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Can Coronary Artery Anomalies Be Detected on CT Calcium Scoring Studies?

Posted Apr 30, 2013 Updated Apr 10, 2023
By P. Tim Maddux BS , U. Joseph Schoepf MD , Peter L. Zwerner MD , Alekser W. Krazinski BS , Thomas M. Berghaus MD , Pamela B. Morris MD , Christian Thilo MD
8 min read

Purpose

To determine whether coronary artery anomalies can be detected on noncontrast computed tomography (CT) coronary artery calcium scoring (CCS) studies.

Materials and Methods

A total of 126 patients (mean age 62 years; 35 women) underwent noncontrast CCS and contrast enhanced coronary CT angiography (cCTA). Thirty-three patients were diagnosed with a coronary anomaly on cCTA, whereas coronary anomalies were excluded in 93. Two observers (reader 1 [R1] and reader 2 [R2]), blinded to patient information independently evaluated each CCS study for: 1) visibility of coronary artery origins, 2) detection of coronary anomalies, and 3) benign or malignant (ie, interarterial) course. Using cCTA as the reference standard, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of CCS studies for detecting coronary anomalies were calculated.

Results

Of the 33 coronary anomalies, 16 were benign and 17 malignant. Based on noncontrast CCS studies, R1 and R2 correctly identified the left main origin in 123/126 (97.6%) and 121/126 (96%) patients; the left anterior descending origin in 125/126 (99.2%) and 122/126 (96.8%); the circumflex origin in 120/126 (95.2%) and 105/126 (83.3%); and the right coronary artery origin in 117/126 (92.9%) and 103/126 (81.7%), respectively. R1 and R2 identified 34 and 27 coronary anomalies and classified 19 and 15 as malignant, respectively. Interobserver reproducibility for detection of coronary anomalies was good (k = 0.76). Interobserver agreement for detection of malignant variants was even stronger (k = 0.80). On average, coronary artery anomalies were diagnosed with 85.2% sensitivity, 96.4% specificity, 90.5% PPV, and 94.1% NPV on noncontrast CCS studies.

Conclusion

Benign and malignant coronary artery anomalies can be detected with relatively high accuracy on noncontrast-enhanced CCS studies. CCS studies should be reviewed for signs of coronary artery anomalies in order to identify malignant variants with possible impact on patient management.

The anatomy of the coronary arteries is not always predictable. Normal coronary anatomy is defined by a left coronary artery (LCA) and a right coronary artery (RCA) originating from the left and right aortic sinus, respectively. Coronary artery anomalies are variants rarely observed in the common population. Some are classified as benign while others—malignant types—can be life-threatening. Anomalies of the coronary arteries can be defined by their origin, course, or termination . Other variants such as anomalies of intrinsic coronary arterial anatomy (eg, congenital ostial stenosis, coronary aneurysms) were not subject of this study. Prognostically important variants, sometimes referred to as “malignant” anomalies, take an interarterial proximal course between the main pulmonary artery and the aorta. This path is subject to compression—especially during exercise—whereas “benign” coronary artery anomalies (non-interarterial, eg, retro-aortic course) do not carry such risk . Specific examples of interarterial coronary anomalies include an anomalous origin of the LCA from the RCA or right coronary sinus, or the anomalous origin of the RCA from the LCA or left coronary sinus. A common example of an anomaly not associated with possible myocardial ischemia is the circumflex artery (Cx) originating from the right coronary sinus without interarterial course.

Malignant coronary artery anomalies have been linked with chest pain, sudden death, cardiomyopathy, syncope, dyspnea, arrhythmia, ventricular fibrillation, and myocardial infarction . The prevalence of these anomalies in society is estimated to be at or less than 1% but that number may be misleading because of the number of asymptomatic patients that go undiagnosed . Some studies suggest that sudden cardiac death is caused by malignant coronary artery anomalies in upwards of 12% of cases .

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Materials and methods

Patient Population

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CT Protocol

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Image Review

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Statistical Analysis

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Results

cCTA

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Figure 1, A 49-year-old male presenting with chest pain. (a) Transverse image of a noncontrast enhanced calcium scoring (CCS) study demonstrates an anomalous origin of the right coronary artery (RCA) from the left aortic cusp ( arrow ). (b) Transverse contrast-enhanced computed tomography angiogram at the same level as the CCS demonstrates the interarterial course of the RCA between the pulmonary trunk and the aorta. (c) Off-sagittal multiplanar reformat with arrow indicating the RCA origin and its interarterial course. The anomaly profiled in these images is malignant.

Figure 2, A 40-year-old female presenting with exertional shortness of breath. (a) Transverse image of a noncontrast-enhanced calcium scoring study demonstrates an anomalous origin ( arrow ) of the right coronary artery (RCA) from the pulmonary artery. (b) Transverse contrast enhanced computed tomography angiogram at the same level verifies the abnormal origin. (c) Three-dimensional reconstruction with arrow indicating the RCA origin.

Figure 3, A 60-year-old male patient with diabetes mellitus and exercise-induced shortness of breath. (a) Transverse image of noncontrast calcium scoring study demonstrates benign course of left anterior descending (LAD) artery ( arrow ) anterior to the pulmonary artery. (b) Transverse image of a computed tomography angiogram at the same level confirms the benign course of the LAD. 3D volume rendered image (c) shows the common origin of LAD and right coronary artery ( arrow ).

Figure 4, A 64-year-old male patient with coronary artery disease referred with atypical chest pain and abnormal nuclear stress test. (a) Transverse image of a noncontrast enhanced calcium scoring (CCS) study demonstrates an anomalous course of the left circumflex (Cx, arrow ) traveling between aorta and right/left atrium. (b) Transverse contrast enhanced computed tomography angiogram at the same level as the CCS confirms the underlying benign anomaly. Maximum intensity projection (c) shows the Cx coursing between aorta and atria.

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CCS Studies

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Table 1

Diagnostic Performance of CCS for Detecting Coronary Anomalies

Sensitivity (%) Specificity (%) PPV (%) NPV (%) R1 91.7 95.9 89.2 96.9 R2 78.6 96.9 91.7 91.2 Average 85.2 96.4 90.5 94.1

CCS, coronary calcium scoring; NPV, negative predictive value; PPV, positive predictive value; R1, reader 1; R2, reader 2.

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Table 2

Number of Patients with Detectable Coronary Artery Origin at CCS

LM LAD Cx RCA Yes No % Yes No % Yes No % Yes No % R1 123 3 (97.6) 125 1 (99.2) 120 6 (95.2) 117 9 (92.9) R2 121 5 (96.0) 122 4 (96.8) 105 21 (83.3) 103 23 (81.7)

CCS, coronary calcium scoring; Cx, left circumflex coronary artery; LAD, left anterior descending coronary artery; LM, left main coronary artery; R1, reader 1; R2, reader 2; RCA, right coronary artery.

Percentage of correct identification in parentheses.

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Table 3

Inter-observer Agreement of Overall Coronary Anomalies and Malignant Anomalies (n = 126)

Coronary Anomalies Malignant Yes No Yes No R1 34 92 19 15 R2 27 99 15 12 Interobserver agreement (Κ) 0.76 0.80

R1, reader 1; R2, reader 2.

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Discussion

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Acknowledgments

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Academic Radiology, Volume 20, Issue 5
Journals General Radiology
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