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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cardiac computed tomography &#40;CT&#41; angiography &#40;CCTA&#41; is established as an essential technique in the assessment of coronary artery disease&#46; Although the latter is its primary indication&#44; the range of application has progressively extended to other areas of cardiology&#44; and it is now an important tool for the assessment of structural heart disease and the planning of procedures in arrhythmology and interventional cardiology&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> particularly transcatheter aortic valve implantation and atrial fibrillation ablation&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">However&#44; the main challenge for CCTA remains assessment of the coronary arteries&#44; due to their small size and their movement&#44; which create difficulties for the equipment&#39;s hardware and software&#46; Technological advances in recent years have led to improvements in spatial and temporal resolution and craniocaudal coverage&#44; with reductions in contrast and radiation dose without compromising diagnostic accuracy&#44; making these exams increasingly reliable&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">It is against this background that the article by Rosa et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> published in this issue of the <span class="elsevierStyleItalic">Journal</span>&#44; addresses a question of practical importance in the acquisition of CCTA studies&#44; namely the efficacy and particularly the safety of beta-blockers for patient preparation before CCTA&#46; The authors assessed a protocol for reducing heart rate &#40;HR&#41; as bailout for failed oral metoprolol regimens in patients undergoing non-invasive coronary angiography on a conventional 64-slice CT scanner&#46; The study analyzed 947 exams&#44; in 14&#37; of which supplementary esmolol was required due to failure to achieve HR of &#60;65 bpm following administration of oral metoprolol alone&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The strong points of the study are &#40;1&#41; that it presents a protocol that could be adopted by other institutions beginning to use CCTA&#44; particularly with a conventional 64-slice machine&#59; &#40;2&#41; it showed that oral metoprolol &#40;50-100 mg 1 h before the exam&#41; resulted in HR of &#60;65 bpm in 86&#37; of cases&#59; and &#40;3&#41; it demonstrated that supplementary esmolol increased this figure to 95&#37; with few adverse effects &#40;the combined safety endpoint of symptomatic hypotension or symptomatic bradycardia was only observed in 1&#46;5&#37; of cases&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The study by Rosa et al&#46; focuses on fundamental questions&#58; what is the rationale for the use of beta-blockers to reduce HR&#63; In what circumstances should we persist in efforts to optimize this aspect of patient preparation&#63; The need to reduce HR before performing CCTA depends on the individual patient&#39;s characteristics &#40;including age&#44; pretest probability&#44; degree of calcification&#44; body mass index&#44; and presence of arrhythmias&#41;&#44; which can affect the quality of the exam&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> and the type of CT scanner used&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5&#44;6</span></a> The present article was based on studies with a 64-slice scanner&#44; which is currently considered the minimum for such exams&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> having been introduced into clinical practice in 2004&#46; Such machines are heavily dependent on low HR during acquisition&#44; but technological advances have made this less important and low HR is almost irrelevant with more recent equipment&#44; especially with the high temporal resolution of dual-source scanners&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5&#44;8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">At the same time&#44; although feasible and safe&#44; beta-blocker therapy before CCTA is always a limiting factor and should be seen as a necessary evil&#44; not only clinically &#40;due to possible contraindications and&#47;or adverse effects such as hypotension or symptomatic bradycardia&#41; but also logistically&#44; due to the need to keep the patient under surveillance for longer after the exam or even before it&#44; in the case of oral beta-blockade as in the present work&#44; requiring the use of more human and other resources&#44; such as recovery rooms&#46; An illustration of these limitations is the fact that in Rosa et al&#46;&#8217;s study the mean time between administration of oral metoprolol and of intravenous esmolol was 82 min&#44; and although the combined safety endpoint was only observed in 1&#46;5&#37; of cases&#44; systolic blood pressure fell to &#60;90 mmHg in 8&#37; of cases&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">These issues have been taken on board by the medical equipment industry&#44; along with other unmet needs such as reducing contrast and radiation doses&#44; and the latest generations of cardiac CT scanners have been designed to address them&#46; For example&#44; the mean radiation dose reported in the study by Rosa et al&#46; with a 64-slice scanner was 9&#46;8 mSv&#44; significantly higher than that reported in a recently published Portuguese multicenter registry &#40;5&#46;4 mSv&#41; using a first-generation dual-source machine&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> It is thus to be hoped that such problems will soon be a thing of the past&#44; as within a few years new-generation dual-source 2&#215;192-slice scanners and single-source 320-slice devices will progressively replace the current 64-slice machines&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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