Cardiac computed tomography and its use in clinical practice: a
review

Sidhi Laksono; Ananta Siddhi Prawara; Hillary Kusharsamita

doi:10.53986/ibjm.2023.0022

Review

Cardiac computed tomography and its use in clinical practice: a review

Tomografía computerizada cardiac y su uso en la práctica clínica: una revisión

Sidhi Laksono, Ananta Siddhi Prawara, Hillary Kusharsamita

http://dx.doi.org/10.53986/ibjm.2023.0022 Iberoam J Med, vol.5, n3, p.123-134, 2023

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Abstract

Cardiac computed tomography (CT) is an imaging modality that can visualize the anatomy of the heart and its surroundings. The technological advancement in cardiac CT gave better accuracy with lower radiation than earlier models. Its entire procedure took a relatively short time and minimal contact. Cardiac CT is an important imaging modality in clinical practice during emergencies and non-emergency settings and in planning comprehensive management of cardiac patients. Cardiac CT is useful in emergency settings, acting as a triple rule-out imaging modality. Cardiac CT in non-emergency settings can determine coronary artery calcium (CAC) score and detect left atrial appendage (LAA) thrombus before cardioversion. Furthermore, cardiac CT is now more commonly used as a modality in planning comprehensive management of cardiac patients’ especially coronary CT angiography (CCTA) in planning for cardiac intervention. This imaging modality becomes more relevant to use in clinical practice during the pandemic due to less contact with the patient needed during the procedure, and physicians may get used to cardiac CT. This article aims to explain the advantages of CCTA in emergency and non-emergency settings and discuss its limitation so that we can make the best use of it. This writing is a literature review. The literature search using PubMed and Google Scholar.

Keywords

Cardiac imaging techniques; Coronary occlusion; CT angiography; Developing countries; Thrombosis

Resumen

La tomografía computarizada (TC) cardíaca es una modalidad de imagen que puede visualizar la anatomía del corazón y su entorno. El avance tecnológico en la TC cardíaca brindó una mayor precisión con una radiación más baja que los modelos anteriores. Todo su procedimiento tomó un tiempo relativamente corto y un contacto mínimo. La TC cardíaca es una modalidad de imagen importante en la práctica clínica durante emergencias y entornos que no son de emergencia y en la planificación del manejo integral de pacientes cardíacos. La TC cardíaca es útil en situaciones de emergencia, ya que actúa como una modalidad de imagen de triple exclusión. La TC cardíaca en entornos que no son de emergencia puede determinar la puntuación de calcio en la arteria coronaria (CAC) y detectar trombos en el apéndice auricular izquierdo (LAA) antes de la cardioversión. Además, la TC cardíaca ahora se usa más comúnmente como una modalidad en la planificación del manejo integral de pacientes cardíacos, especialmente la angiografía por TC coronaria (CCTA) en la planificación de una intervención cardíaca. Esta modalidad de imagen se vuelve más relevante para su uso en la práctica clínica durante la pandemia debido a que se necesita menos contacto con el paciente durante el procedimiento, y los médicos pueden acostumbrarse a la TC cardíaca. Este artículo tiene como objetivo explicar las ventajas de CCTA en entornos de emergencia y no emergencia y discutir su limitación para que podamos hacer el mejor uso de ella. Este escrito es una revisión de la literatura. La búsqueda bibliográfica utilizando PubMed y Google Scholar.

Palabras clave

Imágenes técnicas cardiacas; Oclusión coronaria; Angiografía TC; Países en desarrollo; Trombosis

References

1. Van Der Bijl N, Geleijns J, MS Joemai R, Bax JJ, Shuijf JD, de Roos A. Recent developments in cardiac CT. Imaging Med. 2011;3(2):167-92.
2. McKavanagh P, Walls G, McCune C, Malloy J, Harbinson MT, Ball PA, et al. The Essentials of Cardiac Computerized Tomography. Cardiol Ther. 2015;4(2):117-29. doi: 10.1007/s40119-015-0052-0.
3. Halpern EJ. Clinical applications of cardiac CT angiography. Insights Imaging. 2010;1(4):205-22. doi: 10.1007/s13244-010-0038-3.
4. Paichadze N, Afzal B, Zia N, Mujeeb R, Khan M, Razzak JA. Characteristics of chest pain and its acute management in a low-middle income country: analysis of emergency department surveillance data from Pakistan. BMC Emerg Med. 2015;15 Suppl 2(Suppl 2):S13. doi: 10.1186/1471-227X-15-S2-S13.
5. Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021;42(14):1289-1367. doi: 10.1093/eurheartj/ehaa575.
6. Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39(2):119-177. doi: 10.1093/eurheartj/ehx393.
7. De Filippo M, Capasso R. Coronary computed tomography angiography (CCTA) and cardiac magnetic resonance (CMR) imaging in the assessment of patients presenting with chest pain suspected for acute coronary syndrome. Ann Transl Med. 2016;4(13):255. doi: 10.21037/atm.2016.06.30.
8. Hong KH, Bae SJ, Lee DH, Lee CA, Park SH, Kim DH, et al. Higher Frequency of Undetected Acute Coronary Syndrome in Elderly Patients with
Chest Pain Who Visited the Emergency Department: A Large-Cohort Retrospective Study. Biomed Res Int. 2021;2021:6611051. doi: 10.1155/2021/6611051.
9. Stepinska J, Lettino M, Ahrens I, Bueno H, Garcia-Castrillo L, Khoury A, et al. Diagnosis and risk stratification of chest pain patients in the emergency department: focus on acute coronary syndromes. A position paper of the Acute Cardiovascular Care Association. Eur Heart J Acute Cardiovasc Care. 2020;9(1):76-89. doi: 10.1177/2048872619885346.
10. Sawyer KN, Shah P, Qu L, Kurz MC, Clark CL, Swor RA. Triple Rule Out versus CT Angiogram Plus Stress Test for Evaluation of Chest Pain in the Emergency Department. West J Emerg Med. 2015;16(5):677-82. doi: 10.5811/westjem.2015.6.25958.
11. Branch KR, Strote J, Shuman WP, Mitsumori LM, Busey JM, Rue Tet al. Diagnostic accuracy and clinical outcomes of ECG-gated, whole chest CT in the emergency department. PLoS One. 2013;8(4):e61121. doi: 10.1371/journal.pone.0061121.
12. Dodd JD, Kalva S, Pena A, Bamberg F, Shapiro MD, Abbara S, et al. Emergency cardiac CT for suspected acute coronary syndrome: qualitative and quantitative assessment of coronary, pulmonary, and aortic image quality. AJR Am J Roentgenol. 2008;191(3):870-7. doi: 10.2214/AJR.07.3387.
13. Chae MK, Kim EK, Jung KY, Shin TG, Sim MS, Jo IJ, et al. Triple rule-out computed tomography for risk stratification of patients with acute chest pain. J Cardiovasc Comput Tomogr. 2016;10(4):291-300. doi: 10.1016/j.jcct.2016.06.002.
14. Budoff MJ, Dowe D, Jollis JG, Gitter M, Sutherland J, Halamert E, et al. Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial. J Am Coll Cardiol. 2008;52(21):1724-32. doi: 10.1016/j.jacc.2008.07.031.
15. Cakmakci E, Ozkurt H, Tokgoz S, Karabay E, Ucan B, Akdogan MP, et al. CT-angiography protocol with low dose radiation and low volume contrast medium for non-cardiac chest pain. Quant Imaging Med Surg. 2014;4(5):307-12. doi: 10.3978/j.issn.2223-4292.2014.10.03.
16. Wnorowski AM, Halpern EJ. Diagnostic Yield of Triple-Rule-Out CT in an Emergency Setting. AJR Am J Roentgenol. 2016;207(2):295-301. doi: 10.2214/AJR.15.15717.
17. Soliman HH. Value of triple rule-out CT in the emergency. Egypt. J Radiol Nucl Med. 2015;46(3):621-7. doi: 10.1016/j.ejrnm.2015.03.010.
18. Eltabbakh AR, Dawoud MA, Langer M, Moharm MA, Hamdy EA, Hamisa MF. ‘Triple-rule-out’ CT angiography for clinical decision making and early triage of acute chest pain patients : use of 320-multislice CT angiography. Egypt. J Radiol Nucl Med. 2019;50(3):1-10. doi: 10.1186/s43055-019-0003-1.
19. Maaniitty T, Stenström I, Uusitalo V, Ukkonen H, Kajander S, Bax JJ, et al. Incidence of persistent renal dysfunction after contrast enhanced coronary CT angiography in patients with suspected coronary artery disease. Int J Cardiovasc Imaging. 2016;32(10):1567-75. doi: 10.1007/s10554-016-0935-8.
20. Abuelhia E, Alghamdi A. Evaluation of arising exposure of ionizing radiation from computed tomography and the associated health concerns. J Radiat Res Appl Sci. 2020;13(1):295-300. doi: 10.1080/16878507.2020.1728962.
21. Wu W, Budovec J, Foley WD. Prospective and retrospective ECG gating for thoracic CT angiography: a comparative study. AJR Am J Roentgenol. 2009;193(4):955-63. doi: 10.2214/AJR.08.2158.
22. McParland P, Nicol ED, Harden SP. Cardiac drugs used in cross-sectional cardiac imaging: what the radiologist needs to know. Clin Radiol. 2010;65(9):677-84. doi: 10.1016/j.crad.2010.04.002.
23. Pannu HK, Alvarez W Jr, Fishman EK. Beta-blockers for cardiac CT: a primer for the radiologist. AJR Am J Roentgenol. 2006;186(6 Suppl 2):S341-5. doi: 10.2214/AJR.04.1944.
24. Takx RA, Suchá D, Park J, Leiner T, Hoffmann U. Sublingual Nitroglycerin Administration in Coronary Computed Tomography Angiography: a Systematic Review. Eur Radiol. 2015;25(12):3536-42. doi: 10.1007/s00330-015-3791-3.
25. Cronin M, Wheen P, Armstrong R, Kumar R, McMahon A, White M, et al. CT coronary angiography and COVID-19: inpatient use in acute chest pain service. Open Heart. 2021;8(1):e001548. doi: 10.1136/openhrt-2020-001548.
26. Yoo SM, Rho JY, Lee HY, Song IS, Moon JY, White CS. Current Concepts in Cardiac CT Angiography for Patients With Acute Chest Pain. Korean Circ J. 2010;40(11):543-9. doi: 10.4070/kcj.2010.40.11.543.
27. Kim H, Kim S, Han S, Rane PP, Fox KM, Qian Y, et al. Prevalence and incidence of atherosclerotic cardiovascular disease and its risk factors in Korea: a nationwide population-based study. BMC Public Health. 2019;19(1):1112. doi: 10.1186/s12889-019-7439-0.
28. Roy S. Atherosclerotic Cardiovascular Disease Risk and Evidence-based Management of Cholesterol. N Am J Med Sci. 2014;6(5):191-8. doi: 10.4103/1947-2714.132916.
29. Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice. Rev Esp Cardiol (Engl Ed). 2016;69(10):939. doi: 10.1016/j.rec.2016.09.009.
30. Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;140(11):e596-e646. doi: 10.1161/CIR.0000000000000678.
31. Cheong BYC, Wilson JM, Spann SJ, Pettigrew RI, Preventza OA, Muthupillai R. Coronary artery calcium scoring: an evidence-based guide for primary care physicians. J Intern Med. 2021;289(3):309-24. doi: 10.1111/joim.13176.
32. Hecht HS, Cronin P, Blaha MJ, Budoff MJ, Kazerooni EA, Narula J, et al. 2016 SCCT/STR guidelines for coronary artery calcium scoring of noncontrast noncardiac chest CT scans: A report of the Society of Cardiovascular Computed Tomography and Society of Thoracic Radiology. J Cardiovasc Comput Tomogr. 2017;11(1):74-84. doi: 10.1016/j.jcct.2016.11.003.
33. Neves PO, Andrade J, Monção H. Coronary artery calcium score: current status. Radiol Bras. 2017 May-;50(3):182-9. doi: 10.1590/0100-3984.2015.0235.
34. Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2019;73(24):e285-e350. doi: 10.1016/j.jacc.2018.11.003.
35. Lo-Kioeng-Shioe MS, Vavere AL, Arbab-Zadeh A, Schuijf JD, Rochitte CE, Chen MY, et al. Coronary Calcium Characteristics as Predictors of Major Adverse Cardiac Events in Symptomatic Patients: Insights From the CORE 320 Multinational Study. J Am Heart Assoc. 2019;8(6):e007201. doi: 10.1161/JAHA.117.007201.
36. Lo-Kioeng-Shioe MS, Rijlaarsdam-Hermsen D, van Domburg RT, Hadamitzky M, Lima JAC, Hoeks SE, et al. Prognostic value of coronary artery calcium score in symptomatic individuals: A meta-analysis of 34,000 subjects. Int J Cardiol. 2020;299:56-62. doi: 10.1016/j.ijcard.2019.06.003.
37. Xia C, Vonder M, Pelgrim GJ, Rook M, Xie X, Alsurayhi A, et al. High-pitch dual-source CT for coronary artery calcium scoring: A head-to-head comparison of non-triggered chest versus triggered cardiac acquisition. J Cardiovasc Comput Tomogr. 2021;15(1):65-72. doi: 10.1016/j.jcct.2020.04.013.
38. Sandfort V, Bluemke DA. CT calcium scoring. History, current status and outlook. Diagn Interv Imaging. 2017;98(1):3-10. doi: 10.1016/j.diii.2016.06.007.
39. Shah NR, Coulter SA. An evidence-based guide for coronary calcium scoring in asymptomatic patients without coronary heart disease. Tex Heart Inst J. 2012;39(2):240-2.
40. Nusair M, Flaker GC, Chockalingam A. Electric cardioversion of atrial fibrillation. Mo Med. 2010;107(1):59-64.
41. Pisters R, Nieuwlaat R, Prins MH, Le Heuzey JY, Maggioni AP, Camm AJ, et al. Clinical correlates of immediate success and outcome at 1-year follow-up
of real-world cardioversion of atrial fibrillation: the Euro Heart Survey. Europace. 2012;14(5):666-74. doi: 10.1093/europace/eur406.
42. Romero J, Husain SA, Kelesidis I, Sanz J, Medina HM, Garcia MJ. Detection of left atrial appendage thrombus by cardiac computed tomography in patients with atrial fibrillation: a meta-analysis. Circ Cardiovasc Imaging. 2013;6(2):185-94. doi: 10.1161/CIRCIMAGING.112.000153.
43. Melillo E, Palmiero G, Ferro A, Mocavero PE, Monda V, Ascione L. Diagnosis and Management of Left Atrium Appendage Thrombosis in Atrial Fibrillation Patients Undergoing Cardioversion. Medicina (Kaunas). 2019;55(9):511. doi: 10.3390/medicina55090511.
44. Dentamaro I, Vestito D, Michelotto E, De Santis D, Ostuni V, Cadeddu C, Colonna P. Evaluation of left atrial appendage function and thrombi in patients with atrial fibrillation: from transthoracic to real time 3D transesophageal echocardiography. Int J Cardiovasc Imaging. 2017;33(4):491-8. doi: 10.1007/s10554-016-1026-6.
45. Pathan F, Hecht H, Narula J, Marwick TH. Roles of Transesophageal Echocardiography and Cardiac Computed Tomography for Evaluation of Left Atrial Thrombus and Associated Pathology: A Review and Critical Analysis. JACC Cardiovasc Imaging. 2018;11(4):616-27. doi: 10.1016/j.jcmg.2017.12.019.
46. Task Force for the management of COVID-19 of the European Society of Cardiology. ESC guidance for the diagnosis and management of cardiovascular disease during the COVID-19 pandemic: part 2-care pathways, treatment, and follow-up. Eur Heart J. 2022;43(11):1059-103. doi: 10.1093/eurheartj/ehab697.
47. Tanaka M, Yasuoka R, Nagano T, Kotake Y, Maruyama M, Yamamoto H, et al. A novel method to demonstrate thrombus formation of the left atrial appendage in patients with persistent atrial fibrillation by cardiac computed tomography. Int J Cardiol Heart Vasc. 2021;36:100866. doi: 10.1016/j.ijcha.2021.100866.
48. Tamis-Holland JE, Jneid H. Myocardial Infarction With Nonobstructive Coronary Arteries (MINOCA): It's Time to Face Reality! J Am Heart Assoc. 2018;7(13):e009635. doi: 10.1161/JAHA.118.009635.
49. Vidal-Perez R, Abou Jokh Casas C, Agra-Bermejo RM, Alvarez-Alvarez B, Grapsa J, Fontes-Carvalho R, et al. Myocardial infarction with non-obstructive coronary arteries: A comprehensive review and future research directions. World J Cardiol. 2019;11(12):305-15. doi: 10.4330/wjc.v11.i12.305.
50. Tamis-Holland JE, Jneid H, Reynolds HR, Agewall S, Brilakis ES, Brown TM, et al. Contemporary Diagnosis and Management of Patients With Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease: A Scientific Statement From the American Heart Association. Circulation. 2019;139(18):e891-e908. doi: 10.1161/CIR.0000000000000670.
51. Feuchtner GM, Barbieri F, Luger A, Skalla E, Kountchev J, Widmann G, et al. Myocardial injury in COVID-19: The role of coronary computed tomography angiography (CTA). J Cardiovasc Comput Tomogr. 2021;15(1):e3-e6. doi: 10.1016/j.jcct.2020.07.002.
52. Everaert BR, Muylle J, Bartholomeus Twickler T. Emerging cardiological issues during the COVID-19 pandemic. Eur J Clin Invest. 2020;50(7):e13270. doi: 10.1111/eci.13270.
53. Peretto G, Sala S, Caforio ALP. Acute myocardial injury, MINOCA, or myocarditis? Improving characterization of coronavirus-associated myocardial involvement. Eur Heart J. 2020;41(22):2124-5. doi: 10.1093/eurheartj/ehaa396.
54. Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019;40(2):87-165. doi: 10.1093/eurheartj/ehy394.
55. Cheung SC, Lim MC, Chan CW. The role of coronary CT angiography in chronic total occlusion intervention. Heart Asia. 2010;2(1):122-5. doi: 10.1136/ha.2010.002261.
56. Morino Y, Abe M, Morimoto T, Kimura T, Hayashi Y, Muramatsu T, et al. Predicting successful guidewire crossing through chronic total occlusion of native coronary lesions within 30 minutes: the J-CTO (Multicenter CTO Registry in Japan) score as a difficulty grading and time assessment tool. JACC Cardiovasc Interv. 2011;4(2):213-21. doi: 10.1016/j.jcin.2010.09.024.
57. Opolski MP, Achenbach S, Schuhbäck A, Rolf A, Möllmann H, Nef H, et al. Coronary computed tomographic prediction rule for time-efficient guidewire crossing through chronic total occlusion: insights from the CT-RECTOR multicenter registry (Computed Tomography Registry of Chronic Total Occlusion Revascularization). JACC Cardiovasc Interv. 2015;8(2):257-67. doi: 10.1016/j.jcin.2014.07.031.
58. Hong SJ, Kim BK, Cho I, Kim HY, Rha SW, Lee SH, et al. Effect of Coronary CTA on Chronic Total Occlusion Percutaneous Coronary Intervention: A Randomized Trial. JACC Cardiovasc Imaging. 2021;14(10):1993-2004. doi: 10.1016/j.jcmg.2021.04.013.
59. Hennessey B, Vera-Urquiza R, Mejía-Rentería H, Gonzalo N, Escaned J. Contemporary use of coronary computed tomography angiography in the planning of percutaneous coronary intervention. Int J Cardiovasc Imaging. 2020;36(12):2441-59. doi: 10.1007/s10554-020-02052-8.
60. Mintz GS, Popma JJ, Pichard AD, Kent KM, Satler LF, Chuang YC, et al. Patterns of calcification in coronary artery disease. A statistical analysis of intravascular ultrasound and coronary angiography in 1155 lesions. Circulation. 1995;91(7):1959-65. doi: 10.1161/01.cir.91.7.1959.
61. Qi L, Tang LJ, Xu Y, Zhu XM, Zhang YD, Shi HB, Yu RB. The Diagnostic Performance of Coronary CT Angiography for the Assessment of Coronary Stenosis in Calcified Plaque. PLoS One. 2016;11(5):e0154852. doi: 10.1371/journal.pone.0154852.
62. Li L, Hao J, Qu S, Fang Y. The diagnostic value of three-dimensional CT angiography for patients with acute coronary artery disease. Exp Ther Med. 2018;16(2):945-9. doi: 10.3892/etm.2018.6257.
63. Abdelrahman KM, Chen MY, Dey AK, Virmani R, Finn AV, Khamis RY, et al. Coronary Computed Tomography Angiography From Clinical Uses to Emerging Technologies: JACC State-of-the-Art Review. J Am Coll Cardiol. 2020;76(10):1226-43. doi: 10.1016/j.jacc.2020.06.076.
64. Zhao N, Gao Y, Xu B, Jiang T, Xu L, Hu H, et al. CT-FFR vs a model of combined plaque characteristics for identifying ischemia: Results from CT-FFR CHINA trial. Eur J Radiol. 2021;138:109634. doi: 10.1016/j.ejrad.2021.109634.
65. Pijls NH, De Bruyne B, Peels K, Van Der Voort PH, Bonnier HJ, Bartunek J et al. Measurement of fractional flow reserve to assess the functional severity
of coronary-artery stenoses. N Engl J Med. 1996;334(26):1703-8. doi: 10.1056/NEJM199606273342604.
66. Peper J, Suchá D, Swaans M, Leiner T. Functional cardiac CT-Going beyond Anatomical Evaluation of Coronary Artery Disease with Cine CT, CT-FFR, CT Perfusion and Machine Learning. Br J Radiol. 2020;93(1113):20200349. doi: 10.1259/bjr.20200349.
67. Patel AR, Bamberg F, Branch K, Carrascosa P, Chen M, Cury RC, et al. Society of cardiovascular computed tomography expert consensus document on myocardial computed tomography perfusion imaging. J Cardiovasc Comput Tomogr. 2020 Jan-;14(1):87-100. doi: 10.1016/j.jcct.2019.10.003.
68. Celeng C, Leiner T, Maurovich-Horvat P, Merkely B, de Jong P, Dankbaar JW, et al. Anatomical and Functional Computed Tomography for Diagnosing Hemodynamically Significant Coronary Artery Disease: A Meta-Analysis. JACC Cardiovasc Imaging. 2019;12(7 Pt 2):1316-25. doi: 10.1016/j.jcmg.2018.07.022.
69. Conte E, Mushtaq S, Marchetti D, Mallia V, Belmonte M, Melotti E, et al. Potential Application of Cardiac Computed Tomography for Early Detection of Coronary Atherosclerosis: From Calcium Score to Advanced Atherosclerosis Analysis. J Clin Med. 2021;10(3):521. doi: 10.3390/jcm10030521.
70. Saremi F, Achenbach S. Coronary plaque characterization using CT. AJR Am J Roentgenol. 2015;204(3):W249-60. doi: 10.2214/AJR.14.13760.
71. Conte E, Dwivedi A, Mushtaq S, Pontone G, Lin FY, Hollenberg EJ, et al. Age- and sex-related features of atherosclerosis from coronary computed tomography angiography in patients prior to acute coronary syndrome: results from the ICONIC study. Eur Heart J Cardiovasc Imaging. 2021;22(1):24-33. doi: 10.1093/ehjci/jeaa210.

Submitted date:
05/29/2023

Reviewed date:
06/16/2023

Accepted date:
07/02/2023

Publication date:
07/02/2023