Incidental pulmonary nodules in emergent coronary CT angiography for suspected acute coronary syndrome: Impact of revised 2017 Fleischner Society Guidelines

J Cardiovasc Comput Tomogr. Jan-Feb 2018;12(1):28-33. doi: 10.1016/j.jcct.2017.11.005. Epub 2017 Nov 14.


Background: Pulmonary nodules (PN) are frequently detected incidentally during coronary computed tomography angiography (CTA). We evaluated whether the 2017 Fleischner Society guidelines may result in a decrease of follow-up testing of incidental PN as compared to prior guidelines in patients undergoing coronary CTA.

Methods: We conducted a retrospective study of a registry of emergency department patients who underwent coronary CTA for acute coronary syndrome assessment between 2012 and 2017. Based on guidelines, patients <35 years, history of cancer, or prior exams showing stability of PN were excluded. Patients >60 years, history of smoking, irregular/spiculated PN morphology, or PN size >20 mm were classified as high-risk for lung cancer. Radiological findings pertaining to PN were identified (PN size, morphology, quantity) through review of radiology reports. PN follow-up recommendations were established using 2017 Fleischner Society Guidelines and compared with prior guidelines for solid (2005) and subsolid (2013) PN. Data were analyzed with Student's t-test.

Results: The registry included 2066 patients (female 45.1%, 52.9 ± 11.0 years), of which 578 (28.0%) reported PN. 438 of those (21.2%) were eligible for guideline-based follow-up evaluation. 205 (4 6.8%) were classified as high-risk for lung cancer. 2017 guidelines reduced the number of individuals requiring follow-up by 64.5%, from 264 (12.8%) to 94 patients (4.5%) when compared to prior guidelines (p < 0.001). The minimum number of follow-up chest CTs decreased by 55.8% from 430 to 190 (p < 0.001).

Conclusion: Application of the 2017 Fleischner Society Guidelines resulted in a significant decrease of follow-up testing for incidental PN in patients undergoing coronary CTA for suspected acute coronary syndrome.

Keywords: Acute coronary syndrome; Coronary computed tomography angiography; Fleischner Society Guidelines; Follow-up CT; Incidental findings; Lung nodule; Management of incidental lung nodules; Pulmonary nodule.

Publication types

  • Comparative Study

MeSH terms

  • Acute Coronary Syndrome / diagnostic imaging*
  • Adult
  • Computed Tomography Angiography / standards*
  • Coronary Angiography / methods
  • Coronary Angiography / standards*
  • Emergency Service, Hospital*
  • Female
  • Humans
  • Incidental Findings*
  • Male
  • Middle Aged
  • Multiple Pulmonary Nodules / diagnostic imaging*
  • Practice Guidelines as Topic / standards*
  • Predictive Value of Tests
  • Registries
  • Retrospective Studies
  • Solitary Pulmonary Nodule / diagnostic imaging*