Recommended Use of OUTPATIENT Cardiac/Coronary CTA
Optimal patient characteristics*
- Resting sinus heart rate < 100 beats per minute
- Able to safely take metoprolol
- Able to hold breath for 10 seconds
- Body mass index (BMI) < 40 kg/m2
- No stent or single proximal stent at least 3 mm in diameter, and no coronary artery bypass surgery
*Expect sensitivity > 95% and specificity > 80% for detecting stenotic CAD in patients meeting above criteria
Strong Contraindications
- Severe contrast allergy (anaphylaxis, shock, coma, seizure)
- Creatinine clearance < 30 ml/min or acute kidney injury
- More than 10 PVCs/min
- Cannot follow instructions or cannot hold breath for 10 seconds
- High suspicion for acute coronary syndrome or symptomatic CAD
Relative Contraindications
- Heart rate > 100 bpm and cannot take metoprolol
- Creatinine clearance 30-45 ml/min (we will use IV hydration protocol)
- Coronary stent(s) < 3 mm in diameter
- Extremely severe coronary calcification
- Body mass index (BMI) > 55 kg/m2
RECOMMENDED INDICATIONS (ONE INDICATION IS SUFFICIENT)
Note: The language used for indications below is meant to be compatible with the approved use of cardiac CTA by most major insurers
Diagnosis of coronary artery disease (CAD) in a patient with symptom(s) that may represent anginal equivalent:
- IF BLUE CROSS BLUE SHIELD OR FULL MEDICARE COVERAGE: Intermediate probability (10-90%) of stenotic CAD or stenotic bypass graft disease in a symptomatic patient is sufficient (helpful for the provider to clearly document “intermediate probability”).
- IF NOT BLUE CROSS BLUE SHIELD OR MEDICARE then need low or intermediate probability AND one of the following (please note that Medicaid currently does not approve outpatient use of coronary CTA):
- Stress testing is contraindicated (uncontrolled severe hypertension, large aortic aneurysm), not tolerated, or likely to generate artifact (body habitus, left bundle branch block)
- Stress testing result is equivocal or discrepant from clinical presentation
- Persistence of symptoms despite normal stress test result – in place of catheterization
- Evaluation of bypass graft anatomy – in place of catheterization
- Concurrent evaluation of aorta or another cardiac structure is desired
Cardiomyopathy
- Evaluation of CAD as etiology of newly diagnosed cardiomyopathy – in place of catheterization
Coronary anomaly
- < 40 years-old and symptoms or prior imaging suggests possible coronary anomaly
- Coronary anomaly identified on catheterization or other imaging, and more detailed delineation of anomaly anatomy will affect management
Planning interventional/surgical procedures
- Evaluation for stenotic CAD before valvular or aortic surgery – in place of catheterization
- Evaluation of bypass graft and chest wall anatomy before redo open heart surgery
- Left atrial / pulmonary vein evaluation before EP procedures to treat atrial fibrillation
- Evaluation of left ventricular outflow tract and aorta before transcatheter aortic valve replacement (TAVR)
- Measurement of left atrial appendage dimensions before appendage occluder device placement
- Evaluation of mitral valve annulus before transcatheter mitral valve prosthesis implantation
Other cardiac structures, cardiac function, or congenital heart disease
- Echo and/or MRI produced inconclusive results or are contraindicated