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(Circulation. 2004;109:e318-e319.)
© 2004 American Heart Association, Inc.

Images in Cardiovascular Medicine

Superiority of Computed Tomography Coronary Angiography Over Calcium Scoring to Accurately Evaluate Atherosclerotic Disease in a 35-Year-Old Man

Jeffrey M. Schussler, MD; William D. Dockery, MD; Kenneth B. Johnson, MD; Robert L. Rosenthal, MD; John R. Schumacher, MD; Robert C. Stoler, MD

From the Departments of Cardiovascular Disease (J.M.S., K.B.J., R.L.R., J.R.S., R.C.S.) Radiology (W.D.D.), Baylor University Medical Center, Dallas, Tex.

Correspondence to Jeffrey M. Schussler, MD, 621 N Hall St, Suite 500, Dallas, TX 75226. E-mail JSchussler{at}heartplace.com

A 35-year-old man with juvenile onset diabetes mellitus presented with exertion-associated chest pain. His risk factors also included smoking, hyperlipidemia, and strong family history. As part of a research protocol, he received a calcium score as well as multislice (computed tomography [CT]) coronary angiography using a new, 16-slice scanner (Lightspeed 16, GE Systems).

There was no detectable epicardial coronary calcium (Figure 1). However, his noninvasive coronary angiogram demonstrated a high-grade stenosis in his mid-left anterior descending artery (LAD) (Figure 2 and Figure 3). Additionally, there was a significant amount of plaque burden noted in the proximal LAD and right coronary artery (RCA) (Figure 4).

View larger version (56K): [in this window] [in a new window]   Figure 1. Representative images from the patient’s calcium score. Calcium scoring demonstrated no calcification reaching the threshold for significance (>130 HU) in any major epicardial artery.

View larger version (106K): [in this window] [in a new window]   Figure 2. Volume rendered model of the patient’s heart. A stenosis (X) is in the mid-LAD, just distal to a moderately sized first diagonal artery. The course of the distal LAD should run in the interventricular groove (between arrowheads).

View larger version (76K): [in this window] [in a new window]   Figure 3. CT angiogram (A) and invasive angiogram (B) of the left anterior descending artery. This demonstrates the CT appearance of a high-grade stenosis in the mid-LAD (X). Large plaque burden is noted in the proximal LAD (arrowheads). The distal LAD reconstitutes from right-to-left collaterals (between arrowheads).

View larger version (92K): [in this window] [in a new window]   Figure 4. CT angiogram (A) and invasive angiogram (B) of the right coronary artery. Soft plaque is clearly seen in the wall of the artery in the CT angiogram (arrowheads). The corresponding area is seen in the invasive angiogram.

Invasive cardiac catheterization confirmed the presence of an occluded mid LAD, with collateral circulation from the RCA. Angioplasty was performed, and a drug-eluting stent was placed. The proximal LAD, although clearly not normal angiographically, did not have any flow-limiting stenosis shown by invasive angiography.

Noninvasive angiography clearly demonstrated a 40% diameter reduction and a large burden of soft plaque in the proximal LAD. The outer diameter of the artery was >5 mm as shown by CT angiography. The lumen of the proximal LAD measured 3 mm by both CT and invasive coronary angiography.

This case demonstrates very clearly the difficulties in utilizing calcium scoring alone to screen for coronary artery disease in some patients. It also demonstrates the superiority of CT coronary angiography to evaluate coronary anatomy, and to demonstrate both the coronary lumen and the soft plaque in the artery wall. Particularly interesting is how well the CT angiogram demonstrates the severity of plaque burden in arteries that have no significant flow-limiting stenosis by invasive angiography.

Footnotes

The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.

Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Schussler, J. M. Articles by Stoler, R. C. Search for Related Content PubMed PubMed Citation Articles by Schussler, J. M. Articles by Stoler, R. C. Pubmed/NCBI databases Compound via MeSH Substance via MeSH Medline Plus Health Information Angina Coronary Artery Disease CT Scans Hazardous Substances DB CALCIUM COMPOUNDS CALCIUM, ELEMENTAL Related Collections Type 1 diabetes Coronary imaging: angiography/ultrasound/Doppler/CC CT and MRI Other diagnostic testing