1. Overview

Coronary computed tomography angiography (CCTA) is a non-invasive diagnostic for detecting coronary

artery disease (CAD). CCTA is increasingly utilized in clinical practice for evaluating coronary anatomy for

obstructive disease and plaque.

It is, however, imperative that artifact free CCTA image data is obtained in order for it to be successfully

analysed for anatomic assessment and/or to act as adequate input for adjunct analyses such as physiologic

simulations. Data acquisition strategies and scanning protocols may vary depending on scanner manufacturer,

system, and institutional preferences. This document provides references for reliable image acquisition

for CCTA.

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2. Introduction

Image acquisition in computed tomography is governed ultimately by the principle of As Low As Reasonably

Achievable (ALARA). In the first 10 years of CCTA, the focus was almost exclusively on the detection of

anatomical stenosis in low to intermediate risk patients. With the evolution of technology, the clinical utility

of CCTA has extended beyond stenosis assessment to atherosclerosis characterization, the evaluation of

structural heart disease, and the functional and physiological assessment of coronary stenoses. Recently

the SCCT acquisition guidelines were updated and provide an excellent reference for Cardiac CT imaging

specialists to help optimize their scan protocols. That being said, given the growing information that is

provided from cardiac CT, the imaging requirements have evolved and require tailoring to meet the clinical

indication. The purpose of this white paper is to highlight the parameters and image acquisition protocols that

are important to help optimize image quality, provide accurate representation of anatomy and thus enable

quantitative CT.

Importance of Heart Rate Control

With the advancements in scanner technology, the necessary requirement for heart rate reduction has

decreased over time. The demands for a low and steady heart rate to ensure diagnostic image quality may not

be what they once were but best practice remains to optimize image quality through heart rate control. SCCT

guidelines recommend performing CCTA with heart rates below 60 bpm.

In addition, CCTA no longer simply provides stenosis evaluation but needs to enable the interpreting physician

to identify and characterize plaque and, following the identification of a stenosis, to perform functional or

physiologic evaluation. As a result, while latest generation CT scanners may enable diagnostic image quality

at higher heart rates, there remains meaningful image quality benefits from heart rate reduction. In addition,

lower heart rates allow the use of lower dose scan acquisitions that are not possible at higher heart rates. Heart

rate control strategies are well established and the appropriate strategy is dependent on a number of variables

including available medications, setting of practice and site preference. For recommendations please refer to

the recently updated SCCT acquisition guidelines.

Importance of Nitrates

Nitrates as smooth muscle dilators have direct effect on coronary vasodilation and result in tangible

enlargement of coronary size. As such, similar to invasive coronary catheterization, nitroglycerine (glyceryl

trinitrate) should be administered prior to CCTA to optimize image quality and enable the most accurate

stenosis evaluation. A commonly used regimen is 400-800 µg of sublingual nitroglycerin administered as either

sublingual tablets or a metered lingual spray (commonly 1-2 tablets or 1-2 sprays) prior to the CCTA. While

the evidence is modest and there is no randomized data, both a higher dose and administration via spray are

becoming increasingly preferred in clinical practice and have been shown to help optimize coronary evaluation.

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Selection of Tube Current and Potential

The scan parameters used for any cardiac CT should be tailored to the individual patient but also the intended

application. The image quality issues with the greatest impact on the interpretability of CT are misalignment

and image noise. As such, care must be given to ensure that image noise properties are appropriate and

adequate for accurate lumen segmentation. To do so, tube current and potential should be selected carefully,

guided by chest wall circumference, the iodine concentration of the intravenous contrast medium, and whether

iterative reconstruction is available or not.

Iterative reconstruction (IR) has the ability to reduce image noise in CT without compromising the diagnostic

quality of the CT image dataset, which permits a significant reduction in effective radiation dose. In current

clinical practice, IR has enabled a significant reduction in radiation dose by allowing for a reduction in tube

current and is now increasingly available across all cardiac capable CT scanners. IR commonly takes the form

of a blended reconstruction of IR and filtered back projection (FBP). While a very helpful tool, care should

be given when using a very high percentage of IR for quantitative CT analysis due to the potential impact on

vessel segmentation.

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3. Recommended Protocol:

PHILIPS BRILLIANCE iCT and IQon

SPECTRAL CT

1. Surview

General

Data Acquisition

Comments

Lateral and AP surview covering the

• AP Surview: 120kVp/50mA

Position the patient for AP surview to

heart and coronaries

acquire AP and lateral surview.

• Lat Surview: 120kVp/100mA

Offset the patient to the right so the

• Surview Angle: Dual

heart is at the center of the scan field.

• Surview Length (mm): 300

Place the patient's arms above their

• Surview FOV: 500

head with the ECG leads outside the

• Surview Auto Voice: S Ins

scan range.

• Surview Breathing Lights: Yes

Have the patient practice breath-

holding before starting the

examination. This should be a single

"breathe in and hold" command.

2. CTA Acquisition

General

Data Acquisition

Data Reconstruction

Acquiring CT coronary Angiogram

Helical CCTA Acquisition

Coronary CTA (Acquisition)

• kV: 120 or 100 when appropriate

• Field of View limited to the heart

(220 mm)

• mAs: 800 (standard patients),

1000 (large patients)

• Slice thickness 0.8mm

• Scan Type: Cardiac

• Increment 0.4mm

• DoseRight: Off

• Acquisition Length (mm) 140.4

• Cardiac DoseRight: On

• Result Scan Length (mm): 140.4

• Collimation: Auto

• Pitch: 0.16

• Rotation Time: 0.27

• No of cycles/scan: N/A

• Scan time 5.30 seconds

• Resolution: STD

• Auto Voice: s.insp.

Stepandshoot,breath (longer

instruction with longer delay

at end)

• Breathing Lights: Yes

• Auto Pitch & RT based on HR: No

• ECG Gating Phase: 75%

• Handle irregularities On-line: Yes

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2. CTA Acquisition (contd.)

General

Data Acquisition

Data Reconstruction

Step & Shoot (Acquisition)

• kV: 120

•

Field of View limited to the heart

• mAs: 155 to 200 if phase

(220 mm)

tolerance = 0

•

Slice thickness 0.8mm

phase tolerance = 5, system will

•

Increment 0.4mm

recommend more MAS

•

Acquisition Length (mm) 144.5

• Scan Type: Cardiac

•

Result Scan Length (mm): 140.8

• Collimation: Auto

• DoseRight: Off

• Cardiac DoseRight: On

• Pitch: N/A

• No of cycles/scan: 2

• Scan time: 4-9 seconds

• Rotation Time: 0.27

• Resolution: STD

• Auto Voice: s.insp.

Stepandshoot,breath (longer

instruction with longer delay

at end)

• Breathing Lights: Yes

• Auto Pitch & RT based on HR: N/A

• ECG Gating Phase: 75%

• Handle irregularities On-line: Yes

• ECG Gating Phase Tolerance: 5%

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3. CTA Post-processing (Reconstructions)

General

Data Acquisition

Data Reconstruction

Coronary CTA (Acquisition)

• Reconstructions: Standard

• iMR Level: None

• iDose Level: 3 to 5

• Filter: XCB and XCC

• Single Cycle Reconstruction: No

• ECG Gating Recon Phase: 75%

• Edge Correction: N/A

Step & Shoot (Acquisition)

• Reconstructions: Standard

• iMR Level: None

• iDose Level: 3 to 5

• Filter: XCB and XCC

• Single Cycle Reconstruction: No

• ECG Gating Recon Phase: 75%

• Edge Correction: No

4. Contrast Protocol

General

Parameter

Comments

The injection rate should be

Coronary CTA & Large (Acquisition)

increased for shorter scan times and

• Bolus Tracking: Yes

larger patients!

• Trigger: 100 HU over blood

CTA requires contrast medium with

base line

an iodine concentration of at least

• Post Threshold Delay: 5 Seconds

350 mgI/mL.

Step & Shoot (Acquisition)

Place a 20- or 18-gauge IV cannula in

• Bolus Tracking: Yes

the RIGHT arm.

• Trigger: 100 HU over blood

base line

• Post Threshold Delay: 7 Seconds

HeartFlow, Inc.

| Acquisition and Reconstruction Techniques for Coronary CT Angiography: Philips Healthcare Scanner Platforms

15991244 V2

4. Recommended Protocol:

PHILIPS BRILLIANCE iCT SP

1. Surview

General

Data Acquisition

Comments

Lateral and AP surview covering the

• AP Surview: 120kVp/50mA

Position the patient for AP surview to

heart and coronaries

acquire AP and lateral surview.

• Lat Surview: 120kVp/100mA

Offset the patient to the right so the

• Surview Angle: Dual

heart is at the center of the scan field.

• Surview Length (mm): 300

Place the patient's arms above their

• Surview FOV: 500

head with the ECG leads outside the

• Surview Auto Voice: S Ins

scan range.

• Surview Breathing Lights: Yes

Have the patient practice breath-

holding before starting the

examination. This should be a single

"breathe in and hold" command.

2. CTA Acquisition

General

Data Acquisition

Data Reconstruction

Acquiring CT coronary Angiogram

Helical CCTA Acquisition

• kV: 120

• Field of View limited to the heart

(220 mm)

• mAs: 800 (standard patients),

1000 (large patients)

• Slice thickness 0.8mm

• Scan Type: Cardiac

• Increment 0.4mm

• DoseRight: Off

• Acquisition Length (mm) 140.4

• Cardiac DoseRight: On

• Result Scan Length (mm): 140.4

• Collimation: Auto

• Pitch: 0.16

• Rotation Time: 0.27

• No of cycles/scan: N/A

• Scan time 8.20 seconds

• Resolution: STD

• Auto Voice: s.insp.

Stepandshoot,breath (longer

instruction with longer delay

at end)

• Breathing Lights: Yes

• Auto Pitch & RT based on HR: No

• ECG Gating Phase: 75%

• Handle irregularities On-line: Yes

HeartFlow, Inc.

| Acquisition and Reconstruction Techniques for Coronary CT Angiography: Philips Healthcare Scanner Platforms

15991244 V2

2. CTA Acquisition (contd.)

General

Data Acquisition

Data Reconstruction

Step & Shoot CCTA Acquisition

• kV: 120

• Field of View limited to the heart

• mAs: 155

(220 mm)

• Scan Type: Cardiac

• Slice thickness 0.8mm

• Collimation: Auto

• Increment 0.4mm

• DoseRight: Off

• Acquisition Length (mm) 144.5

• Result Scan Length (mm): 134.8

• Cardiac DoseRight: On

• Pitch: N/A

• No of cycles/scan: 2

• Scan time: 9.17 seconds

• Rotation Time: 0.27

• Resolution: STD

• Auto Voice: s.insp.

Stepandshoot,breath (longer

instruction with longer delay

at end)

• Breathing Lights: Yes

• Auto Pitch & RT based on HR: N/A

• ECG Gating Phase: 078Handle 75%

irregularities On-line: Yes

• ECG Gating Phase Tolerance: 5%

HeartFlow, Inc.

| Acquisition and Reconstruction Techniques for Coronary CT Angiography: Philips Healthcare Scanner Platforms

15991244 V2

3. CTA Post-processing (Reconstructions)

General

Data Acquisition

Data Reconstruction

Acquiring CT coronary Angiogram

Coronary CTA (Acquisition)

• Reconstructions: Standard

• iMR Level: None

• iDose Level: 3 to 5

• Filter: XCB and XCC

• Single Cycle Reconstruction: No

• ECG Gating Recon Phase: 75%

• Edge Correction: N/A

Step & Shoot (Acquisition)

• Reconstructions: Standard

• iMR Level: None

• iDose Level: 3 to 5

• Filter: XCB and XCC

• Single Cycle Reconstruction: No

• ECG Gating Recon Phase: 75%

• Edge Correction: No

4. Contrast Protocol

General

Parameter

Comments

The injection rate should be

Coronary CTA & Large (Acquisition)

increased for shorter scan times and

• Bolus Tracking: Yes

larger patients!

• Trigger: 100 HU over blood

CTA requires contrast medium with

base line

an iodine concentration of at least

• Post Threshold Delay: 5 Seconds

350 mgI/mL.

Step & Shoot (Acquisition)

Place a 20- or 18-gauge IV cannula in

• Bolus Tracking: Yes

the RIGHT arm.

• Trigger: 100 HU over blood

base line

• Post Threshold Delay: 7 Seconds

HeartFlow, Inc.

| Acquisition and Reconstruction Techniques for Coronary CT Angiography: Philips Healthcare Scanner Platforms

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This paper is presented as a service to medical personnel by HeartFlow and Philips. The information in this white paper has been compiled

from available literature and best practices from expert users. Although every effort has been made to faithfully convey this information, the

editors and publisher cannot be held responsible for their correctness. This paper is not intended to be, and should not be construed as,

medical advice. For any use, the product information guides, inserts, and operation manuals of the various CT acquisition devices should

be consulted. HeartFlow and the editors disclaim any liability arising directly or indirectly from the use of drugs, devices, techniques, or

procedures described in this paper.

WARNING: Any references to x-ray exposure, intravenous contrast dosage, and other medication are intended as reference guidelines only.

The guidelines in this document do not substitute for the judgment of a trained healthcare provider. Each scan requires medical judgment by

the healthcare provider about exposing the patient to ionizing radiation. Use the As Low As Reasonably Achievable (ALARA) radiation dose

principle to balance factors such as the patient’s condition, size and age; region to be imaged; and diagnostic task.

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| Acquisition and Reconstruction Techniques for Coronary CT Angiography: Philips Healthcare Scanner Platforms

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