Diagnostic Imaging has an article that talks about a presentation at the Stanford meeting, where there was a presentation from Dr David Kandzari of the Duke Centre for Evidence-Based Practice. He reviewed all the evidence for the use of coronary CTA, after being asked to do so by the Agency for Healthcare Quality and Research and this data was then presented to the centres for Medicare and Medicaid.
The article says that the data needs to be examined with caution, since all the studies so far have skewed populations and many patients who have been excluded from the studies due to high calcium scores or poor-quality. If you take a real-life situation, we all know that in patients with calcified plaques, there are always issues with accuracy, despite whatever hype our publications give us. The best results are in the younger patients with a low to intermediate risk of coronary artery disease with a low pre-test probability of disease. But if we were to take anyone and everyone into the scanners, our accuracy will definitely drop.
This 56-years old man came with a history of hyperlipedemia and a family history of coronary artery disease. He had a calcium score of around 500. In most of his vessels (Figs. 2, 3), the LAD can be seen to be normal despite the dense calcification. Using an automatic vessel-tracing software helps in this situation. However, one segment opposite the D1 origin in the LAD (Figs. 4, 5), cannot be evaluated despite the calcium not being particularly dense. Sometimes, the way the calcium involves the vessel makes it extremely difficult to differentiate it from the lumen and most often we then give a report saying "a calcified plaque is seen hampering adequate visualization of the lumen". We then often advise an adenosine stress perfusion MRI, especially if the patient is not particularly symptomatic.