A Prospective Randomized Controlled Trial to Assess the Diagnostic Performance of Reduced Tube Voltage for Coronary CT Angiography

OBJECTIVES: Tube voltage reduction has been shown to be an effective method to reduce radiation dose in nonobese patients undergoing coronary CT angiography. To date, the impact of reduced tube voltage on objective measures of diagnostic accuracy, as defined by quantitative coronary angiography (QCA), has not been established. The purpose of this article was to investigate the impact of tube voltage reduction on the diagnostic performance of coronary CTA compared with QCA.

METHODS. We performed a prospective randomized trial evaluating 50 consecutive patients referred for catheter angiography with a body mass index (BMI) 35 kg/m2. Patients were randomly assigned to reduced (n = 24) or standard tube voltage (n = 26). Reduced tube voltage was defined as 80 or 100 kVp for individuals with BMI < 25 kg/m2 or 25–35 kg/m2, respectively; whereas standard tube voltage was defined as 100 or 120 kVp for individuals with BMI < 25 kg/m2 or 25–35 kg/m2, respectively. Tube current was fixed by study protocol as 600 mA (BMI < 30 kg/m2) or 650 mA (BMI 30 kg/m2). Coronary CTA examinations were interpreted by two blinded experienced readers with a third reader providing consensus. QCA was performed by an independent experienced core laboratory blinded to coronary CTA findings. Coronary artery segments were graded for stenosis as < 50%, 50–69%, and 70% by coronary CTA and as percentage stenosis by QCA. In an intention-to-diagnose fashion, all segments were included for final analysis, with nonevaluable segments by coronary CTA graded as obstructive. Signal and noise; contrast (mean signal–signal in left ventricular myocardium); and signal-to-noise ratio (SNR) and contrast-to-noise (CNR) ratio were compared.

RESULTS: Mean age of the study cohort was 60.2 years; 78% were men. Prospective ECG gating was used in all patients, and no differences existed in scan length between groups (p = 0.19). Standard versus reduced tube voltage was associated with a reduction in effective radiation dose (2.6 ± 0.4 vs 1.3 ± 0.5 mSv, p < 0.001). The patient prevalence of luminal stenosis 50% was 56% (28/50). For detection of 50% stenosis in the standard versus reduced kVp groups, there were no differences in per-segment sensitivity (87% vs 84%, p = 0.73), specificity (92% vs 93%, p = 0.81), or accuracy (92% vs 91%, p = 0.70). No differences were noted for reduced versus standard tube current for SNR (13 ± 4 vs 13 ± 3, p = 0.59), CNR (10 ± 3 vs 10 ± 2, p = 0.99), or graded (0–4) image quality score (3.4 ± 0.8 vs 3.5 ± 0.6, p = 0.19).

CONCLUSIONS: Compared with standard tube voltage, coronary CTA using reduced tube voltage results in lower effective radiation dose with comparable diagnostic performance.


Jacobo Kirsch

Associate Center Director, Imaging Institute
Cardiopulmonary Imaging, Section Head
Cleveland Clinic Florida
Weston, FL
Posted in Computed Tomography and tagged , , , .


  1. Very nice paper!
    Things to ponder:
    1) Prospective ECG gating without a glitch. Nice.
    2) Iterative reconstruction… Does the findings translate to backprojection algorithms?

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