LETTER
Electron-Beam Computed Tomography for Evaluating Coronary Artery Disease
Paolo Raggi, MD
15 December 1998 | Volume 129 Issue 12 | Pages 1076-1077
TO THE EDITOR:
Some of the conclusions reached by Dr. Fiorino [1] in his review on electron-beam computed tomography (CT) seem misleading and confusing. In his final statement, he affirms that "Electron-beam CT has the greatest sensitivity for the detection of angiographically significant lesions, so stenoses of less than 50% that may be at high risk for rupture can be missed ... . Given these reservations, the current role for electron-beam CT in clinical practice is unclear." Although it is true that the more extensive the atherosclerotic disease, the greater the likelihood of finding coronary calcifications, Dr. Fiorino neglects to remind the reader that this technology is the most sensitive tool available for the detection of minimal and still subclinical atherosclerotic disease [2]. Furthermore, critical coronary artery obstruction is present in only 2.5% of the segments that have no detectable calcium on electron-beam CT [2]. Vascular remodeling hampers the ability of coronary angiography to detect nonobstructive coronary artery disease [3], and it is well known that two thirds of myocardial infarctions and sudden deaths occur in patients with non-flow-limiting lesions [4]. Therefore, the real value of electron-beam CT resides in its ability to detect a silent but incipient problem, giving the physician a chance to address it early and possibly change its course.
We recently reported that electron-beam CT can be used to noninvasively follow the evolution of atherosclerotic coronary disease in patients receiving treatment with lipid-lowering drugs [5]. This information may become extremely important in the hands of physicians practicing careful preventive medicine. The time has come to redirect our attention from the critical, flow-limiting lesion to the subliminal lesion that only electron-beam CT and intravascular ultrasonography can so far detect. Several investigators are accumulating outcomes data that will soon be available to demonstrate the clear role of electron-beam CT in clinical practice.
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Author and Article Information
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EBT Research Foundation; Nashville, TN 37075
1. Fiorino AS. Electron-beam computed tomography, coronary artery calcium, and evaluation of patients with coronary artery disease. Ann Intern Med. 1998; 128:839-47.
2. Simons DB, Schwartz RS, Edwards WD, Sheedy PF, Breen JF, Rumberger JA. Noninvasive definition of anatomic coronary artery disease by ultrafast computed tomographic scanning: a quantitative pathologic comparison study. J Am Coll Cardiol. 1992; 20:1118-26.
3. Glagov S, Weisenberg E, Zarins CK, Stankunavicius R, Kolettis GJ. Compensatory enlargement of human atherosclerotic coronary arteries. N Engl J Med. 1987; 316:1371-5.
4. Davies MJ, Thomas AC. Plaque fissuring-the cause of acute myocardial infarction, sudden cardiac death, and crescendo angina. Br Heart J. 1985; 53:363-73.
5. Callister TQ, Russo DJ, Lippolis NJ, Raggi P. Effect of lipid lowering therapy on plaque burden: accurate assessment by electron beam computed tomography [Abstract]. Circulation. 1997; 96:1-305.
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