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CHAPTER 25 Noncardiac CT Findings
Sopo Lin / Minh Lu / Charles S. White
The Dilemma
Protocol Type
Small Versus Full Field of View
Categories of Findings
Clinical Significance Versus Nonsignificance
Asymptomatic Versus Symptomatic Patients
Cardiac computed tomography (CT) is an important tool for
the evaluation of multiple aspects of cardiac anatomy and
pathology, including coronary artery stenosis and extra-
coronary cardiac structures. It is often used for important
clinical indications such as the establishment of the pres-
ence or absence of coronary artery atherosclerosis, and as-
sessment of patency following a coronary artery bypass graft
procedure. Because of its cross-sectional nature, cardiac CT
studies also include portions of the lungs, mediastinum,
chest wall, and abdomen, and as such may reveal unex-
pected findings. These unanticipated or incidental findings
are considered clinically significant if they lead to imaging
follow-up or a therapeutic intervention.
15
Since many extracardiac findings lack clinical rele-
vance, debate exists over the extent to which interpreters of
cardiac CTshouldseekandbe responsible for suchfindings.
Animportant component of this debate is the type of cardiac
CTprotocol and field of view(FOV) that are used, as these fac-
tors influence the prevalence andscope of incidental lesions.
Rather than detailing the spectrumof imaging findings and
their imaging appearance, the purpose of this chapter is to
focus on the controversy regarding identification of non-
cardiac findings with specific discussion pertaining to the
CT protocol, FOV, clinically significant from insignificant
findings and abnormalities in symptomatic versus asymp-
tomatic patients.
THE DILEMMA
Cardiac CT has the capability to detect abnormalities be-
yond the heart. This ability to reveal such findings through-
out the thorax and adjacent structures presents a challenge.
In some cases, the incidental findings on cardiac CT can
provide a clear-cut diagnosis and direct the path of workup
and treatment that is deemed most beneficial to the pa-
tient. However, the findings may be nonspecific in which
case, additional work-up may be required in order to ex-
clude significant pathology with the potential for increased
patient anxiety and healthcare costs, and complications dur-
ing follow-up procedures.
In order to address the question of whether physicians
should actively search for, report, and follow up inciden-
tal findings discovered on cardiac CT, the potential costs
and benefits must be weighed. One approach suggests that
identification of a maximal number of incidental findings is
the optimal course of action. In contrast, others argue that
pursuing incidental findings sets the stage for increased
radiation exposure and unnecessary procedures that result
in inflated health care costs necessitated by discovery of
these unexpected findings. More problematic is the mor-
bidity and potential mortality of unnecessary follow-up pro-
cedures, such as biopsy or resection of noncalcified nod-
ules that prove to be benign. Finally, there is the potential
for unwarranted anxiety imposed upon both the patient and
physician as a result of nonpathological incidental findings.
PROTOCOL TYPE
The literature on cardiac CT-related noncardiac findings is
becoming more extensive with widely varying prevalence
numbers (Table 25-1). Some of this variability is related to
the reporting of findings across a range of cardiac CT proto-
cols, which include calciumscoring, cardiac CT angiography
(CCTA), and coronary artery bypass graft CTA (CABG CTA).
675
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676 Section IV Controversy
Table 25-1. Prevalence of significant noncardiac findings on cardiac CT
Total Relevant
Article N findings N (%) findings N (%) Protocol Definition for relevant findings
Law et al. 295 56 (19) 56 (19) CTA Needed clinical or imaging follow-up
..................................................................................................................................................................................................................................................................................................................................
Schietinger et al. 149 102 (69) 45 (30) CTPV Clinical or imaging follow-up
..................................................................................................................................................................................................................................................................................................................................
Koonce et al. 1764 441 (25) 325 (18.4) CTA Clinical or imaging follow-up
..................................................................................................................................................................................................................................................................................................................................
Kawano et al. 617 142 (23) 7 (1.1) CTA Cancer
..................................................................................................................................................................................................................................................................................................................................
Gil et al. 258 145 (56) N/A CTA Additional work-up
..................................................................................................................................................................................................................................................................................................................................
Kirsch et al 100 67 (67) 16 (11) CTA Immediate intervention
..................................................................................................................................................................................................................................................................................................................................
Haller et al. 166 41 (24.7) 8 (4.8) (two cancers) CTA Immediate change in management
..................................................................................................................................................................................................................................................................................................................................
Onuma et al. 503 292 (58.1) 114 (22.7) (four cancers) CTA Clinically relevant
..................................................................................................................................................................................................................................................................................................................................
Mueller et al. 259 51 (19) 34 (13.1) CTCABG Unsuspected findings including cardiac
..................................................................................................................................................................................................................................................................................................................................
Hunold et al. 1812 953 (53) N/A CTCS Total findings
..................................................................................................................................................................................................................................................................................................................................
Horton et al. 1326 103 (7.8) 103 (7.8) CTCS Needed clinical or imaging follow-up
Reprinted with permission from Ref. 34. Copyright 2009 Elsevier.
Key: CTCS = CT calcium score; CTA = coronary angiography; CTCABG = CT coronary artery bypass grafts; CTPV = CT pulmonary veins; N/A = not
supplied.
The prevalence of incidental findings varies according
to the type of examination protocol (Figure 25-1). For ex-
ample, a calcium score CT study is performed with thick
sections and could make lesions such as small pulmonary
nodules difficult to visualize. Additionally, vascular lesions
may not be evident due to the lack of intravenous contrast
media in these studies. On the other hand, z-axis coverage
for a CABGCTAis more extensive than a cardiac CTAin or-
der to include the subclavian and internal mammary artery
origins andthus may result inanincreaseddetectionof non-
cardiac findings due to the increased volume of coverage.
An example of such differences is demonstrated by
Northam et al., who described the incidental detection of
pulmonary nodules on cardiac CT.
6
Four different tech-
niques for image acquisition were employed, depending
upon the indication for the study. All studies were per-
formed on a 64-MDCT. For calcium scoring, imaging ac-
quisitionwas performedwithprospective gatingfrombelow
the aortic arch through the base of the heart with 1.2-mm
detector collimation and image reconstruction at 3-mm or
5-mmintervals depending upon the chosen FOV. Coronary
CTA examinations were performed with retrospective gat-
ing from below the transverse aortic arch through the base
of the heart with 0.6-mm detector collimation, and recon-
structed at 0.75-mm or 3-mm intervals depending upon the
chosen FOV. The pulmonary vein evaluation protocol was
identical to that of coronary CTA studies. For CABG evalu-
ation, the protocol was similar to the aforementioned CTA
protocol, with the exception being extension of z-axis cepha-
lad to include the subclavian arteries. Of the 15 pulmonary
nodules greater than 1 cm detected in this study, 47% were
found on CTA, 27% on pulmonary vein cases, and 26% on
post-CABG studies. No pulmonary nodules greater than 1
cm were detected on calcium scoring examinations.
Horton et al.
1
assessed the prevalence of noncardiac
findings found on calcium scoring screening examinations
on EBCT. Of the 1,326 consecutive patients, 103 (7.8%)
showedsignificant extracardiac pathology that requiredclin-
ical or imaging follow-up.
SMALL VERSUS FULL FIELD OF VIEW
Another important topic is the appropriate FOV. In order to
maximize spatial resolution on cardiac CT, it is necessary
to utilize a small FOV, usually 25 cm, which contains only
the heart during image acquisition (Figure 25-2). Following
image acquisition, however, full FOV images can be recon-
structed from skin to skin in the region irradiated without
additional radiation to the patient. These additional images
will allow analysis of the entirety of the lung parenchyma,
chest wall, and upper abdomen in the area covered. A full
FOV will certainly identify a greater variety and number
of both benign and significant lesions, while a small FOV
includes a limited portion of the chest volume,
7
thus ex-
cluding much of the lung parenchyma and other areas that
may contain potentially clinically significant extracardiac
findings.
The controversy surrounding the use of full FOV im-
ages in cardiac CT is multifaceted. One study quantified the
volume of lung parenchyma included on a standard FOV
compared to a small FOV. Using a vendor-recommended
protocol, an average of 58% of the lung parenchyma was
included on a standard cardiac FOV, with a range of 26
86%, while an average of 14% of lung parenchyma was
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Chapter 25 Noncardiac CT Findings 677
14
12
CTCS (3138) CABG (259) CTPV (149) CTA (3703)
P
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Figure 25-1. Prevalence of significant noncardiac findings on calcium scoring CT (CTCS), coronary CTA
(CTA), bypass graft CTA (CABG), and pulmonary vein CT (CTPV) Note: Numbers in brackets indicate patient
numbers. Reprinted with permission from Ref. 34. Copyright 2009 Elsevier.
A B
Figure 25-2. Full versus small FOV
Axial CT image demonstrates the difference in image data available for interpretation between (A) full and
(B) small FOV reconstructed images.
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678 Section IV Controversy
included on a tightly coned FOV, with a range of 7.5
22%.
8
The researchers concluded that the percentage of
lung parenchyma included on a standard cardiac FOV is
variable but considerable, whereas utilization of a tight FOV
results in the potential for exclusion of additional findings.
Proponents of a small FOV point to the fact that the
focus of a cardiac CT examination is detection of cardiac
disease. This argument is essentially the same as those
who seek to avoid an active search for noncardiac findings,
namely, that the focus for cardiac disease assessment should
obviate the need for a complete evaluationof other anatomic
areas that can be accomplished only by reconstructing im-
ages with a full FOV. Also contended is that reportable find-
ings made outside a small FOV require multiple additional
studies, resulting in increased cost, unnecessary radiation
exposure, and psychological stress imparted to the patient.
Additionally, small FOV advocates note that there are
multiple instances in which the standard of practice for cer-
tain targeted areas of the body does not involve wider FOV
reconstructions. For example, radiologists do not routinely
reconstruct or interpret the entire chest on thoracic spine
CT studies, even though the entire thorax is irradiated. Sim-
ilarly, inner ear CT studies are not typically reconstructed
more widely to include the entire head, despite irradiation
of the entire area. Finally, it is suggested that these examples
are precedents that justify a targetedcardiac CTexamination
with a small FOV.
9
Conversely, full FOV supporters cite evidence that
many patients have benefited from the incidental discovery
of pathology that would otherwise go undetected. Moreover,
proponents of the full FOV approach argue that optimal pa-
tient care involves interpretationof all images ona full width
reconstructed FOV, with additional evaluation or follow-up
of incidental findings as deemed necessary and appropriate.
Finally, medicallegal issues due to failure to report clini-
cally significant findings outside the cardiac FOV are of
potential concern. With this in mind, full FOV proponents
Table 25-2. Prevalence of pulmonary nodules on cardiac CT
Number of patients Percent of Percent of
with incidental patients with patients with lung
Study Study type findings lung nodules nodules >1 cm
Hunold et al. EBCT 620/1,812 (34%) 0.44
..................................................................................................................................................................................................................................................................................................................................
Horton et al. EBCT for CAC scoring 103/1,326 (7.8%) 4.0 0.90
..................................................................................................................................................................................................................................................................................................................................
Schragin et al. EBCT 278/1,356 (20.5%) 3.4 0.07
..................................................................................................................................................................................................................................................................................................................................
Onuma et al. 64-slice MDCT 67/100 (67%) 5.0 1.60
..................................................................................................................................................................................................................................................................................................................................
Haller et al. 16-slice MDCT 41/166 (25%) 2.4
..................................................................................................................................................................................................................................................................................................................................
Gil et al. 64-slice MDCT 145/258 (56%) 19.0 1.20
..................................................................................................................................................................................................................................................................................................................................
Lehman et al. 64-slice MDCT 177/395 (44.8%) 4.1

No distinction was made between pulmonary nodules and pulmonary masses >1 cm in these studies. EBCT = electron-beam CT; CAC = coronary artery
calcification.
contend that the most prudent and appropriate approach
is to view and evaluate all available information in the ir-
radiated area with further workup based upon the imag-
ing finding and clinical situation. In accordance with this
reasoning, several studies suggest that the majority of pul-
monary nodules greater than 1 cm, those most likely to be
malignant, are peripheral and would be missed on a small
FOV.
2
Consensus on this subject is lacking, and practice
standards vary between institutions and even fromprotocol
to protocol within the same department.
CATEGORIES OF FINDINGS
Extracardiac findings can be grouped into the following
three anatomic categories: (1) pulmonary, (2) mediastinal,
and (3) abdominal.
Pulmonary
Pulmonary Nodules
Pulmonary nodules are by far the most common extracar-
diac abnormality identified on cardiac CT as such, much of
the debate regarding incidental findings on cardiac CT cen-
ters on the pulmonary nodule (Table 25-2). Approximately
150,000 pulmonary nodules are detected annually as inci-
dental findings on chest radiographs or chest CT scans.
10,11
A nodule is defined as less than 3 cm in diameter, com-
pletely surrounded by lung parenchyma, and not associated
with lymphadenopathy, pneumonia, or atelectasis.
3,12
The
frequency of all incidental pulmonary nodules on cardiac
CT varies, with a range of 0.4420%.
25,12
In asymptomatic patients undergoing coronary cal-
cium scoring, the reported frequency of pulmonary nod-
ules is on the range 0.444.9%.
2,3,5
In symptomatic pa-
tients undergoing coronary CTA for evaluation of coronary
artery disease, the frequency of lung nodules ranges from
3.7% to 20%.
7,13,14
The higher prevalence in symptomatic
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Chapter 25 Noncardiac CT Findings 679
Figure 25-3. Full FOV
Axial CT image with full FOV reconstruction in a chest pain
patient reveals an incidental finding of a subpleural soft tissue
density in the lateral basilar segment of the left lower lobe (arrow)
that would not have been visible on small FOV reconstructed
data.
individuals likely stems from the fact that patients present-
ing with chest painare evaluated for both cardiac and extrac-
ardiac sources of pain, leading to interpretation of a larger
FOV. The prevalence of pulmonary findings is certainly re-
lated to the FOV due to the peripheral location of many pul-
monary lesions (Figure 25-3). Another important difference
is that calciumscore examinations are usually reconstructed
with thicker slices (2.53 mm) compared to coronary CTA
studies (<1 mm), so a higher prevalence on the latter is not
surprising.
Nodule size also influences the frequency of detection.
The prevalence of incidental pulmonary nodules larger than
1 cm ranges from 0.9% to 2.4% versus 9.3% to 19% for pul-
monary nodules less than 1 cm in size.
1,4,7,12
Although 90%
of pulmonary nodules less than2 cmare benign, by virtue of
biopsy or radiographic stability in size over 2 years,
5
further
workup to exclude lung cancer is still required (Figure 25-4).
Previous studies showthat 0.41%of pulmonary nodules re-
ported on cardiac CT resulted in a malignant diagnosis.
12,14
Haller et al. reported a malignant nodule frequency of 1.2%
in patients with small pulmonary nodules detected on car-
diac CT. On the contrary, a retrospective study by Kim et al.
reported a lung cancer prevalence of 0.31% in pulmonary
nodules detected on cardiac CT.
15
The incidental pulmonary lesion detected on cardiac
CT presents a challenge to clinicians. Many radiologists
and pulmonologists use the Fleischner Society recommen-
Figure 25-4. Pulmonary nodule
An incidental finding of an irregular right upper lobe lobular
mass with an adjacent satellite nodule (arrows) on prospective
ECG-gated cardiac CT. Biopsy revealed squamous cell carcinoma.
dations as a guideline for further evaluation of small pul-
monary nodules (Table 25-3). These recommendations sug-
gest that further imaging may not be necessary for a nodule
4mminlow-risk patients. Incontrast, the society suggests
a 3-, 9-, and 24-month follow-up CT with consideration of
biopsy in high-risk patients with a nodule >8 mm.
16
Lung Cancer Screening
The efficacy of lung cancer screening enters into the discus-
sion when determining whether to utilize a full FOV when
reconstructing cardiac CT studies. The risks and benefits of
lung cancer screening efforts have been debated within the
literature. Due to the fact that the 5-year survival rates for
stage I cancer is 6070%
1719
but only 16% of newly diag-
nosed lung cancer are localized (stage I/II),
20
there has been
a major effort to detect early lung cancer. CT has been at
the forefront of this endeavor, because of its demonstrated
ability to detect small nodules. However, a number of ob-
stacles have been encountered related to CT screening for
lung cancer. Most experts presume that screening efforts
should show a mortality benefit.
Nonrandomized studies have shown potential bene-
fits of screening, such as earlier detection of malignancy,
but a substantive impact on eventual mortality remains
unclear.
21,22
Because most pulmonary nodules are benign,
screening for lung cancer with CT may also be associ-
ated with inconvenience, cost, morbidity, and occasional
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680 Section IV Controversy
Table 25-3. The Fleischner Society guidelines for the follow-up of indeterminate pulmonary nodules measuring <8 mm
detected on CT in persons 35 years of age or older
Nodule Low-risk patient High-risk patient
size (mm) Minimal or no smoking history and no other risk factors Smoking history or other risk factors
4 mm No follow-up needed
1
Follow-up CT at 12 months; if unchanged,
no further follow-up
..................................................................................................................................................................................................................................................................................................................................
>46 Follow-up CT at 12 months; if unchanged, Initial follow-up CT at 612 months, then
no further follow-up 1824 months if no change
..................................................................................................................................................................................................................................................................................................................................
>68 Initial follow-up CT at 612 months then Initial follow-up CT at 36 months, then
1824 months if no change 9, 12, and 24 months if no change
..................................................................................................................................................................................................................................................................................................................................
>8 Follow-up CT at 3, 9, and 24 months, dynamic contrast-enhanced CT, PET and/or biopsy
Nodule size is determined by the average of length and width.
Ground-glass or partly solid nodules of any size carry an increased likelihood of malignancy and may require a longer follow-up period.
1
The risk of malignancy (<1%) in this category is substantially less than that of a baseline CT scan of an asymptomatic smoker.
mortality from false-positive nodules. For example, in an
18-month follow-up study with a cohort of 966 patients who
underwent coronary CTA, MacHaalany et al. reported80pa-
tients with clinically significant or indeterminate findings.
This group had 87 follow-up diagnostic imaging studies,
consultations, and other procedures, including nine biop-
sies that resulted in a total additional cost of $1,038 per
patient. In addition, one patient died of complications from
a transthoracic needle biopsy for a pulmonary nodule.
23
Results from the National Lung Cancer Screening
Trial (NLST) suggest that full FOV analysis of the lung
parenchyma is worthwhile, at least in high-risk patients.
This national trial randomized 53,000 current or former
heavy smokers, aged 5574, to screening examinations with
either standard chest radiography or low-dose CT. A 20.3%
reduction in lung cancer mortality was identified in the CT
cohort. The NLST is the first randomized controlled trial
that has documented a significant reduction in lung cancer
mortality with a screening examination.
35
The suggestion that the search for extracardiac findings
on CT equates to lung cancer screening clearly has some
merit, because so many of the findings are lung nodules.
There are, however, important differences. First, although
lung nodules account for the largest number of findings,
other clinically important pulmonary and nonpulmonary
disease processes will be uncovered. Second, while it is true
that calcium scoring is a screening study, many patients
who undergo coronary CTA have symptoms such as chest
pain, whose source may be noncardiac, yet visible on full
FOV reconstructed images.
This debate will continue in the literature, among soci-
eties, within health care systems and facilities and the use of
small versus full FOV reconstructed images remains unre-
solved. The contentiousness of this issue is demonstrated in
the practice guidelines developed by the American College
of Cardiology Foundation, American College of Radiology,
and other societies defining the necessary skills for evalu-
ation and interpretation of cardiac CT, who are unable to
reach consensus regarding extracardiac findings on coro-
nary CTA.
24
Other Pulmonary Findings
Comprehensive evaluation of the lung parenchyma using
full FOV reconstructed images can reveal other pulmonary
findings including pneumonia (1.1%), pleural effusion (1
2.8%), pleural disease other than fluid (1%), emphysema
(1.86%), and pneumothorax (0.3%), which may or may not
be of clinical relevance. These findings can sometimes be
identified on a restricted FOV. Pleural fluid loculated along
the lateral pleural space or an anterior pneumothorax may
not be visible with a limited FOV.
Mediastinum
Clinically significant mediastinal findingsthose that re-
quire further imaging or therapeutic interventionare of-
ten detected on coronary CTA. It should be noted that the
FOV debate is not pertinent to this section, because the
volume of mediastinal anatomy included on both full and
small FOV is identical. Instead, the concern should focus
on recognition and accurate interpretation of mediastinal
pathology.
Lymphadenopathy is the most common mediastinal
finding and represents 0.79% of extracardiac findings.
2,25
Lymph nodes smaller than 1 cm are usually considered be-
nign, whereas larger nodes or multiple nodes associated
with a mass may represent a pathologic process.
7
Differ-
ential possibilities for multiple small lymph nodes include
sarcoidosis, lymphoma, or other inflammatory or infectious
processes. Enlarged, calcified mediastinal or hilar lymph
nodes often are a result of prior granulomatous disease.
26
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Chapter 25 Noncardiac CT Findings 681
Other clinically significant mediastinal findings include thy-
moma and other anterior mediastinal lesions (0.23.1%),
hiatal hernia (23.5%), and mediastinitis (0.4%).
6,9,26,27
Al-
though not strictly within the mediastinal compartment,
bone metastases (0.1%) may present as single or multiple
sclerotic or lytic foci in the vertebrae.
3
Abdomen
Abdominal findings oncardiac CTare localized to the upper
abdomen with the overwhelming majority of these findings
hepatic in etiology, such as cysts and fatty change. Focal
hypervascular hepatic lesions and hypodense lesions that
are not clearly cysts may necessitate dedicated liver imag-
ing to evaluate for a primary hepatic neoplasm such as a
hepatoma or metastatic disease.
8
Hunold et al. revealed
diaphragmatic dehiscence or hernia in 1% (19 of 1,812) of
patients on EBCT.
3
In the same study, liver lesions were
detected in 2% or 37 patients for which follow-up sonog-
raphy was performed, while one patient underwent liver
CT. Hepatic cysts were confirmed in the majority of these
patients. Other less-frequent findings included ascites and
splenomegaly.
CLINICAL SIGNIFICANCE VERSUS
NONSIGNIFICANCE
A consideration of clinical importance should focus on the
prevalence of significant versus nonsignificant noncardiac
findings. An accepted definition of a clinically significant
finding is straightforward and encompasses any imaging
abnormality requiring further diagnostic workup. Despite
this clear-cut terminology, the ratio of significant to non-
significant findings varies greatly from study to study. For
instance, the percentage of patients with at least one clini-
cally significant finding varies from2.8%to 45.6%.
15
Sim-
ilarly, if findings are compared according to their location
and nature, a wide variation exists in the percentage of find-
ings that qualify as clinically significant.
These variations can be partially explained by site-to-
site differences in interpretation of the term clinically sig-
nificant. While some standards include all findings that
require or suggest the importance of additional workup,
other parameters specify only those findings that involve
immediate therapeutic consequences, suchas a malignancy
or pulmonary embolism. Thus, although most studies use
the same definition, actual determination regarding follow-
up recommendations is not standardized but varies greatly
frominstitutionto institution. While there is a needto estab-
lish a practical approach for the detection and evaluation of
extracardiac findings on cardiac CT, a set of definite guide-
lines for the management of incidental findings does not
exist. Currently, the most prudent strategy is to individual-
ize further evaluation.
ASYMPTOMATIC VERSUS
SYMPTOMATIC PATIENTS
The frequency of noncardiac findings also differs between
asymptomatic versus symptomatic patients. Many patients
who undergo coronary CTAexhibit symptoms or the exami-
nation is performed to clarify results of other investigations,
such as myocardial perfusion scanning or exercise stress
testing. With this in mind, other extracardiac conditions
may produce symptoms similar to those associated with
cardiac disease and include aortic and pulmonary pathol-
ogy such as aortic dissection, aortic aneurysm, pulmonary
embolism, pneumonia, pleural effusion, pulmonary hyper-
tension, and pulmonary edema. One study showed that in
32 of 201 cases (16%), coronary artery disease was excluded
but noncardiac CT findings were sufficient to explain the
patients symptoms.
2
This would imply a higher frequency
of incidental findings in symptomatic patients compared to
asymptomatic patients.
Risk factors for coronary artery disease, particularly
cigarette smoking, also are associated with lung cancer and
chronic obstructive pulmonary disease. Froma compilation
of studies, the frequency of lung nodules detected in asymp-
tomatic patients undergoing calcium scoring CT ranged
from0.44%to 4.9%.
1,3,4,28
Onthe other hand, symptomatic
patients undergoing coronary CTAhad incidental lung nod-
ules ranging from 3.7% to 20.2%.
2,5
The prevalence of noncardiac findings inasymptomatic
patients undergoing coronary CTA compared to calcium
scoring CT is uncertain. For example, Gil et al. evaluated
asymptomatic patients who underwent coronary CTA due
to risk factors for coronary artery disease, of which nearly
50%of the study population had cigarette smoking history.
5
Of the 258 patients, 145 (56.2%) were found to have a sig-
nificant noncardiac abnormality, of which 91 lung abnor-
malities were detected, but only three nodules were greater
than 1 cm. The higher rate of findings in this study may
be attributable to the thinner section protocol and contrast
media used for coronary CTAin addition to the patient pop-
ulation characteristics, which included a large number of
active or former smokers, rather than an expression of a
true incidence difference.
125
The increased detection of incidental findings in post-
operative coronary artery bypass graft patients may be a re-
flection of increased z-axis coverage or due to the postop-
erative condition of the patient. For instance, Mueller et al.
reported a 1.9% incidence of pulmonary embolism on post-
CABG cardiac CT.
29
This could also indicate the increased
frequency inthe number of unsuspected pulmonary emboli
detected on chest CT, as reported by Dentali et al. with a
prevalence of 2.6%.
30
Despite some overlap, the difference
in frequency of significant extracardiac findings between
asymptomatic and symptomatic patients and asymptomatic
and postoperative patients is not surprising.
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MCGH209-c25 9-780-7817-XXXX-X MCGH209-Abramson-v1 August 16, 2011 14:11
682 Section IV Controversy
CONCLUSION
Cardiac CT has the potential to detect extracardiac ab-
normalities, some of which may reflect clinically im-
portant pathology. The study protocol, patient popula-
tion, and FOV will greatly influence the prevalence of
these findings. Coronary CTAis commonly utilized in
symptomatic patients in the evaluation of chest pain.
Extracardiac analysis should be performed in these
patients in order to ascertain an alternative source
of symptoms. On the other hand, the prevalence of
noncardiac findings on calcium score examinations
is lower and may result in undue anxiety and cost
in this asymptomatic population. Identification of the
solitary pulmonary nodule is a matter of much debate,
and the Fleischner Society guidelines should serve as
a beneficial resource. While coronary andcardiac find-
ings should be the focus of the examination, the preva-
lence and possible significance of extracardiac find-
ings should not be ignored. Collaboration between
radiologists and cardiologists in this area may prove
the most beneficial for patient care.
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