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1. What is the purpose of PROMISE CTA Case Review?
2. What are the benefits of completing the CTA Case Review?
3. How do I complete the PROMISE CTA Case Review?
4. How does the CTA Case Review software work?
5. Do I have to set anything up before beginning the CTA Case Review?
6. How is each vessel classified?
7. What if I want to report a vessel as "non-diagnostic"?
8. How were the cases selected?
9. How long do I have to complete each case?
10. How is my work saved?
11. Are my results scored?
12. Will I receive my results?
13. How do I use TeraRecon’s iNtuition viewer?
14. What are the minimum requirements for running STAT and TeraRecon’s iNtuition viewer?

1. What is the purpose of PROMISE CTA Case Review?

Because cardiac CT is a relatively new technology compared to other diagnostic tests, case review for CT has been incorporated into the trial to promote a high and consistent level of reporting among all participating PROMISE sites. Completion of the CTA Case Review is required for all Level II readers intending to participate in the PROMISE trial. Participation is strongly encouraged and optional for Level III readers.

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2. What are the benefits of completing the CTA Case Review?

In addition to helping increase the equipoise between cardiac CT and functional testing in the PROMISE trial, we hope that you may appreciate personal benefits from participation as well:

  • Review of twenty-five (25) cases from our teaching database, all with corresponding invasive coronary angiography. Opportunity to review an additional 25 cases is available by request.

  • Readers will receive an MGH Certificate of Completion indicating the number of cases read, which may be applied toward requirements for various certification bodies.

  • Acknowledgement in any publications resulting from the use of data collected as part of the PROMISE CTA Case Review. Individual results will remain confidential.

  • Discounts towards educational products and membership fees offered by professional societies such as the SCCT and NASCI.

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3. How do I complete the PROMISE CTA Case Review?

The PROMISE Case Review is available online via a web-based system and includes 25 cardiac CT cases with corresponding invasive coronary angiography. For the full functionality of a dedicated cardiac CT workstation at the convenience of your PC, we use a thin client TeraRecon platform, which is easily downloaded from our website. All PROMISE readers need to register and receive a Reader ID that will be used throughout the study. The Case Review needs to be completed within one week, selected during registration, and can be done from any suitable PC. Readers will interpret CT cases for coronary stenosis and LV function according to PROMISE interpretation protocols. The software permits an immediate comparison to invasive coronary angiography. After the 25 cases are completed you will receive an email and confirmation that you have completed the case review. You are now able to participate as a PROMISE CT reader.

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4. How does the CTA Case Review software work?

After registration and installing the pre-requisite software onto your system, you will be able to use STAT to conduct reads from your internet browser. The pre-requisite software includes TeraRecon’s iNtuition thin client and the supporting software of Managed DirectX, both available from the Setup page. STAT consists of three main components: scoring, CT image manipulation, and viewing the invasive coronary angiography.

  • Scoring – When initiating a session, an electronic case report form will appear in your browser window. The report form contains drop down menus for different pathologies at different locations and provides some help functions.

  • Image manipulation – There is a button located near the top of the Scoring screen titled “Launch Case in iNtuition Viewer” which will launch the thin client with the CT images of the corresponding case. TeraRecon’s iNtuition viewer provides you with the advanced functionality of a stand-alone workstation, such as viewing images in 3D and performing Time Volume Analysis for assessing LV function.

  • Coronary angiography – After the CT read has been submitted, the option of displaying the results from the invasive coronary angiography and viewing the corresponding videos will be displayed.
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5. Do I have to set anything up before beginning the CTA Case Review?

Yes, you will need to install DirectX if it is not already installed on your workstation. You will also need to install TeraRecon’s iNtuition Viewer (AQi). Complete instructions can be found under Setup, available from the toolbar.

Angiography videos are displayed in Flash, if Flash is not installed for your browser, you will be prompted to install it upon viewing the first angiography video.

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6. How are the data assessed?

The assessment for coronary artery stenosis should be performed on a per-vessel basis for the left main (LM), left anterior descending (LAD), left circumflex (LCx), and right coronary artery (RCA).

The ramus intermedius, D1, and D2 should be included under the LAD assessment.

The OM1 and OM2 should be included in the LCx assessment.

Posterior descending artery (PDA) and posterior left ventricular (PLV) branch should be included in either RCA or LCx, depending on the dominance.

No other vessels or branches are assessed (i.e. do not include OM3 or D3 even if there is presence of disease). Lastly, please also assess RCA in non-dominant right cases.

Stenosis severity is defined as:

  • No stenosis
  • Mild stenosis (1-40%)
  • Moderate stenosis (41-70%)
  • Severe stenosis (71-99%)
  • Total occlusion (100%)

Please note: for the purposes of this case review, scoring “Indeterminate” is counted as severe.

In cases with LV function, assessment of normal or abnormal should be performed. If abnormal, the CT reader should report whether the LV dysfunction is matching to the coronary stenosis territory.

The matrix size of multiphase datasets is 256x256 and reconstructed at 1.5mm slice thickness with 1.5mm increments. These datasets are NOT the standard high-resolution 512x512 matrix that are reconstructed at 0.75mm slice thickness with 0.4mm increments, which are optimal for coronary artery assessment. The multiphase dataset can be identified by the large number of images (>800) and should only be used for funtional analysis.

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7. What if I want to report a vessel as "non-diagnostic"??

For the purpose of the case review, we require "forced" interpretations of all coronary arteries for stenosis. Unless a significant stenosis can be definitively excluded, the vessel (including those you may consider to be "non-diagnostic" or "cannot exclude significant stenosis") should be scored as having a significant stenosis.

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8. How were the cases selected?

The cases in this review were selected in order to represent the cardiac CT imaging in the population expected in the PROMISE trial in a real world scenario. The represent the expected distribution of severity of disease (normal, non-obstructive disease, stenosis) and image quality (artifacts, presence of coronary calcification, motion artifacts, noise, etc). Some cases are very difficult.

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9. How long do I have to complete each case?

There is no time limit per case. However, the software will automatically log you off after 30 minutes of inactivity. There is a one-week time limit for completing all 25 review cases.

Please carefully consider which week you select during registration. An account will only be active for the one-week period selected during registration. Accounts are activated/deactivated at midnight on Sundays.

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10. How is my work saved?

You may save your work at any time during a case by selecting “Save.” If you should log off, either intentionally or due to inactivity, STAT will recall the case you were working on. Selecting “Next” commits your reads to the database, after which point you may not revise your assessments. It is recommended that you complete cases before logging off.

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11. How are my results used?

Individual results will remain confidential and not published. Howerever aggregate results of all PROMISE CT case reviews may be published. You will be acknowledged in any publications resulting from this data.

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12. Will I receive my results?

You will be prompted at the conclusion of the Case Review to indicate whether you would like to receive a copy of your results as compared to consensus opinions from a panel of expert cardiac radiologists and cardiologists as well as compared to invasive coronary angiography. If selected, results will be e-mailed to you within one week.
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13. How do I use TeraRecon’s iNtuition viewer?

A Quick Reference Guide is available during Sample and Certification Sessions for commonly used features.

For more detailed information, TeraRecon tutorials are available here.
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14. What are the minimum requirements for running STAT and TeraRecon’s iNtuition viewer?

Minimum Hardware Recommended Hardware
Pentium III, 1 GHz, 256 MB RAM
Disk space: 10 GB
True Color Display
Video card memory: 64MB
Screen Resolution: 1280x1024

Pentium IV, 2 GHz, 1 GB RAM
Video card memory: 256MB
Screen Resolution: 1600 x 1200 or greater
Minimum Software Bandwidth Requirement
Windows 2K, XP SP2 x32 or greater
.NET 2.0 Runtime, Direct X End-User Runtime
5 Mbps and less than 30 ms ping time

Supported browsers are Internet Explorer 7 and 8, and Mozilla Firefox


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