Abstract
Objective
To analyse extracardiac findings in patients without significant coronary artery disease (CAD) in general and in symptomatic patients in particular.
Methods
We searched the Radiology Information System database for coronary computed tomography angiographies (CTA) performed from 2000−2014 and retrospectively enrolled 3,898 patients without significant CAD (coronary stenosis < 50%) in CTA. In 2,330 symptomatic patients, we analysed the spectrum of extracardiac findings and identified pathologies potentially explaining chest pain. Finally, we investigated variables affecting the number of extracardiac findings detected in CTA.
Results
Overall extracardiac findings were found in 1,177 patients (30.2%; 95%CI, 28.8−31.7%). 94 patients (2.4%; 95%CI, 2.0−2.9%) had extracardiac findings with a recommendation for follow-up, sixteen patients (0.4%; 95%CI, 0.3−0.7%) had incidental urgent, and another three patients (0.1%; 95%CI, 0.1−0.2%) had incidental malignant extracardiac findings. 185 of 2,330 symptomatic patients (7.9%; 95%CI, 6.9−9.1%) revealed extracardiac findings potentially explaining chest pain after exclusion of significant CAD. The number of extracardiac findings increased significantly with patient age (p < 0.001) and the cumulative experience of the CT reader (p < 0.001).
Conclusion
30.2% of patients undergoing CTA for exclusion of CAD had ECF, and 7.9% of symptomatic patients without significant CAD on their examination had findings that could potentially explain their symptoms.
Key Points
• Of patients undergoing CTA, 2.8% have relevant incidental extracardiac findings.
• CTA could identify the differential diagnosis of chest pain when excluding significant CAD.
• Patient age and reader’s professional experience influence the number of detected ECFs.
Similar content being viewed by others
Abbreviations
- CAD:
-
Coronary artery disease
- CTA:
-
Coronary computed tomography angiography
- ECF:
-
Extracardiac finding
- ECG:
-
Electrocardiogram
- FOV:
-
Field of view
- MDCT:
-
Multiple-detector computed tomography
- NCCP:
-
Noncardiac chest pain
- PET:
-
Positron emission tomography
- RIS:
-
Radiology Information System
- SPECT:
-
Single-photon emission computed tomography
References
SCOT-HEART Investigators (2015) CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): an open-label, parallel-group, multicentre trial. Lancet 385:2383–2391
Schlattmann P, Schuetz GM, Dewey M (2011) Influence of coronary artery disease prevalence on predictive values of coronary CT angiography: a meta-regression analysis. Eur Radiol 21:1904–1913
Taylor AJ, Cerqueira M, Hodgson JM et al (2010) ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 Appropriate Use Criteria for Cardiac Computed Tomography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Cardiovasc Comput Tomogr 4:407.e401–407.e433
Dewey M, Rief M, Martus P et al (2016) Evaluation of computed tomography in patients with atypical angina or chest pain clinically referred for invasive coronary angiography: randomised controlled trial. BMJ 355:i5441
Kalra MK, Abbara S, Cury RC, Brady TJ (2007) Interpretation of incidental findings on cardiac CT angiography. Catheter Cardiovasc Interv 70:324–325 author reply 326-328
Spalding L, Reay E, Kelly C (2003) Cause and outcome of atypical chest pain in patients admitted to hospital. J R Soc Med 96:122–125
Tavella R, Cutri N, Tucker G, Adams R, Spertus J, Beltrame JF (2016) Natural history of patients with insignificant coronary artery disease. Eur Heart J Qual Care Clin Outcomes 2:117–124
Kienzl D, Prosch H, Töpker M, Herold C (2012) Imaging of non-cardiac, non-traumatic causes of acute chest pain. Eur J Radiol 81:3669–3674
Torres FS (2014) Extracardiac findings in cardiac CT. AJR Am J Roentgenol 202:W411
Kim JW, Kang EY, Yong HS et al (2009) Incidental extracardiac findings at cardiac CT angiography: comparison of prevalence and clinical significance between precontrast low-dose whole thoracic scan and postcontrast retrospective ECG-gated cardiac scan. Int J Cardiovasc Imaging 25(Suppl 1):75–81
Budoff MJ, Fischer H, Gopal A (2006) Incidental findings with cardiac CT evaluation: should we read beyond the heart? Catheter Cardiovasc Interv 68:965–973
Budoff MJ, Gopal A (2007) Incidental findings on cardiac computed tomography. Should we look? J Cardiovasc Comput Tomogr 1:97–105
Karius P, Schuetz GM, Schlattmann P, Dewey M (2014) Extracardiac findings on coronary CT angiography: a systematic review. J Cardiovasc Comput Tomogr 8(174-182):e171–e176
National Lung Screening Trial Research Team, Aberle DR, Adams AM et al (2011) Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 365:395–409
Brown LD, Cai TT, DasGupta A et al (2001) Interval estimation for a binomial proportion. Statistical Science 16:101–133
von Elm E, Altman DG, Egger M et al (2014) The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. Int J Surg 12:1495–1499
Johnson KM, Dennis JM, Dowe DA (2010) Extracardiac findings on coronary CT angiograms: Limited versus complete image review. AJR Am J Roentgenol 195:143–148
Lazoura O, Vassiou K, Kanavou T, Vlychou M, Arvanitis DL, Fezoulidis IV (2010) Incidental non-cardiac findings of a coronary angiography with a 128-slice mufti-detector CT scanner: should we only concentrate on the heart? Korean J Radiol 11:60–68
Killeen RP, Dodd JD, Cury RC (2009) Noncardiac findings on cardiac CT part I: Pros and cons. J Cardiovasc Comput Tomogr 3:293–299
Kirsch J, Araoz PA, Steinberg FB, Fletcher JG, McCollough CH, Williamson EE (2007) Prevalence and significance of incidental extracardiac findings at 64-multidetector coronary CTA. J Thorac Imaging 22:330–334
Turkvatan A, Akdur PO, Akgul A, Olcer T, Cumhur T, Duru E (2009) Prevalence of incidental extracardiac findings on multidetector computed tomographic coronary angiography. Turkiye Klinikleri J Med Sci 29:169–175
Venkatesh V, You JJ, Landry DJ, Ellins ML, Sheth T (2010) Extracardiac findings in cardiac computed tomographic angiography in patients at low to intermediate risk for coronary artery disease. Can Assoc Radiol J 61:286–290
Cademartiri F, Malagò R, Belgrano M et al (2007) Spectrum of collateral findings in multislice CT coronary angiography. Radiol Med 112:937–948
Gil BN, Ran K, Tamar G, Shmuell F, Eli A (2007) Prevalence of significant noncardiac findings on coronary multidetector computed tomography angiography in asymptomatic patients. J Comput Assist Tomogr 31:1–4
Dewey M, Schnapauff D, Teige F, Hamm B (2007) Non-cardiac findings on coronary computed tomography and magnetic resonance imaging. Eur Radiol 17:2038–2043
Haller S, Kaiser C, Buser P, Bongartz G, Bremerich J (2006) Coronary artery imaging with contrast-enhanced MDCT: extracardiac findings. AJR Am J Roentgenol 187:105–110
Mueller J, Jeudy J, Poston R, White CS (2007) Cardiac CT angiography after coronary bypass surgery: prevalence of incidental findings. AJR Am J Roentgenol 189:414–419
Machaalany J, Yam Y, Ruddy TD et al (2009) Potential clinical and economic consequences of noncardiac incidental findings on cardiac computed tomography. J Am Coll Cardiol 54:1533–1541
Onuma Y, Tanabe K, Nakazawa G et al (2006) Noncardiac findings in cardiac imaging with multidetector computed tomography. J Am Coll Cardiol 48:402–406
Flor N, Di Leo G, Squarza SA et al (2013) Malignant incidental extracardiac findings on cardiac CT: systematic review and meta-analysis. AJR Am J Roentgenol 201:555–564
Buckens CF, Verkooijen HM, Gondrie MJ, Jairam P, Mali WP, van der Graaf Y (2012) Unrequested findings on cardiac computed tomography: looking beyond the heart. Plos One:7
Lehman SJ, Abbara S, Cury RC et al (2009) Significance of cardiac computed tomography incidental findings in acute chest pain. Am J Med 122:543–549
MacMahon H, Naidich DP, Goo JM et al (2017) Guidelines for management of incidental pulmonary nodules detected on CT images: From the Fleischner Society 2017. Radiology. https://doi.org/10.1148/radiol.2017161659
Fass R, Achem SR (2012) Noncardiac chest pain: diagnostic evaluation. Dis Esophagus 25:89–101
Al-Ani M, Winchester DE (2015) Prevalence and overlap of noncardiac conditions in the evaluation of low-risk acute chest pain patients. Crit Pathw Cardiol 14:97–102
Burgstaller JM, Jenni BF, Steurer J, Held U, Wertli MM (2014) Treatment efficacy for non-cardiovascular chest pain: a systematic review and meta-analysis. PLoS One 9:e104722
Wertli MM, Ruchti KB, Steurer J, Held U (2013) Diagnostic indicators of non-cardiovascular chest pain: a systematic review and meta-analysis. BMC Med 11:239
Sussman WI, Makovitch SA, Merchant SH, Phadke J (2015) Cervical angina: an overlooked source of noncardiac chest pain. Neurohospitalist 5:22–27
Teraguchi M, Yoshimura N, Hashizume H et al (2014) Prevalence and distribution of intervertebral disc degeneration over the entire spine in a population-based cohort: the Wakayama Spine Study. Osteoarthritis Cartilage 22:104–110
Matsumoto M, Okada E, Ichihara D et al (2010) Age-related changes of thoracic and cervical intervertebral discs in asymptomatic subjects. Spine (Phila PA 1976) 35:1359–1364
Vanichkachorn JS, Vaccaro AR (2000) Thoracic disk disease: diagnosis and treatment. J Am Acad Orthop Surg 8:159–169
Funding
Prof. Dewey has received grant support from the Heisenberg Program of the DFG for a professorship (DE 1361/14-1).
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Guarantor
The scientific guarantor of this publication is Prof. Dr. Marc Dewey
Conflict of interest
The authors of this manuscript declare relationships with the following companies:
Prof. Dewey has received grant support from the Heisenberg Program of the DFG for a professorship (DE 1361/14-1), the FP7 Program of the European Commission for the randomized multicentre DISCHARGE trial (603266-2, HEALTH-2012.2.4.-2), the European Regional Development Fund (20072013 2/05, 20072013 2/48), the German Heart Foundation/German Foundation of Heart Research (F/23/08, F/27/10), the Joint Program from the German Research Foundation (DFG) and the German Federal Ministry of Education and Research (BMBF) for meta-analyses (01KG1013, 01KG1110, 01KG1210), GE Healthcare, Bracco, Guerbet, and Toshiba Medical Systems.
Prof. Dewey has received lecture fees from Toshiba Medical Systems, Guerbet, Cardiac MR Academy Berlin, and Bayer (Schering-Berlex).
Prof. Dewey is a consultant to Guerbet and one of the principal investigators of multicentre studies (CORE-64 and 320) on coronary CT angiography sponsored by Toshiba Medical Systems. He is also the editor of Coronary CT Angiography and Cardiac CT, both published by Springer, and offers hands-on workshops on cardiovascular imaging (www.ct-kurs.de). Prof. Dewey is a consultant to the editor of Radiology and an associate editor of European Radiology. Institutional master research agreements exist with Siemens Medical Solutions, Philips Medical Systems, and Toshiba Medical Systems. The terms of these arrangements are managed by the legal department of Charité-Universitätsmedizin Berlin.
Prof. Dr. Bernd Hamm has received research grants from GE Healthcare, Schering, Siemens Medical Solutions, and Toshiba Medical Systems. Speakers Bureau: Siemens Medical Solutions and Schering.
Statistics and biometry
One of the authors has significant statistical expertise.
Informed consent
Written informed consent was waived by the Institutional Review Board.
Ethical approval
Institutional Review Board approval was obtained.
Methodology
• retrospective
Electronic supplementary material
ESM 1
(DOCX 28 kb)
Rights and permissions
About this article
Cite this article
Karius, P., Lembcke, A., Sokolowski, F.C. et al. Extracardiac findings on coronary computed tomography angiography in patients without significant coronary artery disease. Eur Radiol 29, 1714–1723 (2019). https://doi.org/10.1007/s00330-018-5688-4
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00330-018-5688-4