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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\u003Cp id=\u0022p-1\u0022\u003EIn selected symptomatic patients with suspected coronary artery disease, cardiac computed tomography coronary angiography combined with myocardial perfusion imaging provide complementary information about the structure and function of the heart. This improves the risk assessment and treatment decisions for these patients, compared with imaging alone.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Ecoronary artery disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Epositron emission tomography\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ecomputed tomography\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Emyocardial perfusion imaging\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ecoronary artery calcium scoring\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ecardiac computed tomography angiography\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ecardiology \u0026amp; cardiovascular medicine screening \u0026amp; prevention\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\u003Cp id=\u0022p-2\u0022\u003EMany patients with normal myocardial perfusion assessed by positron emission tomography (PET)\/computed tomography (CT) imaging have undetected coronary artery disease (CAD). Combining myocardial perfusion imaging (MPI) with coronary artery calcium scoring (CACS) improves the detection of CAD. Randall C. Thompson, MD, University of Missouri, Kansas City, Missouri, USA, discussed how the use of multimodality imaging often leads to the reclassification of a patient\u0027s risk for CAD and alters the course of treatment.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EPatients with persistent symptoms and normal myocardial perfusion or mild ischemia on MPI are good candidates for CACS or cardiac computed tomography angiography (CCTA). CCTA can provide information about the amount of calcium in the walls of the coronary arteries and can help predict the risk of heart attack and cardiac death. The Agatston score, a measure of coronary calcification, is based on the area and density of calcified plaques and has been shown to be an independent predictor of mortality (\u003Cem\u003EP\u003C\/em\u003E \u0026lt; .001; \u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) [Shaw LJ et al. \u003Cem\u003ERadiology.\u003C\/em\u003E 2003].\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/16\/20\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Coronary Calcium Score Independent Predictor of All-Cause Mortality\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-488907337\u0022 data-figure-caption=\u0022Coronary Calcium Score Independent Predictor of All-Cause Mortality\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/16\/20\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/16\/20\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/16\/20\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16907\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \u003Cp id=\u0022p-4\u0022 class=\u0022first-child\u0022\u003ECoronary Calcium Score Independent Predictor of All-Cause Mortality\u003C\/p\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EGraph shows risk-adjusted all-cause survival estimates according to calcium score subsets. Even after adjustment, survival rate is proportionally worse as the baseline calcium score increases.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EAdapted from Shaw LJ et al. Graph shows risk-adjusted all-cause sur vival estimates accord i ng to calcium score subsets. Even after adjustment, survival rate is proportionally worse as the baseline calcium score increases. Radiology, 2003;228:826\u2013833. With permission from RSNA.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-5\u0022\u003EIn one study, 200 patients without known CAD were referred for CACS after normal MPI. Based on a CAC score \u0026gt; 100, 17.5% were identified as having CAD. Patients who were reclassified by CACS were not easily identifiable by traditional risk factors, although the patient\u0027s age and Framingham risk score did predict the presence of CAC [Thompson RC et al. \u003Cem\u003EJ Nucl Cardiol\u003C\/em\u003E. 2005]. Another study of 760 patients with no CAD history, a normal PET\/CT stress perfusion study, and a same-setting CAC scan found that 64.1% had subclinical CAD based on an abnormal CACS. Changes in medical therapy appeared to be related to whether the patient had received multimodal therapy (PET\/CT) or dedicated PET [Bybee KA et al. \u003Cem\u003EJ Nucl Cardiol\u003C\/em\u003E. 2010].\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EAlthough there was some residual risk of CAD in those with low CAC scores, higher CAC scores generally predicted a higher likelihood of ischemia. Annualized event rates in patients with normal PET MPI and no CAC were substantially lower than in patients with a CAC score \u2265 1000 (2.6% vs 12.3%). Rates were also lower among patients with ischemia on PET MPI and no CAC compared with those patients with a CAC score \u2265 1000 (8.2% vs 22.1%; \u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E). These data suggest that incremental risk stratification can be achieved by incorporating information on the extent of CAD as measured by CACS, along with the physiological information gleaned from MPI [Schenker MP et al. \u003Cem\u003ECirculation\u003C\/em\u003E. 2008].\u003C\/p\u003E\u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/16\/20\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022High CAC Score Better Predictor of Poor Outcome Than Presence of Ischemia\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-488907337\u0022 data-figure-caption=\u0022High CAC Score Better Predictor of Poor Outcome Than Presence of Ischemia\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/16\/20\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/16\/20\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/16\/20\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16908\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \u003Cp id=\u0022p-7\u0022 class=\u0022first-child\u0022\u003EHigh CAC Score Better Predictor of Poor Outcome Than Presence of Ischemia\u003C\/p\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-3\u0022\u003ECAC, coronary artery calcium; MI, myocardial ischemia.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-4\u0022\u003EAdapted from Schenker MP et al. Interrelation of coronary calcification, myocardial ischemia, and outcomes in patients with intermediate likelihood of coronary artery disease: a combined positron emission tomography\/computed tomography study. \u003Cem\u003ECirculation\u003C\/em\u003E. 2008;117(13):1693\u20131700. With permission from American Heart Association.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-8\u0022\u003EMPI scans and computerized tomography coronary angiograms (CTCAs) have an internal link that provides good diagnostic performance for CAD [Li JM et al. \u003Cem\u003EInt J Mol Imaging\u003C\/em\u003E. 2012]. They provide different and complementary information for detection of ischemia (MPI) versus detection of atherosclerosis (CTCA). There is concern, however, about the possibility of both false-positive and false-negative findings.\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003EIn patients with a negative MPI, 84.7% had a negative CTCA and 15.3% had a positive CTCA, whereas in patients with a positive MPI, 32.8% had a negative CTCA and 67.2% had a positive CTCA. In contrast, in patients with a negative CTCA, the proportion with a negative and positive MPI were 94.4% and 5.6%, respectively, whereas in patients with a positive CTCA, these proportions were 59.8% and 40.2%, respectively.\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003EMultiple studies have noted that the frequency of ischemia in vessels with \u2265 50% stenosis (detected by CTA) had a negative predictive value of 91% to 100% and positive predictive value of 29% to 44%. Dr Thompson advises using MPI to confirm ischemia when stenosis is identified on a coronary CTA. MPI improves the detection of CAD in vessels \u0026lt; 2 mm, whereas CTA contributes to the assessment of multivessel CAD. One advantage of MPI with a hybrid CT device is the ability to obtain same-setting measurement of the CACS, which makes it possible to detect obstructive atherosclerosis causing myocardial ischemia. Both techniques contribute to the management of coronary stenosis.\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003EIn best practice, the routine addition of CACS to MPI improves the detection of disease in patients who merit medical CAD management and prevention strategies. Patients who have normal or mildly ischemic MPI and persistent symptoms are good candidates for CACS or CCTA. Patients with indeterminate, or even severe, lesions on CCTA frequently merit additional testing with MPI, CT angiography with fractional flow reserve for detecting ischemia, and CT MPI.\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EAn anatomy-based testing strategy with CT coronary angiography and a physiology-based testing strategy with MPI may be clinically useful for the evaluation of known or suspected CAD in symptomatic patients. In selected patient cohorts, imaging approaches integrating structure and function may provide improved assessments of risk, thereby allowing a more personalized approach to management.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2015 SAGE Publications\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/16\/20.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzlkje\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzlkje\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}