Skip Navigation


European Heart Journal Advance Access originally published online on November 2, 2007
European Heart Journal 2007 28(24):3042-3050; doi:10.1093/eurheartj/ehm466
This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
28/24/3042    most recent
ehm466v1
Right arrow E-letters: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when E-letters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (19)
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Abdulla, J.
Right arrow Articles by Torp-Pedersen, C.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Abdulla, J.
Right arrow Articles by Torp-Pedersen, C.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2007. For permissions please email: journals.permissions@oxfordjournals.org

64-multislice detector computed tomography coronary angiography as potential alternative to conventional coronary angiography: a systematic review and meta-analysis

Jawdat Abdulla1,*, Steen Z. Abildstrom2, Ole Gotzsche3, Erik Christensen4, Lars Kober5 and Christian Torp-Pedersen6

1 Division of Cardiology, Department of Medicine, Glostrup University Hospital, Copenhagen, Denmark
2 Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark
3 Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
4 Clinic of Internal Medicine I, Bispebjerg University Hospital, Copenhagen, Denmark
5 Rigshospitalet Heart Centre, Department of Medicine, Division of Cardiology, Copenhagen, Denmark
6 Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark

Received 20 March 2007; revised 12 September 2007; accepted 24 September 2007; online publish-ahead-of-print 2 November 2007.

* Corresponding author. Lyovej 18, 3.TV, DK-2000 Frederiksberg, Denmark. Fax: +45 39760107. E-mail address: ja{at}heart.dk


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Clinical implication
 Limitations of the study
 References
 
Aims: To evaluate the diagnostic accuracy of 64-slice multi-detector computed tomography coronary angiography (64-SCTA) compared with the standard reference conventional coronary angiography (CCA).

Methods and results: Based on a systematic search, 27 studies including 1740 patients were eligible for meta-analyses. Nineteen studies examined native coronary arteries (n = 1,251), four studies examined coronary artery by-pass grafts (CABG) (n = 271), and five studies examined coronary stents (n = 270). Overall 18 920 segments were assessable and 810 (4%) were unassessable. The prevalence of native coronary artery stenosis in per-segment (19 studies) and per-patients (13 studies) populations were 19 and 57.5% respectively. Accuracy tests with 95% confidence intervals comparing 64-SCTA vs. CCA showed that sensitivity, specificity, positive predictive and negative predictive values for native coronary arteries were 86(85–87), 96(95.5–96.5), 83, and 96.5% by per-segment analysis; 97.5(96–99), 91(87.5–94), 93, and 96.5% by per-patient analysis; 98.5(96–99.5), 96(93.5–97.5), 92 and 99% for CABGs; 80(70–88.5), 95(92–97), 80, and 95% for stent restenosis; and 87(86.5–88), 96(95.5–96.5), 83.5, and 97% by overall per-segment analysis.

Conclusion: The high diagnostic accuracy of 64-SCTA validates this non-invasive technique as a potential alternative to CCA in carefully selected populations suspected for coronary stenosis.

Key Words: Computed tomography • Angiography • Coronary artery • Coronary artery disease


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Clinical implication
 Limitations of the study
 References
 
Non-invasive examination of coronary artery disease is an attractive and rapidly evolving possibility. Multi-detector computed tomography coronary angiography (MDCTA) is currently considered as a promising alternative to conventional coronary angiography (CCA). The technique is non-invasive, images can be obtained quickly, there are few complications and the preliminary studies show that it may be cost effective but this has to be determined.1,2 Nevertheless, the available equipment suffers from several limitations compared with CCA. During the last few years, substantial technical improvement and encouraging research results have been achieved for MDCTA. The diagnostic accuracy of MDCTA has improved after introduction of newer generations of scanners with high temporal and spatial resolution.

Many studies have addressed the accuracy of evolving generations of MDCTA in a variety of patient groups using CCA as standard reference. Several systematic reviews and meta-analyses combining results of studies using older scanner generations have been published.3–8 The results of the recent studies using 64-slice MDCTA (64-SCTA) appear more promising and many studies have shown that this technique may become a potential alternative to CCA. The plausible clinical application of the currently available technique is primarily to substitute CCA as a diagnostic tool in ruling out CAD or verifying a coronary artery stenosis in selected patients suspected for CAD. In this systematic review, we have combined results of currently available published studies comparing 64-SCTA with the standard reference—CCA—to assess the diagnostic accuracy of this latest generation of MDCTA.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Clinical implication
 Limitations of the study
 References
 
Search strategy
We searched in the electronic databases: PubMed, EMBASE, and Cochrane for all published studies that examined patients with 64-SCTA. The following keywords were used: computed tomography, angiography, coronary artery, coronary artery disease. The search was limited until the end of April 2007. In press online published articles were also screened in the available journals. All published systematic reviews and meta-analyses were identified and their reference lists were screened.3–8 Reference lists of the retrieved articles were screened as well.

Study eligibility
Published studies were considered eligible if they included patients with proven or suspected CAD using 64-SCTA compared with CCA as standard reference. Significant coronary luminal stenosis was defined as ≥50% reduction in diameter using quantitative CCA or visual estimation as reference. Eligible studies should provide absolute numbers of diagnostic accuracy tests using 2x2 tables. Studies not providing relevant data on diagnostic accuracy were excluded.

Data extraction
Demographic, methodological and technical data, numbers of patients and segments, heart rate during scanning, numbers of true positive, false positive, true negative, and false negative values were extracted from each study. The angiographic results, reported either as per-patient or per-segment categories, were also extracted. Two authors contributed to data evaluation and extraction.

Data synthesis
The main analyses were performed using the traditional meta-analytic methods for combining data for diagnostic accuracy tests.9,10 The analyses that were performed to compare accuracy of 64-SCTA vs. CCA as reference incorporated all accuracy tests: sensitivity, specificity, predictive negative value, predictive positive value, likelihood ratios, diagnostic odds ratio, overall accuracy, and finally summarizing data in receiver operating characteristic curves. Accordingly, the absolute numbers of true positive, false positive, true negative, and false negative findings were analysed to provide sensitivity and specificity. Positive likelihood ratios LR+=sensitivity/(1-specificity) and negative likelihood ratios LR–=(1-sensitivity)/specificity were calculated. The likelihood ratio for a positive result (LR+) is a measure of how much the odds of the disease increase when a test is positive, while the likelihood ratio for a negative result (LR–) tells how much the odds of the disease decrease when a test is negative. Thus, the combined likelihood ratios provided the diagnostic odds ratio (=sensitivity/(1-specificity)/(1-specificity)/sensitivity=true positivextrue negative/false positivexfalse negative). The result is a ratio of the odds of a positive test result among diseased to the odds of a positive test result among non-diseased.9,10 Diagnostic odds ratio is considered as a more precise parameter for accuracy tests independent of prevalence. Moreover, prevalence in each data category (patient and segment), predictive positive and negative values were calculated as well.

The two different arms in the study by Ong et al.11 were computed separately. The study by Malagutti12 provided per-segment data on coronary artery by-pass grafts (CABG) as well as native arteries which were analysed separately. In the study by Ropers13 only per-segment graft data were selected to analysis. The study by Rist14 provided data on proximal, distal, and in-stent stenosis which all were combined to one result.

Due to heterogeneity, all the data were analysed by DerSimonian Laird random effects model. Sensitivity and meta-regression analyses were performed.15 P-values<0.05 were considered significant.

Meta-analysis software package Meta-DiSc version 1.4 (Unit of clinical biostatics, the Ramo y Cajal Hospital, Madrid, Spain) was used for all diagnostic accuracy analyses, generating summary receiver operative characteristic (SROC) curves and meta-regression analyses. Predictive values were calculated in MedCalc Meta-analyse package version 9.1.0.1 (Broekstrat 52, Mariakerke, Belgium).


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Clinical implication
 Limitations of the study
 References
 
Search results
The search resulted in detection of 2609 hits. After exclusion of non-relevant articles by title and abstract, 87 articles were retrieved for full text evaluation, and of these 29 studies fulfilled all inclusion criteria. Two studies were excluded because of insufficient data.16–17 Finally, 27 eligible studies were included in the meta-analysis (Table 1).


View this table:
[in this window]
[in a new window]

  		Table 1 Characteristics of the included 27 studies

 
Characteristics of the included studies
Characteristics of the included studies are shown in Table 1. Per-segment analysis of data was performed in all studies, thereof 19 studies examined native coronary arteries,11,12,18–35 four studies examined CABGs,12,13,35,36 and five studies examined implanted stent restenosis14,37–40 (Table 1). The study by Malagutti12 contributed both to the native coronary artery and CABG analyses. Per-patient analysis was available in 13 studies18–24,27,29,30,32–34 that examined native coronary arteries. All studies defined significant luminal stenosis as cut-off ≥50% except two studies that defined it as ≥70%.23,28 The included studies constituted relatively small populations ranging between 25–138 patients. The total included number of patients was 1761, of whom 21 (1.2%) were excluded for a variety of reasons. Thus 1740 were left for analyses.

All studies reported that investigators were blinded for image analyses but this point was unclear in three studies.21,27,31

Angiography protocols in the included studies
The 64-SCTA technique scanning required patients to be in sinus rhythm without tachycardia, to be able to hold their breath for 10–15 s during scanning, be without contrast allergy, and have normal renal function. Patients not fulfilling these criteria were precluded.

Scanning protocols were almost the same in the included studies that used a 64-slice scanner. Only in the study by van Mieghem38 a minority (n = 27) of patients were scanned using 16-SCTA but the majority (n = 43) were scanned by 64-SCTA and the study targeted proximal stents which all were assessable by both methods. Scanners gantry rotation time was 330 ms except in two studies which was 370 ms.20,25 A number of studies reported a regulated rotation time to improve the temporal resolution according to heart rate.12,14,24,32,34,40

The mean volume of the injected intravenous contrast agents was 85 mL with a range of 65–100 mL. The contrast agents used were: Iomeron (Iomeprol 400 mg I/mL), Omnipaque (Iohexol 300–370 mg I/mL), Ultravista 370 (Iopromide 370 mg I/mL)), Visipaque (iodiaxanol 320 mg I/mL), Imeron (Iomeprol 300–350 mg I/mL), Isovue (Iopamidole 370 mg I/mL), and Solustrat 300 (Iopamidole 300 mg I/mL). Either 15 or 17 segment analysis models were used. Assessment of stenosis diameter was done by quantitative CCA (QCCA); however, three studies reported that they used visual estimation.11,23,31 Assessment of coronary stenosis by 64-SCTA was performed visually using axial, multiplanar reconstruction (MPR) and maximum intensity projection (MIP) techniques in most of the studies. Six studies reported using curved MPR.14,18,21,22,29,33 Only five studies on native coronary arteries reported clearly that they assessed segment stenosis in two orthogonal planes.20,25,27,29,38 Only one study reported a quantitative measurement of coronary stenosis in complex lesions.27

The average estimated radiation dose during the whole electrocardiogram cycle (systole and diastole) was determined to be about 15 mSv and 20 mSv for men and women, respectively, in six studies.21,22,26,27,32,38 By restricting the maximal tube current to the diastolic period, the radiation dose was reduced significantly to about 7 mSv and 14 mSv for men and women, respectively, in four other studies.13,30,34,39

Characteristics of included patients
The mean age was 61.5 years with a range of 59–69 years. Males constituted 76.8%. Cardiovascular risk profile was reported in 12 studies:12,18,19,21,25,26,28,30,32,35,38,39 53% had hypertension, 18% had diabetes mellitus, and 56% had hyperlipidaemia. The mean heart rate during scanning was 63/min with a range of 57–77/min. In all but four studies,18–20,25 patients received additional beta-blocker either intravenous or orally to reduce heart rate below 65/min.

Segment assessability
In per-segment analysis of native coronary arteries, a total of 18 920 segments were visualized but 806 segments were unassessable. Thus, 4% of segments (range 0–15) were excluded from analysis. All CABG segments (n = 810) were assessable in the four CABG studies. In one study of stents implanted in proximal vessels (left main coronary artery) it was also possible to assess all segments,38 but in other two studies of smaller stents the percent of unassessable segments was high (Table 1).

Results of the accuracy analyses
The results of the analyses comparing 64-SCTA vs. CCA are shown in Table 2. There were differences in sensitivity and specificity values in per-segment vs. per-patient analysis due to the calculated higher prevalence of CAD in per-patient data. In general, 64-SCTA demonstrated high accuracy particularly by its high negative predictive values. The accuracy was highest in assessing CABG (96.5%) and lowest in stented segments (92%).


View this table:
[in this window]
[in a new window]

  		Table 2 Results of the meta-analyses comparing 64-slice computed tomography coronary angiography with conventional coronary angiography: accuracy results of the group of studies

 
We ran also the analyses by including only the studies that used quantitative coronary angiographic method for assessment of stenosis diameter and by excluding three studies that used visual estimation.11,23,31 The results of 16 studies on per-segment analysis of native coronary arteries showed an increased sensitivity of 88(86–90)% and unchanged specificity of 96(95.5–96.5)%, the studies were heterogeneous P < 0.001. The results of 11 studies on per-patient analyses of native coronary arteries showed unchanged sensitivity of 97.5(96–99)% with P = 0.079 for heterogeneity and an increased specificity of 92(88.5–95.5)% with P = 0.004 for heterogeneity.

The SROC graphs (Figure 1A–C) showed a symmetric area under the curve of 0.98 for per-patient, per-segment, and overall analyses.


Figure 1
View larger version (29K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 1 (A–C) Plot of per-segment (19 studies), per-patient (13 studies), and overall (27 studies) symmetric receiver operating characteristics comparing 64-slice computed tomography coronary angiography vs. conventional coronary angiography. The diagnostic accuracy is shown by plotting 1-specificity against sensitivity, area under curve (AUC), and Q* statistic with their standard errors (SE). The upper and lower lines indicate 95% confidence intervals. SROC, summary receiver operating characteristic.

 
Heterogeneity and sensitivity analyses
The per-segment analyses showed significant heterogeneity for all accuracy analyses, all P < 0.001. The heterogeneity was significant (P < 0.001) even after excluding the small studies with populations below 50 patients. Therefore, meta-regression analyses (27 studies) were performed by including four important covariates, which we presumed to be the most likely source of heterogeneity. These were: age, prevalence of CAD, heart rate during scanning, and percent of unassessable segments. The results showed that age, prevalence of CAD, and heart rate had no significant influence on heterogeneity P = 0.69, P = 0.64, P = 0.83, respectively. Percent of unassessable segments had significant influence, P = 0.03, and after including all the other covariates in the model this influence was still border-line significant, P = 0.053.

The per-patient analyses showed significant heterogeneity only for the specificity P < 0.001 and positive likelihood ratio P < 0.001.

A comparison between results of the current meta-analysis with the previous meta-analyses is shown in Table 3.


View this table:
[in this window]
[in a new window]

  		Table 3 Diagnostic accuracy of computed tomography coronary angiography compared with conventional coronary angiography based on per-segment analyses of native coronary arteries in the successive meta-analyses using different generations of scanners

 

   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Clinical implication
 Limitations of the study
 References
 
The results of the current meta-analysis demonstrate that 64-SCTA has high diagnostic accuracy and assessability of coronary artery segments (Tables 2 and 3). The estimated high negative predictive value by per-patient analysis validates 64-SCTA technique as an alternative to CCA in carefully selected patients suspected for CAD. The accuracy of the technique is robust in assessing bypass grafts but limited in assessing in-stent restenosis. The accuracy of 64-SCTA has also been compared with the other non-invasive methods and shown that 64-SCTA has higher accuracy compared with magnetic resonance imaging angiography and stress nuclear imaging in detecting CAD.3,41–43 Thus, 64-SCTA can be considered as a major option to be used in examining patients suspected for CAD. However, it should be emphasized that these three methods provide different and complementary structural and functional information on CAD.

Although 64-SCTA seems to be an attractive alternative non-invasive method, several limitations remain in clinical practice. In this review, it can be noticed that some preclusion criteria restricted the number of eligible patients prior to scanning, leaving eventually selected groups who were potential candidates for 64-SCTA. Perhaps due to the rigid preclusion criteria, the number of excluded patients during the studies was low, only 1.2%. The number of assessable segments by 64-SCTA was high (96%), but still a considerable number (4%) was not well assessed and might need re-evaluation with CCA (Table 2).

Both types of analyses—per-segment and per-patient—that were performed provided high negative predictive values, though the estimated prevalence of CAD based on per-segment compared with per-patient analysis was as expected much lower (19 vs. 57.5%). However, segmentation separates the coronary tree and individuals as a whole leading clinically to an unrealistic distribution of the disease. An independent analysis based on diseased segments can therefore be misleading and provides no useful information in practice. Accordingly, the results provided by the per-patient analysis in populations with high prevalence of CAD can be considered clinically relevant and the overall results of accuracy in the current study seem therefore to be acceptable.

The rapid technical evolvement in the recent few years indicates that solutions for the restricting technical factors could be possible in the near future. Increasing number of detectors, shortening gantry rotation time, and using dual source technique are possible solutions. Important remaining issues are artefacts due to cardiac, pulmonary and body motion, beam hardening due to metallic objects (surgical clip, marker, wire, and stents), extensive calcifications, and overlying cardiac veins.44,45 Image quality might be worsened by arrhythmias and inability to hold breath.45,46 These are not uncommon problems in patients with heart and lung diseases. Faster acquisition time and increasing resolution by the newer generations of scanners might minimize artefact problems.

The high radiation dose is probably the most undesirable disadvantage concerning the safety of 64-SCTA. The estimated mean effective radiation dose per patient in the included studies was about 15 and 20 mSv and with modulated protocols 7 and 14 mSV for males and females, respectively. This dose is markedly higher compared with the dose associated with an uncomplicated CCA which is about 5–7 mSv,47,48 but is almost similar to the patient dose administered when using nuclear cardiac stress scanning (with technetium is about 6–8 mSv and up to 27 mSV with thalium).49–50

Modulated radiation protocols with dose-saving algorithms are therefore important in daily practice to reduce the risk of radiation and at the same time maintain relevant image quality.51 Patient's age is an important issue when 64-SCTA is chosen as first method, because younger patients have higher lifetime risk of developing cancer as a result of exposure to X-ray. Younger females are in further increased risk of breast radiation and cancer.52 Thus, these patient categories may have higher lifetime cancer mortality than older people in case of repeated examinations with higher cumulative radiation.52,53 A recently published study estimating the radiation risk in phantom male and female models underscored the increased lifetime attributable risk of cancer in younger patients and particularly females.54 However, as noticed in this paper the mean age of patients scheduled for 64-SCTA was 61.5 years, in whom the lifetime cancer risk might be considered relatively lower.54 The risk of contrast agents on renal function and risk of allergy remain important for both procedures. Nevertheless, it should be noticed that the estimated overall risk associated with 64-SCTA is still considered lower than CCA.48,55

In summary, the current 64-SCTA technique can therefore not be recommended for examination of patients with high probability of CAD and coronary intervention and neither for screening of asymptomatic patients. Ideally, cardiologists should use a pretest probability of CAD in order to avoid further interventions associated with increased radiation risk. Appropriate selection of patients can be performed by a pretest probability of CAD,56 assessment of lifetime cancer risk, probability of artefacts induced by motion and arrhythmias, as well as patients' ability to cooperate.57,58

Compared with CCA, 64-SCTA is a non-invasive approach that would more likely be preferred by most of the patients, has the advantage of shorter patient preparation time, provides insight in surrounding tissues and plaque morphology, can construct images both on the coronary tree, cardiac and the other intra-thoracic structures and finally personnel will not be exposed to radiation. While the disadvantages are increased radiation risk for patient, lower resolution, longer analysis time, need for a work-station, patients need to hold breath and finally inadequate image quality in case of arrhythmias and artefacts.

An important issue when comparing the diagnostic accuracy of 64-SCTA with CCA is not only assessment of a significant stenosis by quantitative CCA as reference, but also how the stenosis is reliably assessed by 64-SCTA. The core analysis is usually done by evaluating the axial source images and MPR. These images provide parallel and orthogonal views of the vessels, which are instrumental in detecting and assessing stenosis severity. These can be supplied by MIP technique images, but the disadvantage of this technique is that the presence of calcifications can obscure lower density structures of interest like non-calcified plagues.59 A visual comparison of the stenotic area with the distal and proximal luminal areas as reference provides a qualitative assessment of the stenosis.59–61 In case of excellent image quality, a planimetric measurement of the cross-sectional area can provide a quantitative assessment.60,61 Based on the results of the included studies in this meta-analysis, the method of data evaluation and assessment of coronary artery stenosis varied across the studies and was qualitative. This underscores the need for optimal image quality as well as consensus on using a standard qualitative and quantitative assessment of luminal stenosis by 64-SCTA.

The results of the current and previous meta-analyses showed significant heterogeneity between the included studies. However, the current meta-analysis of studies using only 64-SCTA showed a reduced heterogeneity in per-patient data. Analyses by excluding small size studies or studies using visual estimation of coronary stenosis had no influence on heterogeneity. Exploring for source of heterogeneity by meta-regression analyses showed that age, prevalence of CAD, and heart rate had no influence. The only reasonable source of heterogeneity was a significant difference in the numbers of assessed segments among studies, which might have influenced the absolute numbers of true and false stenoses reported in each study. This variation in segment analysis can be attributed to level of experience with 64-SCTA used in different centres where the studies were performed. Improvement of technical quality and clinical experience might minimize this difference.

There is no consensus about using quality scores in assessment of diagnostic accuracy studies and even the suggested scores have shown no major role in systematic reviews of diagnostic accuracy tests.62 However, identifying inclusion and exclusion criteria and study populations were well described, the reference method used was the same, the index test was well described, the majority of studies used blinded methods in image analysis, and finally the number of unassessable segments and excluded patients were well reported in the studies included in this meta-analysis.


   Clinical implication
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Clinical implication
Limitations of the study
 References
 
The results of this study show that 64-SCTA can be used to rule out or detect the presence of CAD in carefully selected populations suspected for CAD. The method is attractive due to many advantages, however, clinicians should be cautious about the high radiation dose and risk of re-evaluation with CCA in case of failure of adequate assessment by 64-SCTA.


   Limitations of the study
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Clinical implication
 Limitations of the study
References
 
It is likely that the results of this study are biased by the fact that the included populations were of small sizes, selected patients and investigators had a better experience compared with the real-life centres which usually examine larger and more broad-spectrum populations and may have less experience with the technique. The included studies were also likely to be associated with some observational bias due to inter-observer variations.


   Acknowledgments
 
Conflict of interests: none declared.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Clinical implication
 Limitations of the study
 References
 

  1. Budoff MJ, Achenbach S, Blumenthal RS, Carr JJ, Goldin JG, Greenland P, Guerci AD, Lima JA, Rader DJ, Rubin GD, Shaw LJ, Wiegers SE. Assessment of coronary artery disease by cardiac computed tomography: a scientific statement from the American Heart Association Committee on Cardiovascular Imaging and Intervention, Council on Cardiovascular Radiology and Intervention, and Committee on Cardiac Imaging, Council on Clinical Cardiology. Circulation (2006) 114:1761–1791.[Free Full Text]
  2. Dewey M, Hamm B. Cost effectiveness of coronary angiography and calcium scoring using CT and stress MRI for diagnosis of coronary artery disease. Eur Radiol (2007) 17:1301–1309.[CrossRef][Web of Science][Medline]
  3. Schuijf JD, Bax JJ, Shaw LJ, de Roos A, Lamb HJ, van der Wall EE, Wijns W. Meta-analysis of comparative diagnostic performance of magnetic resonance imaging and multislice computed tomography for noninvasive coronary angiography. Am Heart J (2006) 151:404–411.[CrossRef][Web of Science][Medline]
  4. Stein PD, Beemath A, Kayali F, Skaf E, Sanchez J, Olson RE. Multidetector computed tomography for the diagnosis of coronary artery disease: a systematic review. Am J Med (2006) 119:203–216.[CrossRef][Web of Science][Medline]
  5. Sun Z, Jiang W. Diagnostic value of multislice computed tomography angiography in coronary artery disease: A meta-analysis. Eur J Radiol (2006) 60:279–286.[CrossRef][Web of Science][Medline]
  6. Hamon M. Diagnostic performance of multislice computed tomography of coronary arteries as compared with conventional invasive coronary angiography. J Am Coll Cardiol (2006) 48:1896–1910.[Abstract/Free Full Text]
  7. van der Zaag-Loonen HJ, Dikkers R, de Bock GH, Oudkerk M. The clinical value of a negative multi-detector computed tomographic angiography in patients suspected of coronary artery disease: a meta-analysis. Eur Radiol (2006) 16:2748–2756.[CrossRef][Web of Science][Medline]
  8. Jones CM, Athanasiou T, Dunne N, Kirby J, Attaran S, Chow A, Purkayastha S, Darzi A. Multi-slice computed tomography in coronary artery disease. Eur J Cardiothorac Surg (2006) 30:443–450.[Abstract/Free Full Text]
  9. Deeks JJ. Systematic reviews in health care: Systematic reviews of evaluations of diagnostic and screening tests. BMJ (2001) 323:157–162.[Free Full Text]
  10. Deville WL, Buntinx F, Bouter LM, Montori VM, de Vet HC, van der Windt DA, Bezemer PD. Conducting systematic reviews of diagnostic studies: didactic guidelines. BMC Med Res Methodol (2002) 2:9.[CrossRef][Medline]
  11. Ong TK, Chin SP, Liew CK, Chan WL, Seyfarth MT, Liew HB, Rapaee A, Fong YY, Ang CK, Sim KH. Accuracy of 64-row multidetector computed tomography in detecting coronary artery disease in 134 symptomatic patients: influence of calcification. Am Heart J (2006) 151:e1–e6.[Medline]
  12. Malagutti P, Nieman K, Meijboom WB, van Mieghem CA, Pugliese F, Cademartiri F, Mollet NR, Boersma E, de Jaegere PP, de Feyter PJ. Use of 64-slice CT in symptomatic patients after coronary bypass surgery: evaluation of grafts and coronary arteries. Eur Heart J (2006) Published online ahead of print July, 17.
  13. Ropers D, Pohle FK, Kuettner A, Pflederer T, Anders K, Daniel WG, Bautz W, Baum U, Achenbach S. Diagnostic accuracy of noninvasive coronary angiography in patients after bypass surgery using 64-slice spiral computed tomography with 330-ms gantry rotation. Circulation (2006) 114:2334–2341.[Abstract/Free Full Text]
  14. Rist C, von Ziegler F, Nikolaou K, Kirchin MA, Wintersperger BJ, Johnson TR, Knez A, Leber AW, Reiser MF, Becker CR. Assessment of coronary artery stent patency and restenosis using 64-slice computed tomography. Acad Radiol (2006) 13:1465–1473.[CrossRef][Web of Science][Medline]
  15. Zamora J, Abraira V, Muriel A, Khan K, Coomarasamy A. Meta-DiSc: a software for meta-analysis of test accuracy data. BMC Med Res Methodol (2006) 6:31.[CrossRef][Medline]
  16. Fine JJ, Hopkins CB, Ruff N, Newton FC. Comparison of accuracy of 64-slice cardiovascular computed tomography with coronary angiography in patients with suspected coronary artery disease. Am J Cardiol (2006) 97:173–174.[CrossRef][Web of Science][Medline]
  17. Rubenshtein R, Halon DA, Gaspar T, Schliamser JE, Yaniv N, Ammar R, Flugelman MY, Peled N, lewis BS. Usefulness of 64-slice multidetector computed tomography in diagnostic triage of patients with chest pain and negative or nondiagnostic exercise treadmill test result. Am J Cardiol (2007) 99:925–929.[CrossRef][Web of Science][Medline]
  18. Schuijf JD, Pundziute G, Jukema JW, Lamb HJ, van der Hoeven BL, de Roos A, van der Wall EE, Bax JJ. Diagnostic accuracy of 64-slice multislice computed tomography in the noninvasive evaluation of significant coronary artery disease. Am J Cardiol (2006) 98:145–148.[CrossRef][Web of Science][Medline]
  19. Ehara M, Surmely JF, Kawai M, Katoh O, Matsubara T, Terashima M, Tsuchikane E, Kinoshita Y, Suzuki T, Ito T, Takeda Y, Nasu K, Tanaka N, Murata A, Suzuki Y, Sato K. Diagnostic accuracy of 64-slice computed tomography for detecting angiographically significant coronary artery stenosis in an unselected consecutive patient population: comparison with conventional invasive angiography. Circ J (2006) 70:564–571.[CrossRef][Web of Science][Medline]
  20. Leschka S, Alkadhi H, Plass A, Desbiolles L, Grunenfelder J, Marincek B, Wildermuth S. Accuracy of MSCT coronary angiography with 64-slice technology: first experience. Eur Heart J (2005) 26:1482–1487.[Abstract/Free Full Text]
  21. Meijboom WB, Mollet NR, Van Mieghem CA, Kluin J, Weustink AC, Pugliese F, Vourvouri E, Cademartiri F, Bogers AJ, Krestin GP, de Feyter PJ. Pre-operative computed tomography coronary angiography to detect significant coronary artery disease in patients referred for cardiac valve surgery. J Am Coll Cardiol (2006) 48:1658–1665.[Abstract/Free Full Text]
  22. Mollet NR, Cademartiri F, van Mieghem CA, Runza G, McFadden EP, Baks T, Serruys PW, Krestin GP, de Feyter PJ. High-resolution spiral computed tomography coronary angiography in patients referred for diagnostic conventional coronary angiography. Circulation (2005) 112:2318–2323.[Abstract/Free Full Text]
  23. Muhlenbruch G, Seyfarth T, Soo CS, Pregalathan N, Mahnken AH. Diagnostic value of 64-slice multi-detector row cardiac CTA in symptomatic patients. Eur Radiol (2007) 17:603–609.[CrossRef][Web of Science][Medline]
  24. Nikolaou K, Knez A, Rist C, Wintersperger BJ, Leber A, Johnson T, Reiser MF, Becker CR. Accuracy of 64-MDCT in the diagnosis of ischemic heart disease. Am J Roentgenol (2006) 187:111–117.[Abstract/Free Full Text]
  25. Plass A, Grunenfelder J, Leschka S, Alkadhi H, Eberli FR, Wildermuth S, Zund G, Genoni M. Coronary artery imaging with 64-slice computed tomography from cardiac surgical perspective. Eur J Cardiothorac Surg (2006) 30:109–116.[Abstract/Free Full Text]
  26. Pugliese F, Mollet NR, Runza G, van Mieghem C, Meijboom WB, Malagutti P, Baks T, Krestin GP, deFeyter PJ, Cademartiri F. Diagnostic accuracy of non-invasive 64-slice CT coronary angiography in patients with stable angina pectoris. Eur Radiol (2006) 16:575–582.[CrossRef][Web of Science][Medline]
  27. Raff GL, Gallagher MJ, O'Neill WW, Goldstein JA. Diagnostic accuracy of noninvasive coronary angiography using 64-slice spiral computed tomography. J Am Coll Cardiol (2005) 46:552–557.[Abstract/Free Full Text]
  28. Sheth TN, Rieber J, Mooyaart EA, Pena A, Abbara S, Cury RC, Brady T, Hoffmann U. Usefulness of coronary computed tomographic angiography to assess suitability for revascularization in patients with significant coronary artery disease and angina pectoris. Am J Cardiol (2006) 98:1198–1201.[CrossRef][Web of Science][Medline]
  29. Leber AW, Knez A, von Ziegler F, Becker A, Nikolaou K, Paul S, Wintersperger B, Reiser M, Becker CR, Steinbeck G, Boekstegers P. Quantification of obstructive and nonobstructive coronary lesions by 64-slice computed tomography: a comparative study with quantitative coronary angiography and intravascular ultrasound. J Am Coll Cardiol (2005) 46:147–154.[Abstract/Free Full Text]
  30. Ghostine S, Caussin C, Daoud B, Habis M, Perrier E, Pesenti-Rossi D, Sigal-Cinqualbre A, Angel CY, Lancelin B, Capderou A, Paul JF. Non-invasive detection of coronary artery disease in patients with left bundle branch block using 64-slice computed tomography. J Am Coll Cardiol (2006) 48:1929–1934.[Abstract/Free Full Text]
  31. Schlosser T, Mohrs K, Magedanz A, Nowak B, Voigtlander T, Barkhausen J, Schmermund A. Noninvasive coronary angiography using 64-detector-row computed tomography in patients with a low to moderate pretest probability of significant coronary artery disease. Acta Radiol (2007) 48:300–307.[CrossRef][Web of Science][Medline]
  32. Meijboom WB, Mollet NR, van Mieghem CA, Weustink AC, Pugliese F, van Pelt N, Cademartiri F, Vourvouri E, De Jaegere P, Krestin GP, de Feyter PJ. 64-slice computed tomography coronary angiography in patients with non-ST elevation acute coronary syndrome. Heart (2007) Published online ahead of print March, 7.
  33. Oncel D, Oncel G, Tastan A, Tamci B. Detection of significant coronary artery stenosis with 64-section MDCT angiography. Eur J Radiol (2007) Published online ahead of print February, 13.
  34. Ropers D, Rixe J, Anders K, Kuttner A, Baum U, Bautz W, Daniel WG, Achenbach S. Usefulness of multidetector row spiral computed tomography with 64- x 0.6-mm collimation and 330-ms rotation for the noninvasive detection of significant coronary artery stenoses. Am J Cardiol (2006) 97:343–348.[CrossRef][Web of Science][Medline]
  35. Pache G, Saueressig U, Frydrychowicz A, Foell D, Ghanem N, Kotter E, Geibel-Zehender A, Bode C, Langer M, Bley T. Initial experience with 64-slice cardiac CT: non-invasive visualization of coronary artery bypass grafts. Eur Heart J (2006) 27:976–980.[Abstract/Free Full Text]
  36. Meyer TS, Marinoff S, Hadamitzky M, Albrecht W, Kastrati A, Schomig A, Hausleiter J. Improved non-invasive assessment of coronary artery by-pass grafts with 64-slice computed tomographic angiography in a unselected patient population. J Am Coll Cardiol (2007) 49:946-5–950.
  37. Rixe J, Achenbach S, Ropers D, Baum U, Kuettner A, Ropers U, Bautz W, Daniel WG, Anders K. Assessment of coronary artery stent restenosis by 64-slice multi-detector computed tomography. Eur Heart J (2006) 27:2567–2572.[Abstract/Free Full Text]
  38. Van Mieghem CA, Cademartiri F, Mollet NR, Malagutti P, Valgimigli M, Meijboom WB, Pugliese F, McFadden EP, Ligthart J, Runza G, Bruining N, Smits PC, Regar E, van der Giessen WJ, Sianos G, van Domburg R, de Jaegere P, Krestin GP, Serruys PW, de Feyter PJ. Multislice spiral computed tomography for the evaluation of stent patency after left main coronary artery stenting: a comparison with conventional coronary angiography and intravascular ultrasound. Circulation (2006) 114:645–653.[Abstract/Free Full Text]
  39. Ehara M, Kawai M, Surmely JF, Matsubara T, Terashima M, Tsuchikane E, Kinoshita Y, Ito T, Takeda Y, Nasu K, Tanaka N, Murata A, Fujita H, Sato K, Kodama A, Katoh O, Suzuki T. Diagnostic accuracy of coronary in-stent restenosis using 64-slice computed tomography. J Am Coll Cardiol (2007) 49:951–959.[Abstract/Free Full Text]
  40. Oncel D, Oncel G, Karaca M. Coronary stent patency and in-stent restenosis: Determination with 64-section multidetector CT coronary angiography–initial experience. Radiol (2007) 242:403–409.
  41. Schuijf JD, Wijns W, Jukema JW, Atsma DE, de Roos A, Lamb HJ, Stokkel MP, Dibbets-Schneider P, Decramer I, De Bondt P, van der Wall EE, Vanhoenacker PK, Bax JJ. Relationship between noninvasive coronary angiography with multi-slice computed tomography and myocardial perfusion imaging. J Am Coll Cardiol (2006) 48:2508–2514.[Abstract/Free Full Text]
  42. Gallagher MJ, Ross MA, Raff GL, Goldstein JA, O'Neill W, O'Neil B. The diagnostic accuracy of 64-slice computed tomography coronary angiography compared with stress nuclear imaging in emergency department low-risk chest pain patients. Ann Emerg Med (2007) 49:125–136.[CrossRef][Web of Science][Medline]
  43. Hacker M, Jakobs T, Hack N, Nikolaou K, Becker C, von Ziegler F, Knez A, Konig A, Klauss V, Reiser M, Hahn K, Tiling R. Sixty-four slice spiral CT angiography does not predict the functional relevance of coronary artery stenoses in patients with stable angina. Eur J Nucl Med Mol Imaging (2007) 34:4–10.[CrossRef][Web of Science][Medline]
  44. Kaiser C, Bremerich J, Haller S, Rocca Brunner-La, Bongartz G, Pfesterer M, Buser P. Limited diagnostic yield of non-invasive coronary angiography by 16-slice multi-detector spiral computed tomography in routine patients referred fro evaluation of coronary artery disease. Eur Heart J (2005) 26:1987–1992.[Abstract/Free Full Text]
  45. Choi HS, Choi BW, Choe KO, Choi D, Yoo KJ, Kim MI, Kim J. Pitfalls, artefacts and remedies in multi-detector row CT coronary angiography. RadioGraphics (2004) 24:787–800.[Abstract/Free Full Text]
  46. Giesler T, Baum U, Rupers D, Ulzheimer S, Wenkel E, Mennicke M, Bautz W, Kalender WA, Daniel WG, Achenbach S. Noninvasive visualization of coronary arteries using contrast-enhanced multidetector CT: influence of heart rate on image quality and stenosis. Am J Roentgenol (2002) 179:911–916.[Abstract/Free Full Text]
  47. Kocinaj D, Cioppa A, Ambrosini G, Tesorio T, Salemme L, Sorropago G, Rubino P, Picano E. Radiation dose exposure during cardiac and peripheral arteries catheterisation. Int J Cardiol (2006) 113:283–284.[CrossRef][Web of Science][Medline]
  48. Coles DR, Smail MA, Negus IS, Wilde P, Oberhoff M, Karsch KR, Baumbach A. Comparison of radiation doses from multislice computed tomography coronary angiography and conventional diagnostic angiography. J Am Coll Cardiol (2006) 47:1840–1845.[Abstract/Free Full Text]
  49. Gomez-Palacios M, Ternon JA, Dominguez P, Vera DR, Osama RF. Radiation doses in the surroundings of patients undergoing nuclear medicine diagnostic studies. Health Phys (2005) 89(Suppl. 2):S27–S34.[CrossRef][Web of Science][Medline]
  50. Picano E. Economic and biological costs of cardiac imaging. Cardiovasc Ultrasound (2005) 3:13.[CrossRef][Medline]
  51. Hausleiter J, Meyer T, Hadamitzky M, Huber E, Zankl M, Martinoff S, Kastarati A, Schomig A. Radiation dose estimates from cardiac multislice computed tomography in daily practice. Circulation (2006) 113:1305–1310.[Abstract/Free Full Text]
  52. de Gonzales AB, Darby S. Risk of cancer from diagnostic x-rays: estimates for the UK and 14 countries. Lancet (2004) 363:345–351.[CrossRef][Web of Science][Medline]
  53. Bacher K, Bogaert E, Lapere R, De Wolf D, Thierens H. Patient-specific dose and radiation risk estimation in pediatric cardiac catheterisation. Circulation (2005) 111:83–89.[Abstract/Free Full Text]
  54. Einstein AJ, Henzlova MJ, Rajagopolan A. Estimating risk of cancer associated with radiation exposure from 64-slice computed tomography coronary angiography. JAMA (2007) 298:317–323.[Abstract/Free Full Text]
  55. Zanzonico P, Rothenberg LN, Strauss HW. Radiation exposure of computed tomography and direct intracoronary angiography: risk has its reward. J Am Coll Cardiol (2006) 47:1846–1849.[Abstract/Free Full Text]
  56. Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary artery disease. NEJM (1979) 300:1350–1358.[Abstract]
  57. Bax JJ, Schuijf JD. Which patients should be referred for non-invasive angiography with multi-slice CT? Int J Cardiol (2007) 114:1–3.[CrossRef][Web of Science][Medline]
  58. Schoepf UJ, Zwerner PL, Savino G, Herzog C, Kerl JM, Costello P. Coronary CT angiography. Radiology (2007) 244:48–63.[Abstract/Free Full Text]
  59. Hoffmann U, Ferencik M, Cury RC, Pena AJ. Coronary CT angiography. J Nuc Med (2006) 47:797–806.[Abstract/Free Full Text]
  60. Achenbach S, Ropers D, Hoffmann U, MacNeill B, Baum U, Pohle K, Brady TJ, Pomeranstev E, Ludvig J, Flachskampf FA, Wicky S, Jang IK, Daniel WG. Assessment of coronary remodelling in stenotic and nonstenotic coronary atherosclerotic lesions by multidetector spiral computed tomography. J Am Coll Cardiol (2004) 43:842–847.[Abstract/Free Full Text]
  61. Busch S, Johnson RC, Nikolaou K, von Ziegler F, Knez A, Reiser MF, Becker CR. Visual and automatic grading of coronary artery stenoses with 64-slice CT angiography in reference to invasive angiography. Eur Raiol (2007) 17:1445–1451.
  62. Whiting P, Harbord R, Kleijnen J. No role for quality scores in systematic reviews of diagnostic accuracy studies. BMC Med Res Methodol (2005) 5:19.[CrossRef][Medline]

Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?


This article has been cited by other articles:


Home page
 HeartHome page
J M van Werkhoven, O Gaemperli, J D Schuijf, J W Jukema, L J Kroft, S Leschka, H Alkadhi, I Valenta, G Pundziute, A de Roos, et al.
Multislice computed tomography coronary angiography for risk stratification in patients with an intermediate pretest likelihood
Heart, October 1, 2009; 95(19): 1607 - 1611.
[Abstract] [Full Text] [PDF]

Home page
 J Am Coll CardiolHome page
S. Achenbach
Stress computed tomography myocardial perfusion: steps, questions, and layers.
J. Am. Coll. Cardiol., September 15, 2009; 54(12): 1085 - 1087.
[Full Text] [PDF]

Home page
 J Am Coll Cardiol ImgHome page
B. M. Wertman, V. Y. Cheng, S. Kar, H. Gransar, R. A. Berg, H. Naik, R. Makkar, J. D. Friedman, J. N. Schapira, and D. S. Berman
Characterization of Complex Coronary Artery Stenosis Morphology by Coronary Computed Tomographic Angiography
J. Am. Coll. Cardiol. Img., August 1, 2009; 2(8): 950 - 958.
[Abstract] [Full Text] [PDF]

Home page
 Circ Cardiovasc ImagingHome page
N. Bettencourt, J. Rocha, M. Carvalho, D. Leite, A. M. Toschke, B. Melica, L. Santos, A. Rodrigues, M. Goncalves, P. Braga, et al.
Multislice Computed Tomography in the Exclusion of Coronary Artery Disease in Patients With Presurgical Valve Disease
Circ Cardiovasc Imaging, July 1, 2009; 2(4): 306 - 313.
[Abstract] [Full Text] [PDF]

Home page
 J Am Coll Cardiol ImgHome page
S. Achenbach, V. Dilsizian, C. M. Kramer, and W. A. Zoghbi
The Year in Coronary Artery Disease
J. Am. Coll. Cardiol. Img., June 1, 2009; 2(6): 774 - 786.
[Abstract] [Full Text] [PDF]

Home page
 Am. J. Roentgenol.Home page
P. T. Johnson, H. K. Pannu, and E. K. Fishman
IV Contrast Infusion for Coronary Artery CT Angiography: Literature Review and Results of a Nationwide Survey
Am. J. Roentgenol., May 1, 2009; 192(5): W214 - W221.
[Abstract] [Full Text] [PDF]

Home page
 J Am Coll Cardiol ImgHome page
M. Hadamitzky, B. Freissmuth, T. Meyer, F. Hein, A. Kastrati, S. Martinoff, A. Schomig, and J. Hausleiter
Prognostic Value of Coronary Computed Tomographic Angiography for Prediction of Cardiac Events in Patients With Suspected Coronary Artery Disease
J. Am. Coll. Cardiol. Img., April 1, 2009; 2(4): 404 - 411.
[Abstract] [Full Text] [PDF]

Home page
 ESC Textbook of Cardiovascular MedicineHome page
P. J. de Feyter, S. Achenbach, and K. Nieman
CHAPTER 6 Cardiovascular Computed Tomography
ESC Textbook of Cardiovascular Medicine, January 1, 2009; 2(1): med-9780199566990-chapter - med-9780199566990-chapter.
[Abstract] [Full Text] [PDF]

Home page
 HeartHome page
A. J Einstein
Radiation risk from coronary artery disease imaging: how do different diagnostic tests compare?
Heart, December 1, 2008; 94(12): 1519 - 1521.
[Full Text] [PDF]

Home page
 J Am Coll CardiolHome page
M. J. Budoff, D. Dowe, J. G. Jollis, M. Gitter, J. Sutherland, E. Halamert, M. Scherer, R. Bellinger, A. Martin, R. Benton, et al.
Diagnostic Performance of 64-Multidetector Row Coronary Computed Tomographic Angiography for Evaluation of Coronary Artery Stenosis in Individuals Without Known Coronary Artery Disease: Results From the Prospective Multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) Trial
J. Am. Coll. Cardiol., November 18, 2008; 52(21): 1724 - 1732.
[Abstract] [Full Text] [PDF]

Home page
 Circ Cardiovasc ImagingHome page
P. J. de Feyter and R.-J. van Geuns
Noninvasive Coronary Imaging: The Contest Between Magnetic Resonance and Computed Tomographic Coronary Angiography
Circ Cardiovasc Imaging, September 1, 2008; 1(2): 89 - 91.
[Full Text] [PDF]

Home page
 Eur Heart JHome page
B. Kantor, N. S. Anavekar, and T. C. Gerber
Good news on coronary computed tomographic angiography: answers that have questions!
Eur. Heart J., September 1, 2008; 29(17): 2070 - 2072.
[Full Text] [PDF]

Home page
 CirculationHome page
D. A. Bluemke, S. Achenbach, M. Budoff, T. C. Gerber, B. Gersh, L. D. Hillis, W. G. Hundley, W. J. Manning, B. F. Printz, M. Stuber, et al.
Noninvasive Coronary Artery Imaging: Magnetic Resonance Angiography and Multidetector Computed Tomography Angiography: A Scientific Statement From the American Heart Association Committee on Cardiovascular Imaging and Intervention of the Council on Cardiovascular Radiology and Intervention, and the Councils on Clinical Cardiology and Cardiovascular Disease in the Young
Circulation, July 29, 2008; 118(5): 586 - 606.
[Full Text] [PDF]

Home page
 Eur Heart JHome page
H. Van Brabandt
Recommendations or mere prose?
Eur. Heart J., June 1, 2008; 29(11): 1473 - 1473.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
28/24/3042    most recent
ehm466v1
Right arrow E-letters: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when E-letters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (19)
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Abdulla, J.
Right arrow Articles by Torp-Pedersen, C.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Abdulla, J.
Right arrow Articles by Torp-Pedersen, C.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?