Moving Beyond Binary Grading of Coronary Arterial Stenoses on Coronary Computed Tomographic Angiography. Insights for the Imager and Referring Clinician

Victor Cheng, Ariel Gutstein, Arik Wolak, Yasuyuki Suzuki, Damini Dey, Heidi Gransar, Louise E.J. Thomson, Sean W. Hayes, John D. Friedman, Daniel S. Berman

Research output: Contribution to journalArticlepeer-review

81 Citations (Scopus)


Objectives: We evaluated the technical and clinical utility of visual 5-point coronary stenosis grading on coronary computed tomographic angiography (CCTA). Background: The binary approach used to assess coronary stenoses on CCTA does not adequately describe borderline obstructive lesions and limits full expression of clinically useful information. Methods: From 84 patients who underwent CCTA and invasive angiography, we identified 278 native coronary segments with ≥25% stenosis on CCTA after excluding all <25% stenotic, stented, and uninterpretable segments. Fifty <25% stenotic segments were randomly selected as controls. Segmental stenosis severity on CCTA was consensually graded using a 0 to 5 scale (grade 0 = none, grade 1 = 1% to 24%, grade 2 = 25% to 49%, grade 3 = 50% to 69%, grade 4 = 70% to 89%, grade 5 = 90% to 100%) by 2 readers, using visual inspection and computed tomography-based quantification (CTQCA). Invasive angiography-based stenosis quantification (IQCA) was performed for all segments, using the same 0 to 5 scale to score stenosis severity. Results: On CCTA, 185 (56%) segments had intermediate stenoses (grade 2 or grade 3). Stenosis severity by IQCA increased significantly with each step-up in CCTA grade (p < 0.001). CTQCA did not perform better than visual inspection. Visual CCTA stenosis grading differed from IQCA by >1 grade in only 4% of grade 2 to grade 5 segments (10 of 278; 2% of CCTA grade 2 segments, 4% of grade 3, 8% of grade 4, 2% of grade 5). Overall quantitative correlation was strong (r = 0.82) with high variability in agreement between CTQCA and IQCA for individual segments (95% of differences between 27.2% and 34.6%). Conclusions: With current CCTA technology, experienced readers should consider adopting a visually based, multitiered grading approach to evaluate coronary stenoses. A ≤49% lesion on CCTA can be considered virtually exclusive of ≥70% stenosis by invasive angiography.

Original languageEnglish
Pages (from-to)460-471
Number of pages12
JournalJACC: Cardiovascular Imaging
Issue number4
Publication statusPublished - Jul 2008
Externally publishedYes


  • computed tomography
  • coronary angiography
  • coronary artery disease
  • predictive value
  • quantification


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