EDITORIAL

MS-CT coronary anglography an emerging technique Diagnostic invasive coronary angiography is the key diagnostic tool in the management of patients with ischaemic coronary artery disease and the outcome of the angiogram plays a decisive role to determine which patients should continue with conservative medical management and who should be referred for percutaneous coronary intervention or coronary bypass surgery. Diagnostic coronary angiography is widely available and has an undisputed longstanding reputation as the standard of reference for the outcome comparison with functional and perfusion tests that assess the presence of myocardial ischaemia. However, the technique also has its drawbacks. The main disadvantage is the invasive nature of the technique requiring a dedicated team (nurse, technician, operator) to perform the investigation and a short postinvestigational stay, often in a monitored facility which makes it an expensive examination. This has prompted the search for a noninvasive technique which is more patient-friendly and less costly. Magnetic resonance coronary angiography (MR-CA) was the first noninvasive technique that appeared on the horizon. The initial MR-CA results were promising but the lack of significant technical advances during recent years resulted in less enthusiasm and a decline in clinical investigations despite the versatility and great potential ofMRimaging, which can be used for the assessment of left ventricular function, perfusion, viability and coronary anatomy.

Recently multislice computed tomography (MS-CT) coronary angiography has emerged as a robust noninvasive diagnostic modality. The newest generation ofcardiac CT scanners offers the best way yet to noninvasively image the coronary arteries. The 16-slice MS-CT scanners are capable ofvisualising the most relevant segments ofthe coronary tree, in particular when combined with 5-blockade to slow the heart rate, thereby minimising the cardiac motion artefacts. The noninvasively obtained MS-CT coronary images are sometimes spectacular and may induce overconfidence in the clinical reliability ofthe technique. Van Ooijen et al. report about their experience with MS-CT coronary angiography. The authors have a great reputation in the field of noninvasive coronary imaging, but overenthusiasm for the technique may have moved them to a powerful statement: coronary multidetector computed tomography (MDCT) provides diagnostic information which equals coronary angiographic diagnosis in most cases and in some cases even provides a better diagnosis.3 I too am enthusiastic, but the reported data so far do not support that MS-CT is equal to or even surpasses the diagnostic performance of invasive diagnostic coronary angiography; in fact the available data demonstrate significant shortcomings of MS-CT coronary angiography. The images still suffer from cardiac and respiratory motion artefacts. Severe calcifications hamper lumen assessment and due to blooming effects may cause overestimation of lesion severity. Irregular heart rhythm precludes reliable MS-CT scanning and so far MS-CT quantification algorithms are lacking and need to be developed. Yet, undoubtedly, MS-CT will play an increasingly significant role in the detection of coronary obstructions while with current MS-CT scanners it Nethcrlands Heart Journal, Volume 12, Number 5, May 2004

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is already easier to recognise the exact nature of coronary anomalies with MS-CT than with invasive coronary angiography. In addition MS-CT has the potential not only to assess the coronary lumen, but can also image calcific and noncalcific nonobstructive plaques. The question remains: can noninvasive coronary imaging equal or surpass the diagnostic performance of invasive coronary angiography? The resolution ofdiagnostic coronary angiography will be very difficult to surpass by any noninvasive imaging modality; furthermore this longexisting technique is still undergoing significant improvements, such as the recently introduced flat panel technology. However, it seems reasonable to accept that at some point the inherently lower resolution of noninvasive techniques will be of sufficient quality to become acceptable as a reliable clinical noninvasive imaging tool. Current MS-CT is a breakthrough technique, but still in need of improvement to be able to reliably identify, localise and assess coronary

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Nieman K, et al. Reliable Noninvasive CoronaryAngiography With Fast Submillimeter Multislice Spiral Computed Tomography. Circulation 2002;106(16):2051-4. Ropers D, et al. Detection of coronary artery stenoses with thin-slice multi-detector row spiral computed tomography and multiplanar reconstruction. Circulation 2003;107(5):6646. Ooijen van PMA, Dorgelo J, Zijlstra F, Oudkerk M, et al. Tackling the challenges of interpretation of conventional coronary angiography using multidetector CT coronary angiography. Neth HeartJ2004;12:203-7.

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