Description:
Coronary computed tomographic angiography (CCTA) is a noninvasive imaging study that uses intravenously administered contrast material and high-resolution, rapid imaging computed tomography (CT) equipment to obtain detailed volumetric images of the coronary blood vessels. Cardiac CT perfusion can be added to the CCTA, with increasing data regarding its diagnostic accuracy (Nakamura, 2018; Pontone, 2018).

Image quality depends on keeping HR optimally < 60 bpm, a regular rhythm, limited coronary calcification, stents > 3.0 mm in diameter, ≥ 5 second breath hold, and vessels requiring imaging ≥ 1.5 mm diameter (Abbara, 2016).

Coronary artery disease (CAD) stenosis ≥ 70% is considered clinically significant or obstructive CAD. Hemodynamically or functionally significant CAD means the degree of stenosis is severe enough to cause ischemia. This is discussed in more detail in the Overview section (Fihn, 2012; Montalescot, 2013; Wolk, 2013).

Stable patients without known CAD fall into 2 categories (Fihn, 2012; Montalescot, 2013; Wolk, 2013):

• Asymptomatic, for whom global risk of CAD events can be determined from coronary risk factors, using calculators available online (see Part III in the Background section).
• Symptomatic, for whom we estimate the pretest probability that their chest-related symptoms are due to clinically significant CAD.

The Three Types of Chest Pain or Discomfort:

• Typical Angina (Definite) is defined as including all 3 characteristics:
• Substernal chest pain or discomfort with characteristic quality and duration
• Provoked by exertion or emotional stress
• Relieved by rest and/or nitroglycerin
• Atypical Angina (Probable) has only 2 of the above characteristics.
• Nonanginal Chest Pain/Discomfort has only 0 – 1 of the above characteristics.
• Once the type of chest pain has been established from the medical record, the Pretest Probability of significant CAD is estimated from the Diamond Forrester Table below, recognizing that additional coronary risk factors could increase pretest probability (Wolk, 2013):   

• Very Low: < 5% pretest probability of CAD
• Low: 5 – 10% pretest probability of CAD
• Intermediate: 10% – 90% pretest probability of CAD
• High: > 90% pretest probability of CAD 

OVERVIEW
Scenarios that support MPI over SE
(Henzlova, 2016)

Poor Quality Echo Image

• Obesity with body mass index (BMI) > 40 kg/m2 or poor acoustic imaging window

Inability to Exercise

• Physical limitations precluding ability to exercise for at least 3 full minutes of Bruce protocol
• The patient has limited functional capacity ( < 4 METS) such as one of the following:
  • Unable to take care of their activities of daily living (ADLs) or ambulate
  • Unable to walk 2 blocks on level ground
  • Unable to climb 1 flight of stairs
  • Unable to vacuum, dust, do dishes, sweep, or carry a small grocery bag

Other Comorbidities

• Prior cardiac surgery (coronary artery bypass graft or valvular)
• Left ventricular ejection fraction ≤ 40%
• Severe chronic obstructive pulmonary disease (COPD) with pulmonary function test (PFT) documentation, severe shortness of breath on minimal exertion, or requirement of home oxygen during the day
• Poorly controlled hypertension, with systolic blood pressure (BP) > 180 or Diastolic BP > 120

ECG and Echo-Related Baseline Findings

• Pacemaker or implantable cardioverter defibrillator (ICD)
• Poorly controlled atrial fibrillation/ectopy
• Resting wall motion abnormalities that would make SE interpretation difficult
• Complete LBBB

Risk-Related

• High pretest probability in suspected CAD
• Intermediate or high global risk in patients requiring type IC antiarrhythmic drugs
• Arrhythmia risk with exercise

ECG Stress Test Alone versus Stress Testing with Imaging
Prominent scenarios suitable for an ECG stress test WITHOUT imaging (i.e., exercise treadmill ECG test) require that the patient can exercise for at least 3 minutes of Bruce protocol with achievement of near maximal heart rate AND has an interpretable ECG for ischemia during exercise (Wolk, 2013):

• The (symptomatic) low or intermediate pretest probability patient who is able to exercise and has an interpretable ECG (Wolk, 2014)
• The patient who is under evaluation for exercise-induced arrhythmia
• The patient who requires an entrance stress test ECG for a cardiac rehab program or for an exercise prescription
• For the evaluation of syncope or presyncope during exertion (Shen, 2017)

Duke Exercise ECG Treadmill Score (Mark, 1987)
Calculates risk from ECG treadmill alone:

• The equation for calculating the Duke treadmill score (DTS) is: DTS = exercise time in minutes - (5 x ST deviation in mm or 0.1 mV increments) - (4 x exercise angina score), with angina score being 0 = none, 1 = non-limiting, and 2 = exercise-limiting. 
• The score typically ranges from - 25 to + 15. These values correspond to low-risk (with a score of ≥ + 5), intermediate risk (with scores ranging from - 10 to + 4), and high-risk (with a score of ≤ - 11) categories. 

An uninterpretable baseline ECG includes (Fihn, 2012):

• ST segment depression of 1 mm or more (not for non-specific ST - T wave changes)
• Ischemic looking T wave inversions of at least 2.5 mm
• LVH with repolarization abnormalities, WPW, a ventricular paced rhythm, or left bundle branch block
• Digitalis use with associated ST - T abnormalities
• Resting HR under 50 bpm on a beta blocker and an anticipated suboptimal workload
• Note: RBBB with less than 1 mm ST depression at rest may be suitable for EKG treadmill testing

Global Risk of Cardiovascular Disease

Global risk of CAD is defined as the probability of manifesting cardiovascular disease over the next 10 years and refers to asymptomatic patients without known cardiovascular disease. It should be determined using one of the risk calculators below. A high risk is considered greater than a 20% risk of a cardiovascular event over the ensuing 10 years.

High global risk by itself generally lacks scientific support as an indication for stress imaging (Cheng, 2011).

There are rare exemptions, such as patients requiring IC antiarrhythmic drugs, who might require coronary risk stratification prior to initiation of the drug, when global risk is moderate or high.

• CAD Risk — Low
  • 10- year absolute coronary or cardiovascular risk less than 10%
• CAD Risk — Moderate
  • 10- year absolute coronary or cardiovascular risk between 10% and 20%
• CAD Risk — High
  • 10- year absolute coronary or cardiovascular risk of greater than 20%  

Websites for Global Cardiovascular Risk Calculators*
*Patients who have already manifested cardiovascular disease are already at high global risk and are not applicable to the calculators.
(Arnett, 2019; D’Agostino, 2008; Goff, 2014; McClelland, 2015; Ridker, 2007)

Coronary Artery Calcium Scoring
(Arnett, 2019)
Non-contrast coronary computed tomography (non-contrast coronary CT) and its older technological version, electron beam computed tomography (EBCT), provide quantitative coronary artery calcium scoring, which is appropriate for further evaluation of coronary risk in asymptomatic patients without known cardiovascular disease, who are at low to intermediate or intermediate global risk for coronary or overall cardiovascular disease. Non-contrast coronary CT (computed tomography) and EBCT are supported by a separate CPT code and guideline document with references titled EBCT or Non-Contrast Coronary CT.

Definitions of Coronary Artery Disease 
(Fihn, 2012; Lofti, 2018; Mintz, 2016; Montalescot, 2013; Patel, 2017)

• Percentage stenosis refers to the reduction in diameter stenosis when angiography is the method and can be estimated or measured using angiography or more accurately measured with intravascular ultrasound (IVUS).
• Coronary artery calcification is a marker of risk, as measured by Agatston score on coronary artery calcium imaging. It is not a diagnostic tool so much as it is a risk stratification tool. Its incorporation into global risk can be achieved by using the MESA risk calculator.
• Stenoses ≥ 70% are considered obstructive coronary artery disease (also referred to as clinically significant), while stenoses ≤ 70% are considered non-obstructive coronary artery disease (Patel, 2017).
• Ischemia-producing disease (also called hemodynamically or functionally significant disease, for which revascularization might be appropriate) generally implies at least one of the following:
  • Suggested by percentage diameter stenosis ≥ 70% by angiography; borderline lesions are 40 – 70% (Fihn, 2012)
  • For a left main artery, suggested by a percentage stenosis ≥ 50% or minimum luminal cross-sectional area on IVUS ≤ 6 square mm (Fihn, 2012; Lofti, 2018; Mintz, 2016)
  • FFR (fractional flow reserve) ≤ 0.80 for a major vessel (Lofti, 2018; Mintz, 2016)
  • iFR (instantaneous wave-free ratio) ≤ 0.89 for a major vessel (Davies, 2017; Gotberg, 2017; Lofti, 2018)
  • Demonstrable ischemic findings on stress testing (ECG or stress imaging), that are at least mild in degree
• A major vessel would be a coronary vessel that would be amenable to revascularization, if indicated. This assessment is made based on the diameter of the vessel and/or the extent of myocardial territory served by the vessel.
• FFR is the distal to proximal pressure ratio across a coronary lesion during maximal hyperemia induced by either intravenous or intracoronary adenosine. Less than or equal to 0.80 is considered a significant reduction in coronary flow.
• Instantaneous wave-free ratio (iFR) measures the ratio of distal coronary to aortic pressure during the wave free period of diastole, with a value ≤ 0.89 considered hemodynamically significant (Davies, 2017; Gotberg, 2017).
• Newer technology that estimates FFR from CCTA images is covered under the separate NIA Guideline for FFR-CT.

Anginal Equivalent 
(Fihn, 2012; Moya, 2009; Shen, 2017)
Development of an anginal equivalent (e.g., shortness of breath, fatigue, or weakness) either with or without prior coronary revascularization should be based upon the documentation of reasons that symptoms other than chest discomfort are not due to other organ systems (e.g., dyspnea due to lung disease, fatigue due to anemia), by presentation of clinical data such as respiratory rate, oximetry, lung exam, etc. (as well as d-dimer, chest CT(A), and/or PFTs, when appropriate), and then incorporated into the evaluation of coronary artery disease as would chest discomfort. Syncope per se is not an anginal equivalent.  

Abbreviations

Policy
INDICATIONS FOR CORONARY COMPUTED TOMOGRAPHIC ANGIOGRAPHY (CCTA)
(Fihn, 2012; Montalescot, 2013; Taylor, 2010; Wolk, 2014)

Evaluation in Suspected Coronary Artery Disease (CAD)
(Cheng, 2011; Douglas, 2015; Fordyce, 2016; Newby, 2015)

• Intermediate pretest probability patients in whom either exercise electrocardiogram (ECG) stress or stress echo cannot be performed (see Background section)
• High pretest probability as an alternative to coronary angiography (can also do MPI)
• Exercise ECG stress test with intermediate Duke Treadmill Score (- 10 to + 4) in whom stress echo cannot be performed
• Equivocal, borderline, or discordant stress imaging evaluation with continued symptoms concerning for CAD
• Repeat testing in patient with new or worsening symptoms since prior normal stress imaging (Taylor, 2010; Wolk, 2013)
• Newly diagnosed clinical systolic heart failure (ejection fraction [EF] < 50%) without recent CAD evaluation, in the presence of angina or an anginal equivalent (Patel, 2012; Patel, 2013; Taylor, 2010; Wolk, 2013)
• Reduced EF (EF ≤ 40%) as an alternative to invasive coronary arteriography
• Before valve surgery or transcatheter intervention as an alternative to coronary angiography (Baumgartner, 2017; Chaikriangkrai, 2018; Nishimura, 2014)
• To establish the etiology of mitral regurgitation (Nishimura, 2014)
• Evaluation of coronary anomaly or aneurysm (CMR favored in young patients) (Bluemke, 2008; Grani, 2017; Newburger, 2016; Sachdeva, 2020)
  • Evaluation prior to planned repair
  • Evaluation due to change in clinical status and/or new concerning signs or symptoms
• Evaluation of coronary artery bypass grafts, to assess (Eisenberg, 2017; Taylor, 2010):
  • Patency and location when invasive coronary arteriography was either nondiagnostic or not performed
  • Location prior to cardiac or other chest surgery

References

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Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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