Non-Cardiovascular Findings on CMR Marty Smith M.D. Instructor in Radiology Beth Israel Deaconess...
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Transcript of Non-Cardiovascular Findings on CMR Marty Smith M.D. Instructor in Radiology Beth Israel Deaconess...
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Non-Cardiovascular Findings on CMR
Marty Smith M.D.Marty Smith M.D.Instructor in Radiology
Beth Israel Deaconess Medical Center
Harvard Medical School
Boston, MA
A major teaching hospital of Harvard Medical School
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Objectives
• Review data for incidental non-cardiovascular findings (NCF) in cross-sectional cardiac imaging
• Approach to non-cardiovascular structures on CMR imaging
• Overview of common lesions and their expected appearance on CMR
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What is covered?
Imaged volume – Base of Neck → Kidneys
Base of Neck - Thyroid, parathyroid, trachea, esophagus, muscles, vertebral bodies, lymph nodes, nerves, fat
Thorax Thyroid Mediastinum – thymus, trachea & bronchi, esophagus,
vertebral bodies, spinal canal, lymph nodes, nerves, fat Lungs and pleura Chest wall – bones, muscles, lymph nodes, nerves, fat Breasts Diaphragm
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What is covered?
Abdomen Liver Gall bladder and bile ducts Pancreas Kidneys Adrenal Glands Spleen Stomach Bowel and Mesentery Vertebral column, nerves, spinal canal, paravertebral
musculature, fat, fascia, & lymph nodes
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Background: Non-Cardiac Findings
Dewey M, et al. Non-cardiac findings on coronary computed tomography and magnetic resonance imaging. Eur Radiol 2007 Feb 1; [Epub ahead of print].
• 108 consecutive patients suspected of having CAD who had CTA & MRA
• Significant NCF → clinical or radiology F/U
• CT – 5 (5%) significant non-cardiac findings
PE, pleural effusion, sarcoid, HH, & pulmonary nodule
• MRI – 2 (2%) significant non-cardiac findings Pleural effusion & sarcoid – both seen on CT
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Non-Cardiac Findings
Conclusion: Incidental NCF are common; images should be analyzed by radiologists to ensure findings not missed & unnecessary follow-up avoided.
Dewey at al. Eur Radiol 2007
Of 108 pts.
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Non-Cardiac Findings on Cardiac CT
• Cardiac MDCT in 503 pts1 346 new NCF in 292 pts (58.1%) 114 pts (22.7%) had clinically significant findings
4 cases of malignancy (0.8%). 49 lung nodules <1cm (12 > 1cm), 8 aortic,17 pleural effs
• Cardiac MDCT in 166 pts, suspected CAD2
NCF in 41 pts (24.7%), major (4.8%)
• EBCT in 1326 pts for coronary Ca2+ scoring3
NCF requiring f/u in 103 pts (7.8%)
• EBCT in 1812 consecutive pts4
NCF in 630 (35%); 50 (2.8%) f/u imaging1 Onuma Y, et al. J Am Coll Cardiol 2006 2 Haller S, et al. AJR Am J Roentgenol; 20063 Horton KM, et al. Circulation 2002 4 Hunold P, et al. Eur Heart J 2001
Summary for CT:
• NCF in 24-58%
• NCF needing f/u in 2-23%
• Classification criteria variable
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BIDMC CMR Experience – Part I
• 1534 clinical CMR reports reviewed 2002-061
• 129 NCF in 116 (8.2%) studies 55 “major” findings in 50 (3.3%) studies
lymphadenopathy - 22 (1.4%) lung abnormalities - 19 (1.2%) mediastinal masses - 6 (0.4%) breast lesions - 4 (0.3%), ascites - 3 (0.2%), soft tissue
masses - 1 (0.1%)
74 “minor” findings in 70 (4.6%) studies pleural effusions, liver lesions, renal cysts, HH,
diaphragmatic abnormalities, splenic abnormalities, paraspinal lipomas, & anomalous vasculature
• NCF mean age 54 vs 49 w/o (p <0.001)
1 Chan PG, etal. JACC 2009
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BIDMC CMR Experience – Part II
• 495 clinical CMR exams in 2006 reviewed for NCF by radiologist w/o prior readings
• NCF classification Benign (gynecomastia, simple cyst) Indeterminate (pleural effusion, liver & renal lesions) Worrisome (lung nodules)
• Follow-up of indeterminate & worrisome NCF using Careweb New vs known abnormality What follow-up performed
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Results: NCF Prevalence
• 295 NCF in 212 / 495 (43%) studies 144 Benign: 123 / 495 (25%) studies 137 Indeterminate: 105 / 495 (21%) studies 14 Worrisome: 14 / 495 ( 3%) studies
Benign: Gynecomastia (41), HH (22), Renal Cyst (17), Liver cyst/hemangioma (16), Scoliosis (11), Mediastinal LAN <1.5 cm (10), Other (27)
Indeterminate:Pleural effusion (29), Renal lesion (27), Atelectasis (11), Mediastinal LAN >1.5 cm (11), Lung consolidation (7), Big HH (6), Liver lesion (6), Other (40)
Worrisome: Lung nodules (11), Aortic dissection (1), Aortic ulcer (1), Mediastinal mass (1)
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Results: NCF Detection & F/U
• 105 / 295 (36%) NCF listed in clinical report Benign (21%), Indeterminate (50%), Worrisome (50%)
• 11 NCF in reports missed by reviewer
• 65 NCF in 52 pts needed f/u → performed on 25 (38%)*
• Of NCF reported, 22 needed f/u → performed on 12 (55%)**
* No online medical record information currently available for pts with 16 findings
** No online medical record information currently available for pts with 7 findings
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Known Follow-up
Management changing findings in 11 pts: • Lung cancer (2)
• Pulmonary nodule requiring further follow-up (2)
• Typical pulmonary carcinoid
• Cryptogenic organizing pneumonitis (COP)
• Multifocal pneumonia secondary to newly diagnosed AML
• Mediastinal lymphadenopathy requiring further follow-up
• Breast implant rupture
• Obstructed atrophic kidney
• New AAA (previously repaired but with recurrence)
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Results: Radiologist’s Presence
• Radiologist at joint read-out – 384/495 (78%) scans
• 42% (95/228) of NCF reported when radiologist at joint readout
• 15% (10/67) of NCF reported when radiologist read remotely (p<0.01)
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Results: Sequences
• Scouts showed NCF 186/295 (63%)
• T1W FSE showed NCF 176/295 (60%)
• Only 12 (4%) NCF not visualized on one of these sequences 10 benign, 2 indeterminate)
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CMR Sequences
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CMR Sequence Overview
• Abdomen & base of neck FFE scouts Limited coverage by other sequences
• Thorax – Potentially all sequences Most → T1-w TSE, FFE scouts, B-FFE cines Other T1-w imaging
T1-w TSE FS Post gado T1-w TSE, T1-w IR GRE, T1-w SPGR
T2-w imaging T2-w TSE dark blood Fat suppressed T2-w → SPIR, STIR
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FFE Scouts
• Limited soft tissue lesion detection & characterization
• Large inter-slice gap, low resolution
• Contrast based on T2/T1 ratio Bright = Fluid or fat Not bright = Soft tissue, some complex fluid
• Motion insensitive Shape & margin with well defined lesions Internal structures of cysts
• B-FFE and TFE similar for NC lesions
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TSE T1
• True T1-weighted sequence with IR blood suppression
Bright – fat, hemorrhage, protein, some flow, some Ca2+
Dark – Simple fluid, most Ca2+, air In-between – most masses
• Cover from top of liver to above arch Excellent for anatomy Best look at mediastinum, breasts, chest wall, lungs
• Navigator problematic around diaphragm
• More helpful when combined with T1 FS
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FFE & TSE T1
FFE
T
1
Bright Not Bright
Bright
Not
Bright
• Most commonly see lesions on T1 & FFE
Fat, Hemorrhage
Hemorrhage, Protein
Cyst Soft Tissue
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Other T1 Weighted Sequences
• T1-w TSE with fat saturation Identify fatty lesions definitively Increased conspicuity of T1 bright lesions
• Post gadolinium – Tissues vs fluids (inflammation, atelectasis, infarcts) T1-w TSE → less conspicuity of enhancement T1-w FS SPGR → usu. early; best for enhancement T1-w IR GRE → Delayed; caveat of IR Subtractions helpful for intrinsic T1 bright lesions
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T2 Weighted Imaging
• T2-w TSE – True T2-w sequence
• STIR –T1-w & T2-w; good fat suppression
• SPIR – True T2-w; less homogeneous fat suppression
• Bright on FFE & T2-w TSE Cysts, hemangiomas, fat, some hemorrhage
• Mildly bright on T2-w TSE → Usu. concerning
• Increased brightness with SPIR, STIR Fibrous tumors (eg, breast ca) still dark
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T2-w TSE
SPIR
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Big Picture
• Brighter lesion on FFE, T1-w TSE, or T2-w TSE → More likely it’s benign Look for subtle nodularity, esp. with hemorrhage
• No gadolinium → f/u imaging or not? Well seen, sharp margin, homogeneously bright on FFE
or T2-w TSE, not bright on T1-w TSE → Benign → Stop Except breast
Not well seen, irregular margin, heterogeneous, bright on T1(& not fat), not bright on T2-w TSE → f/u imaging
• Enhancement → Usu. f/u imaging for further characterization or diagnostic procedure
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Big Picture
• Need to look separately for NCF
• Develop a system
• If you aren’t looking for it, you won’t see it
• Symmetry is your friend
• Use cross referencing tools
• The only thing better than your MR . . . is an old MR (or CT)
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Lesions by Location
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Mediastinum Diversion
Old Radiology
• Anterior Mediastinum – posterior to sternum, anterior to trachea & posterior aspect of heart thymus, lymph nodes, nerves, fat
• Middle Mediastinum – b/w anterior & posterior mediastinum trachea & bronchi, esophagus, lymph nodes, nerves, fat
• Posterior Mediastinum – b/w posterior chest wall & 1 cm behind anterior margin of vertebral column vertebral bodies, spinal canal, lymph nodes, nerves, fat
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Cross Sectional Mediastinum
• Differential based on tissue where mass arises
• If not possible, then localize by region Supraaortic mediastinum (superior mediastinum) Prevascular space, Anterior cardiophrenic angles Pretracheal & subcarinal spaces, AP window Paraesophageal or azygoesophageal recess Paravertebral
• Caveat: Be sure it is from the mediastinum Deep to vessels → Definitely Broad Base, smooth margin; not spiculated or irregular
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Lymph Nodes
• Every site in mediastinum• Lymphoma, Mets, Sarcoid, Granulomatous Infxn• Pattern can be important
Symmetric bilateral hilar & paratracheal – likely sarcoid Prevascular nodal mass – Hodgkin’s Lymphoma > NHL Unilateral hilar +/- paratracheal – Lung > other mets Posterior mediastinum – Lymphoma (NHL) vs mets Cardiophrenic angle – Mets vs lymphoma
• Intermediate T1, bright T2, enhancement Necrosis – Mets, lymphoma (NHL) ,Tb, fungus Ca2+ – Granulomatous infxn, sarcoid; treated lymphoma
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Hodgkin’s Lymphoma
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Sarcoid
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RCC Mets
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Chloroma
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Thyroid Lesions
• Supraaortic Mediastinum Can extend into prevascular space, around trachea
• Goiter Bland Goiter – Low SI T1-wi & intermediate SI T2-wi Multinodular Goiter – Heterogeneous on T1-wi & T2-wi
• Thyroid Cancer Can be invasive, but usually notCarcinoma in multinodular goiter – 7.5 %MRI can not definitively differentiate benign & malignant
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Thymus & Thymic Masses
• Prevascular Space • Normal thymus
Fat proportion increases with age → harder to see Intermediate on T1-w, bright on T2-w; margins important;
interdigitating fat
• Thymic rebound – stress (chemo, burns)• Thymoma – # 1 adult 1° mediastinal tumor
Variable; homogeneous, cystic, nodules; invasion
• Thymolipoma; thymic cyst, carcinoma, carcinoid; lymphoma, mets
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Normal Thymus
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T1-w TSE
SPIR
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Foregut Cysts
• Bronchogenic – Most common Any location – 50% subcarinal, 20% paratracheal Rounded, smooth, sharply defined (imperctible wall) Fluid contents variable
• Pericardial 90% touch diaphragm, 65%R 35%L cardiophrenic angle Usually simple fluid, sometimes hemorrhage
• Esophageal duplication
• Neurenteric Associated vertebral anomaly
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Germ Cell Tumors
• Anterior Mediastinal Mass (prevascular)
• More in young adults; 80% benign
• Teratomas All germinal layers Cysts, fat (Fat-fluid levels), Ca2+, soft tissue
• Seminomas Men; most common malignant GCT; homogeneous
• Nonseminomatous GCT Rare, heterogeneous
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Hernias
• Hiatal Sliding (most common), Paraesophageal, Mixed
• Bochdalek Posterolateral and left more common Retroperitoneal fat, rarely kidney or liver
• Morgagni Anteromedial Omental fat (Pseudomass), Transverse Colon
• Traumatic Diaphragmatic Small at inception → grow latently
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Esophagus
• Thickening Esophagitis, Barrett’s, cancer
• Mass Leiomyoma, lipoma, cancer
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Paravertebral Region
• Neurogenic Tumors Nerve Sheath (Schwannomas), sypmathetic ganglia
tumors, paragangliomas Commonly bright on T2, avidly enhancing
• Thoracic Spine abnormalities Fractures, Malalignment, DDD, Hemangiomas, Tumors
• Meningoceles and nerve sleeve cysts
• Extramedullary hematopoesis Multiple bilateral paravertebral tumors, hyperenhance
• Nodes are still most common
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Vertebral Hemangioma
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Lungs
• All new nodules & masses* need Chest CT Lung cancer can be round, spiculated, infiltrative Multiple – Mets, granulomatous dz, sarcoid, septic emboli
• Atelectasis common dependently; should enhance Non-dependent consolidation → obstruction, other cause
• Pneumonia Non-dependent or patchy, filled airways, Hypoenhancement
• Pulmonary Edema Usu. symmetric; Sometimes difficult to diff from pneumonia
• Pulmonary Infarcts Peripheral wedge shaped, hypoenhancement & necrosis
• Fibrosis (sarcoid, XRT, CTD, Amiodarone)
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Carcinoid
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LLL Pneumonia & Right Effusion
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Pulmonary Infarct
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Pleura
• Pleural effusions Simple vs exudative vs hemorrhagic Associated pleural thickening and enhancement Loculation, empyema
• Plaques - Asbestos
• Masses Metastases – Lung, Breast
Usually associated with effusion
Fibrous Tumors of the Pleura Malignant Mesothelioma
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Chest Wall
• Bones Metastases Primary Benign > Primary Malignant
• Fat Lipoma, Low Grade Liposarcoma
• Muscle Atrophy, Edema Intramuscular Lipomas Mets > Sarcomas
• Subcutaneous and Dermis Sebaceous cysts most common
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IntramuscularLipoma
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Breasts
• Simple Cysts Must be FFE +/- T2 Bright and T1 dark, no enhancement → still
confirm with Ultrasound
• Proteinaceous / Hemorrhagic Cysts → US• Fibroadenoma
Well circumscribed, T1 dark, usu. T2 bright, progressive enhancement → mammogram & US
• Breast Cancer Not always spiculated; also can be in cysts T1 dark and usu. TSE T2 dark, mildly bright STIR/SPIR Variable enhancement, but usu peak 90-180 sec. Any concern → Mammogram & US +/- MRI
• Only Fat containing lesions do not need workup
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Liver• Cysts – most common
Smooth margin, round or oval, bright FFE +/- T2, dark T1, no enhancement → Benign
Other than thin septation, any complexity → F/U MRI
• Hemangiomas – second most Similar to cyst in shape & on FFE, T1, T2, but enhance
Flash fill or peripheral discontinuous → filling centripetally
• Any non cyst-like lesion → f/u MRI Focal Nodular Hyperplasia (FNH) – Most common mass Primary Malignancies – HCC and Cholangio Ca Metastases – Colon, Gastric, Pancreaticobiliary, Lung, Breast,
Melanoma
• Diffuse Dz – Cirrhosis, Fatty, Hemachromatosis
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RCC Mets
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Hemochromatosis
Cirrhosis
Hemosiderosis
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Gall Bladder
• Gall Stones – very common Round or faceted filling defects in GB Usu. dark on all sequences; can be bright on T1-w
• Polyps – common Hard to diff. from adherent gall stones w/o contrast
• Adenomyomatosis – common Usu. Fundal, wall thickening, can have T2-bright foci
• GB wall edema – uncommon Usu. liver dysfxn; if not T2-bright ? Chronic cholecystitis
• GB Cancer – rare Any GB mass requires work-up
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Kidney
• Cysts – most common Smooth margin, round or oval, bright FFE +/- T2, dark
T1, no enhancement → Benign Other than thin septation, any complexity → F/U
If hemorrhagic or clearly nodules → MRI
• Masses All potential masses (heterogeneous, not bright FFE or
T2, not dark T1) need F/U Renal Cell > Transitional Cell
• Hydronephrosis – Partial or Complete• Renal Atrophy, Agenesis
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Parapelvic Cyst
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Sag Right Sag Left
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Spleen
• Splenomegaly, Splenules, No spleen - Common
• Hemangiomas Just like liver for the most part
• False Cysts Post traumatic or infarct Can be hemorrhagic and calcify
• Epithelial Cysts, Lymphangioma -rare
• Metastases – uncommon
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Splenectomy post trauma Splenosis
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Splenic Cyst – Rim Calcification
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Final Thoughts
• Surprising No Adrenal Lesions No Pancreatic cysts or lesions No upper abdominal nodes No real bone lesions
• Not surprising No bowel or stomach lesions (motion) No mesenteric masses Minimal unknown cancers
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ReferencesChan PG, Rofsky NM, Yeon SB, Hauser TH, Appelbaum E, Smith MP,
Manning WJ. Non-cardiac pathology on clinical cardiac magnetic resonance imaging. Accepted for publication in JACC Cardiovascular Imaging 2009.
Dewey M, Schnapauff D, Teige F, Hamm B. Non-cardiac findings on coronary computed tomography and magnetic resonance imaging. Eur Radiol 2007 Feb 1; [Epub ahead of print].
Onuma Y, Tanabe K, Nakazawa G et al. Noncardiac findings in cardiac imaging with multidetector computed tomography. J Am Coll Cardiol 2006; 48:402–406.
Haller S, Kaiser C, Buser P, Bongartz G, Bremerich J. Coronary artery imaging with contrast-enhanced MDCT: extracardiac findings. AJR Am J Roentgenol; 2006; 187:105–110
Horton KM, Post WS, Blumenthal RS, Fishman EK. Prevalence of significant noncardiac findings on electron-beam computed tomography coronary artery calcium screening examinations. Circulation 2002; 106:532–534
Hunold P, Schmermund A, Seibel RM, Gronemeyer DH, Erbel R. Prevalence and clinical significance of accidental findings in electron-beam tomographic scans for coronary artery calcification. Eur Heart J 2001; 22:1748–1758