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Research Article

Incidental findings on computed tomography coronary angiography and its impact on respiratory services in a United Kingdom district general hospital

[version 1; peer review: 1 not approved]
PUBLISHED 14 Aug 2020
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Abstract

Background: Computed tomography coronary angiography is used to assess for coronary artery disease but can also pick up non-cardiac pathology. Previous studies have assessed the frequency of non-cardiac pathology. We investigated the non-cardiac findings and resulting follow up in a District General Hospital.
Methods: All computed tomography coronary angiography scans for 1 year were retrospectively collected. Basic demographics and the non-cardiac findings were recorded from electronic health records. The significant respiratory findings and the respiratory follow up of these non-cardiac findings were recorded.
Results: A total of 503 scans were carried out in one year. Of these scans, 24% had non cardiac findings present. Older patients were more likely to have non cardiac findings. The most common non cardiac findings were lung nodules, emphysema and hiatus hernias. Significant respiratory findings were present in 35 cases, which generated 24 episodes of respiratory follow up. Some patients who met criteria for follow up had not been referred.
Conclusions: Non cardiac findings are common on computed tomography coronary angiography and in our hospital these findings led to significant follow up in respiratory services.

Keywords

computed tomography coronary angiogram, incidental findings, lung nodule

Introduction

Computed tomography coronary angiography (CTCA) is used to assess for coronary artery disease in patients with chest pain and in preprocedural planning. In the United Kingdom the National Institute for Health and Care Excellence (NICE) guidelines 2016 have recommended CTCA as the first-choice imaging modality in patients with chest pain1. Aside from imaging the coronary arteries, CTCA will also image surrounding structures and can pick up non-cardiac findings (NCF). Some of the NCF will need follow up and further investigation, which has cost and service delivery implications2.

The NCF of CTCA have been previously investigated in prospective and retrospective cohort studies with greatly varying proportions of incidental finding in scans215. A systematic review of all forms of cardiac CT found NCF in 7%-100% of studies included16. The most common findings in previous studies have been respiratory, in particular lung nodules.

The British thoracic society guidelines and the Fleischner society have guidelines of the follow up of lung nodules17,18.

In this study of a district general hospital we assessed the frequency of NCF on CTCA, their significance and the follow up requested. The hospital provides secondary care services for cardiology, respiratory, gastroenterology and orthopaedics among other services.

Methods

Ethical approval for data collection and analysis was received from our institution’s clinical effectiveness team and all patient data has been anonymised. As the data was retrospectively collected and did not affect the included patients care no further ethical approval was required.

All CTCA performed for one year (2018) were collected retrospectively. Data were reviewed on electronic health records with demographics of patient’s age and sex recorded in an Excel spreadsheet. The CTCA’s had been performed on a Toshiba Acquillion One using the standard protocol and the images reported by consultant radiologists. NCF were recorded and divided by speciality. Patients with respiratory NCF had their notes reviewed for significance of findings, initial referral and follow up. Findings were assessed as significant if they required further investigation, follow up or treatment. For lung nodules significance was determined by whether they met criteria for further follow up according to British Thoracic Society Guidelines18. If a significant finding had not been followed up the primary care provider for the patient involved was informed.

Statistical analysis

Statistical analysis was performed using Jamovi (version 1.2.22)19. Normally distributed data are presented as means and standard deviations. Statistical significance was assessed by t-test or chi squared test, as appropriate. A p value <0.05 was deemed significant.

Results

A total of 503 CTCA were requested in 12 months with nearly all being requested by cardiology and 3 by primary care. There were 284 scans on females and 219 scans on males. The average age of the patients was 60.

NCF were identified in 120 (24%). NCF were more frequent in older patients with statistical significance. For gender there was no statistically significant difference in likelihood to have NCF (Table 1). Details of all CTCA and resultant NCF are available as Underlying data20.

Table 1. The baseline characteristics of patients who had CTCA split by presence of non-cardiac findings.

VariableNon-cardiac findings presentNon-cardiac findings absentp value
Number of patients (%)120 (24%)382 (76%)
Age (years) mean ± SD63 ± 1259 ± 120.002
Male, n (%)51 (42%)167 (44%)0.745

Of the NCF identified, 95 were respiratory with the majority being lung nodules (Table 2). The respiratory NCF were judged to be significant in 35 cases (7% of total scans). Other NCF were found in gastroenterology, orthopaedic and endocrine specialties which we did not assess for significance.

Table 2. The frequency of non-cardiac findings on CTCA for investigation of coronary artery disease.

SystemFindingFrequency
(significant)
RespiratoryNodule36 (19)
      Emphysema or parenchymal
      changes
15 (9)
      Atelectasis14 (0)
      Granuloma11 (0)
      Old inflammatory changes6 (0)
      Bronchiectasis3 (0)
      Pneumonitis3 (1)
Lung Mass1 (1)
Raised Hemidiapragm1 (1)
Fibrosis1 (1)
Pulmonary artery dilatation1 (1)
Pleural thickening1 (1)
Pleural effusions1 (1)
Mucous plugging1 (0)
GastrointestinalHiatus Hernia10
OrthopaedicSpinal degeneration8
Sternal abnormality2
Other Findings with n of 1Adrenal Adenoma, Liver Hemangioma, Liver Steatosis, Oesophageal
malignancy, Pancreatic duct dilatation
1

Table 3. The frequency of initial follow up of respiratory non-cardiac findings and not followed up significant findings.

FindingFurther imaging and
referral
Clinic
review
Multidisciplinary
team meeting
Not
followed up
Nodule12115
      Emphysema or
      parenchymal changes
9
      Pneumonitis1
Others6301

Onward referral for imaging (all CT Chest) was requested in 18 patients with results followed up by the respiratory team (Table 3). In addition to this, 5 patients were reviewed in the respiratory clinic without further imaging and 1 in a multidisciplinary team meeting.

There were 16 patients who had significant respiratory findings not referred for secondary care follow up, of these 9 were emphysema or parenchymal changes, 5 were nodules and 1 was a pleural effusion.

Discussion

NCF on CTCA are common, but the majority of these are not significant. If the use of CTCA increases, this will lead to significant downstream effects on other specialties, especially respiratory. In our hospital, one year’s worth of CTCA led to 24 respiratory follow ups in terms of imaging and clinic appointments. Even non-significant findings may lead to referrals and investigations if the ordering clinician is unsure of the current guidelines.

Other similar studies show a large variability in proportion of NCF in CTCA, likely due to variability in study populations, equipment and protocols used. Our results are similar to the most recent large UK dataset from the SCOT HEART trial with NCF more frequent as age increases and the most common findings being lung nodules, emphysema and hiatus hernia2. These additional data from a single district general hospital should inform other healthcare providers of possible service provision consequences from the use of CTCA.

We identified several patients who would have met criteria for follow up with lung nodules but did not receive this follow up. For some of the NCF such as emphysema and hiatus hernia the patients primary care practitioner will be the correct route of follow up and so they should be informed of the result. As these patients are all symptomatic enough to warrant a CTCA optimising their treatment for NCF seems prudent particularly as these may be the underlying cause of the symptoms. Not correctly following up lung nodules can have significant implications for the patient and in our data set some patients were not followed up according to guidelines.

Cardiologists may not be familiar with the follow up of NCF and so should be cautious when interpreting scan reports. As NCF are common in CTCA a standardised method of reviewing scans and referring findings could be considered with the aim to reduce unnecessary follow up requests and missed significant findings.

Conclusion

NCF are frequent on CTCA and will lead to downstream follow up which will have implications in terms of cost, service provision and patient’s time.

Data availability

Underlying data

Figshare: Data from: Incidental findings on computed tomography coronary angiography and its impact on respiratory services in a United Kingdom district general hospital. https://doi.org/10.6084/m9.figshare.12600056.v220.

This project contains details of each computed tomography coronary angiography procedure performed, including a description of the non-cardiac findings, where applicable. To anonymise the data patient age and date of birth is not included.

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

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how to cite this article
Gurung B, Lesser FD, James E and Nandakumar K. Incidental findings on computed tomography coronary angiography and its impact on respiratory services in a United Kingdom district general hospital [version 1; peer review: 1 not approved]. F1000Research 2020, 9:988 (https://doi.org/10.12688/f1000research.25206.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Open Peer Review

Current Reviewer Status: ?
Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 1
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PUBLISHED 14 Aug 2020
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Reviewer Report 08 Feb 2022
Mohammad Kermani-Alghoraishi, Interventional Cardiology Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran 
Not Approved
VIEWS 7
I reviewed this paper regarding to incidental finding in patients underwent CCTA. 

This is good idea, but the methodology and statistics are weak. Also, this title has not enough novelty and it is practical locally.

... Continue reading
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CITE
HOW TO CITE THIS REPORT
Kermani-Alghoraishi M. Reviewer Report For: Incidental findings on computed tomography coronary angiography and its impact on respiratory services in a United Kingdom district general hospital [version 1; peer review: 1 not approved]. F1000Research 2020, 9:988 (https://doi.org/10.5256/f1000research.27816.r96899)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.

Comments on this article Comments (0)

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VERSION 1 PUBLISHED 14 Aug 2020
Comment
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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