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Cardiac CT: Indications and guidelines

Appropriate referral strategy for coronary CT Angiography

Relating to coronary heart disease an appropriate referral strategy for coronary CT Angiography includes:

1. Detection of coronary artery disease (CAD): symptomatic-evaluation of chest pain syndrome (use of CT angiogram)

• Intermediate pre-test probability of CAD
• ECG uninterpretable OR unable to exercise

2. Detection of CAD: symptomatic-evaluation of intra-cardiac structures (use of CT angiogram)

• Evaluation of suspecronary anomalies

3. Detection of CAD: symptomatic-acute chest pain (use of CT angiogram)

• Intermediate pre-test probability of CAD
• No ECG changes and serial enzymes negative

4. Detection of CAD with prior test results-evaluation of chest pain syndrome (use of CT angiogram)

• Uninterpretable or equivocal stress test (Exercise, perfusion or stress echo).

Uncertain indication for coronary CT Angiography

Relating to coronary heart disease an uncertain indication for coronary CT Angiography includes:

1. Detection of CAD: symptomatic-evaluation of chest pain syndrome (use of CT angiogram)

• Intermediate pre-test probability of CAD
• ECG interpretable AND able to exercise

2. Detection of CAD: symptomatic-acute chest pain (use of CT angiogram)

• Low pre-test probability of CAD
• No ECG changes and serial enzymes negative

3. Detection of CAD: symptomatic-acute chest pain (use of CT angiogram)

• High pre-test probability of CAD
• No ECG changes and serial enzymes negative

4. Detection of CAD: symptomatic-acute chest pain (use of CT angiogram)

• “Triple rule out” exclude obstructive CAD, aortic dissection, and pulmonary embolism
• Intermediate pre-test probability for one of the above
• ECG-no ST segment elevation and initial enzymes negative

5. Detection of CAD: asymptomatic (without chest pain syndrome)- symptomatic (use of CT angiogram)

• High coronary heart disease (CHD) risk (Framingham)

6. Detection of CAD: Post-revascularization (PCI or CABG)- Evaluation of chest pain syndrome (use of CT angiogram)

• Evaluation of bypass graft and coronary anatomy
• History of percutaneous revascularization with stents

7. Risk assessment: general population-asymptomatic (calcium scoring)

• Moderate CHD risk (Framingham)
• High CHD risk (Framingham)