Coronary computed tomography – present status and future directions P. Apfaltrer, 1,2 U. J. Schoepf, 1,3 R. Vliegenthart, 1,4 G. W. Rowe, 1 J. R. Spears, 1 C. Fink, 2 J. W. Nance Jr. 1 Introduction Coronary artery disease (CAD) remains one of the most important causes of morbidity and mortality in the Western world (1,2), with an estimated 16,800,000 individuals suffering from CAD in the United States alone. In 2009, it was estimated that 785,000 and 470,000 Americans will have new and recurrent attacks of acute coronary syndrome, respectively, and according to data from 2006, CAD is still responsible for one in five deaths in the Uni- ted States. The medical costs of CAD reflect its bur- den, at $165.4 billion in the United States in 2009 alone (3). Optimisation of preventative and curative medi- cine for CAD has the potential to greatly reduce a significant societal burden and improvements have been made in risk stratification, diagnosis and disease monitoring in the past decades (3). Unfortunately, current strategies are often time consuming (e.g. hos- pital observation and serial serum cardiac enzyme measurements), expensive (e.g. nuclear stress testing), and ⁄ or invasive (e.g. invasive coronary angiography, ICA). Coronary computed tomography angiography (cCTA) has the potential to directly visualise the cor- onary arteries, providing a fast, non-invasive assess- ment of atherosclerotic burden. cCTA has been shown to have a particularly high negative predictive value to rule out significant coronary artery stenosis in selected patients, and for this reason it is increas- ingly utilised in the evaluation of acute chest pain and chest pain syndrome (4) (Figures 1 and 2). Fur- thermore, cCTA is continuing its rapid evolution, with advances in hardware and techniques resulting in improved diagnostic performance, decreased patient radiation exposure and potential expansion of the currently approved clinical applications. Technical Evolution The relatively recent rise in cCTA is a direct reflec- tion of technical advances in CT scanner technology. The heart is subjected to nearly constant intrinsic motion from myocardial contractions, subjecting CT studies to a variety of artefacts that degrade image quality. The fundamental solution to the problem of SUMMARY The use of coronary computed tomography angiography (cCTA) is growing rapidly, in large part because of fast-paced technical innovations that have increased diag- nostic accuracy while providing new opportunities for radiation dose reduction. cCTA using recent generation CT scanners has been repeatedly shown to have excellent negative predictive value for ruling out significant coronary stenosis in comparison with invasive coronary angiography (ICA) and is now accepted for this use in selected populations. Current work is increasingly focused on evaluating and optimising radiation dose reduction techniques, the cost-effectiveness of cCTA implementation, and the impact of cCTA on patient management and outcomes. In addition, the potential value of emerging applications, such as atherosclerotic plaque characterisation and myocardial perfusion and viability assessment, are undergoing intense investigation. Review Criteria PubMed was used to obtain references for this non-systematic review of coronary CT angiography. In addition, unpublished data and expert opinion from the three academic medical centres represented by the authors was incorporated to form a current and future perspective of the technique, its applications and its potential. Message for the Clinic Coronary computed tomography angiography is able to exclude coronary artery disease (CAD) with a high negative predictive value and is therefore recommended in the evaluation of patients with low to intermediate probability of CAD. Ongoing developments in cCTA techniques should refine and expand its clinical role while attenuating worries over patient radiation burden. 1 Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA 2 Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim – Heidelberg University, Mannheim, Germany 3 Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA 4 Department of Radiology, University Hospital Groningen, Groningen, The Netherlands Correspondence to: U. Joseph Schoepf, MD, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Drive, MSC 226, Charleston, SC 29401, USA Tel.: (843) 876 7146 Fax: (843) 876 3157 Email: schoepf@musc.edu Disclosures: UJS is medical consultant for and receives research support from Bayer, Bracco, General Electric, Medrad, and Siemens. . REVIEW ARTICLE ª 2011 Blackwell Publishing Ltd Int J Clin Pract, October 2011, 65 (Suppl. 173), 3–13 doi: 10.1111/j.1742-1241.2011.02784.x 3