as per routine at many centres. The authors suggest this finding could support a rationale to more expeditiously evaluate only the cardiac FOV dataset in resource-limited settings, given the added time and cost burden of requiring a radiologist to review the full FOV scan for incidentals. Currently, as Kelion et al have noted, the minimum recommendation for cardiovascular imaging professionals is to evaluate the cardiac FOV for incidentals and wide FOV for patients meeting screening criteria for lung malignancy (age 55–75 years with >35 pack-years smoking history) in accordance with Society of Cardiovascular Computed Tomography (SCCT) recommendations for interpretation of CCTA and usual radiographic clinical practice.1

Moreover, these results must be considered in concert with a prior evaluation of 11 654 CCTAs by Kim et al.2 In their study, among 36 patients with lung cancer (0.31%), 4 could be detected on limited cardiac FOV vs 19 seen on wide FOV during cardiac CCTA. Sixteen of these occurred in non-smoking patients. Thus, limited scan review may place patients at clinical risk and place health systems in legal jeopardy from missed diagnoses. …

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  • Contributors EH and VLM—design and manuscript drafting, and final approval of the version to be published.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

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