The routine assessment of extracardiac structures in patients referred for coronary computed tomographic angiography (CCTA) leads to a dilemma for the referring cardiologist. Should these extracardiac findings be evaluated with additional imaging or other procedures? Or are these findings unlikely to be clinically relevant? In order to resolve this dilemma, Kelion and colleagues1 reviewed data from 4340 patients (mean age 62±12 years, 49% male) who underwent CCTA over an 8 year period at a single institution. The indication for CCTA was dyspnoea in over 90% of patients. Overall, 717 extracardiac abnormalities were identified in 687 individuals (15.8% of the study group). However, clinical or imaging follow-up was needed in <7% and only 14 patients (0.3% of the entire population) required treatment for the extracardiac findings, with 12/14 of those finding seen on a focused cardiac field-of-view (FOV) (table 1). The cost per discounted quality-adjusted life year was lower using a cardiac FOV compared with a wide FOV. The authors conclude: ‘The way in which CCTAs are scrutinised for extracardiac abnormalities in a resource-limited healthcare system should be questioned.’

Clinical outcome in 687 patients with ≥1 extracardiac abnormality

In the accompanying editorial, Hulten and Murthy2 point out that ‘whereas UK and now ESC and US public health guidance recommend consideration of CCTA as a first-line evaluation for chest pain among low-risk to intermediate-risk patients, the clinical and economic burdens of incidental findings are omitted from consideration.’ In addition, ‘whereas current SCCT guidelines recommend review for incidental findings on limited cardiac FOV only and only recommend review of wide cardiac FOV reconstruction …