Rationale and Objectives
Coronary artery calcium (CAC) scoring is an excellent imaging tool for subclinical atherosclerosis detection and risk stratification. We hypothesize that although CAC has been underreported in the past on computed tomography (CT) scans of the abdomen, specialized resident educational intervention can improve on this underreporting.
Materials and Methods
Beginning July 2009, a dedicated radiology resident cardiac imaging rotation and curriculum was initiated. A retrospective review of the first 500 abdominal CT reports from January 2009, 2011, and 2013 was performed including studies originally interpreted by a resident and primary attending physician interpretations. Each scan was reevaluated for presence or absence of CAC and coronary artery disease (CAD) by a cardiovascular CT expert reader. These data were then correlated to determine if the presence of CAC had been properly reported initially. The results of the three time periods were compared to assess for improved rates of CAC and CAD reporting after initiation of a resident cardiac imaging curriculum.
Results
Statistically significant improvements in the reporting of CAC and CAD on CT scans of the abdomen occurred after the initiation of formal resident cardiac imaging training which included two rotations (4 weeks each) of dedicated cardiac CT and cardiac magnetic resonance imaging interpretation during the resident’s second, third, or fourth radiology training years. The improvement was persistent and increased over time, improving from 1% to 72% after 2 years and to 90% after 4 years.
Conclusions
This single-center retrospective analysis shows association between implementation of formal cardiac imaging training into radiology resident education and improved CAC detection and CAD reporting on abdominal CT scans.
Formal coronary artery calcification scoring via prospectively electrocardiogram (ECG)–triggered cardiac computed tomography (CT) is an excellent imaging tool for subclinical atherosclerosis detection and risk stratification . Guidelines currently suggest formal coronary artery calcium (CAC) scoring for patients in the intermediate (10%–20%) 10-year risk of cardiac events on the basis of Framingham risk scores or other algorithm . However, in certain populations, CAC, even when detected by less-sophisticated tests such as low-dose noncontrast non–ECG-synchronized CT scans of the chest, has been shown to be prognostic of adverse coronary artery–related events . The presence of even the smallest amount of detectable CAC portends higher risk compared to the absence of detectable CAC .
CT scans of the abdomen typically include the inferior most portion of the heart in the superior field of view although there is certainly variability in the extent of included portions between institutions. The American College of Radiology practice parameters specifically indicate initiating abdominal CT just above the level of the diaphragm . In routine clinical practice, however, there is at least moderate variability in the degree of coverage above the diaphragm because of technologist variation and changes in patient inspiration. CAC in the inferior coronary arteries, specifically the distal right coronary artery, posterior descending coronary artery, and the posterior lateral coronary artery can be seen incidentally on some scans of the abdomen ( Fig 1 ). As the presence of CAC is diagnostic of coronary artery disease (CAD), observation of incidental CAC on CT scans of the abdomen may be clinically important . Despite this, current guidelines on abdominal CT incidental findings do not address CAC .
Open full size image
Figure 1
Sagittal multiplanar reformat image of abdominal and pelvic computed tomography with oral and intravenous contrast of a 57-year-old male patient with complete remission of lymphoma status after chemotherapy. The arrow demarcates calcification of the right coronary artery. Note the relatively high level of scan acquisition above the diaphragm in this patient due to improved inspiratory effort after the initial scout image was obtained.
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Materials and methods
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Results
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Table 1
Serial Improvement in CAC Reporting
2009 ( n = 375) 2011 ( n = 361) 2013 ( n = 403) CAC (+) CAC (−) CAC (+) CAC (−) CAC (+) CAC (−) CAC noted 1 0 74 0 122 0 CAC not noted 73 301 29 258 14 267 Sensitivity % 1 72 ∗ 90 † Specificity % 100 100 100 CAD noted 0 0 8 0 17 0 CAD not noted 74 301 95 258 119 267 Accuracy % 0 8 ‡ 13 §
CAC, coronary artery calcium; CAD, coronary artery disease.
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Discussion
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Study Limitations
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Conclusions
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