Myocardial perfusion can be assessed by stress, rest, and/or delayed imaging, which can be accomplished by US (via assessment of wall-motion changes at stress versus rest, or with contrast echocardiography); cardiac perfusion scintigraphy (via comparison of first-pass radiotracer perfusion to the ventricle at stress versus rest, or measurement of coronary blood flow); and MRI (via comparison of wall-motion or first-pass gadolinium enhancement of the ventricle during stress versus rest). Cardiac MRI is performed with ECG synchronization and may be performed without and with IV contrast and before and after vasodilators or inotropes if stress myocardial perfusion assessment is desired. MR angiography (MRA) of the coronary arteries is possible without or with IV contrast, but it only depicts luminal blood and cannot depict calcified plaque. Myocardial scarring, infarction, and viability can be assessed by cardiac MRI or cardiac PET. All elements are essential: 1) timing, 2) reconstructions/reformats, and 3) 3-D renderings. Standard CTs with contrast also include timing issues and reconstructions/reformats. Only in CTA, however, is 3-D rendering a required element. This corresponds to the definitions that the CMS has applied to the Current Procedural Terminology codes. OR Discussion of Procedures by Variant Variant 1: Asymptomatic patient. Low risk for coronary artery disease. Initial imaging. CT Coronary Calcium The CAC score first became available and validated with electron beam CT, and in the modern era, MDCT is used to acquire this data. Several multicenter trials have assessed the use of CAC in asymptomatic patients at intermediate risk for CAD. In the Multi-Ethnic Study of Atherosclerosis (MESA), Joshi et al [14] followed 6,814 participants CTA Coronary Arteries There is no relevant literature supporting the use of coronary CTA (CCTA) in asymptomatic patients at low risk of CAD.
Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. Myocardial perfusion can be assessed by stress, rest, and/or delayed imaging, which can be accomplished by US (via assessment of wall-motion changes at stress versus rest, or with contrast echocardiography); cardiac perfusion scintigraphy (via comparison of first-pass radiotracer perfusion to the ventricle at stress versus rest, or measurement of coronary blood flow); and MRI (via comparison of wall-motion or first-pass gadolinium enhancement of the ventricle during stress versus rest). Cardiac MRI is performed with ECG synchronization and may be performed without and with IV contrast and before and after vasodilators or inotropes if stress myocardial perfusion assessment is desired. MR angiography (MRA) of the coronary arteries is possible without or with IV contrast, but it only depicts luminal blood and cannot depict calcified plaque. Myocardial scarring, infarction, and viability can be assessed by cardiac MRI or cardiac PET. All elements are essential: 1) timing, 2) reconstructions/reformats, and 3) 3-D renderings. Standard CTs with contrast also include timing issues and reconstructions/reformats. Only in CTA, however, is 3-D rendering a required element. This corresponds to the definitions that the CMS has applied to the Current Procedural Terminology codes. OR Discussion of Procedures by Variant Variant 1: Asymptomatic patient. Low risk for coronary artery disease. Initial imaging. CT Coronary Calcium The CAC score first became available and validated with electron beam CT, and in the modern era, MDCT is used to acquire this data. Several multicenter trials have assessed the use of CAC in asymptomatic patients at intermediate risk for CAD. In the Multi-Ethnic Study of Atherosclerosis (MESA), Joshi et al [14] followed 6,814 participants CTA Coronary Arteries There is no relevant literature supporting the use of coronary CTA (CCTA) in asymptomatic patients at low risk of CAD.