Coronary CT angiography:

Developments and Clinical Indications

Eleni C VourvouriCardiologist, PhD, FESC

Euromedica Geniki Kliniki,

Research Associate ,2nd Cardiology Department, Hippokrateio University Hospital, Thessaloniki

15th North Hellenic Cardiology Congress

Thessaloniki , 26-28/5/ 2016

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CT-coronary angiography: developments

Year

Cardiac

motion

Artefacts =

(Temp.

Resolution)

(ms)

Breath hold

time (s)

Spiral

CT

1990

1000

-

EBCT

CA

1995

100

40

4-slice

MS-CT

1998

500

40

12-16 slice

MS-CT

2002

420

20

16 slice

MS-CT

2003

370

20

64 slice

MS-CT

2004

165

10

64 slice

MSCT

Dual

source

2006

75

<10

Year

Cardiac

motion

Artefacts =

(Temp.

Resolution)

(ms)

Breath hold

time (s)

Spiral

CT

1990

1000

-

EBCT

CA

1995

100

40

4-slice

MS-CT

1998

500

40

12-16 slice

MS-CT

2002

420

20

64 slice

MS-CT

2004

165

10

16 slice

MS-CT

2003

370

20

64 slice

MSCT

Dual

source

2006

75

<10

CT-coronary angiography: developments

Expert Review of Medical Devices

2016

• Coronary Calcification (CAS)

• Coronary CT Angiography (CCTA) • Aortic Assessment (anuerysm, dissection)

• Pulmonary Embolism

• Pericardial disease

• Congenital heart disease

• Cardiac thrombi & tumor

• Quantification cardiac anatomy & volumes, global & regional function

• Venous Anatomy – Pulmonary and Coronaryveins pre-procedure

CT – Cardiac Applications

Estimation of presence of coronary artery disease

Age, Sex, Symptoms

Age, Sex, Symptoms,

diabetes, hypertension,

dyslipidaemia and smoking

1.Diamond and Forrester modelN Eng J Med. 1979;300:1350-8

2. Duke clinical scoreAnn Intern Med 1993;118:81-90

Estimation of presence of coronary artery disease

Age, Sex, Symptoms

Age, Sex, Symptoms,

diabetes, hypertension,

dyslipidaemia and smoking

1.Diamond and Forrester modelN Eng J Med. 1979;300:1350-8

2. Duke clinical scoreAnn Intern Med 1993;118:81-90

3. New prediction model

BMJ 2012;344:E3485

Age, Sex, Symptoms,

diabetes, hypertension,

dyslipidaemia and smoking

Coronary Calcium Score

No calcification Mild Severe

CT Calcium Score : Predictive Value

Calcium Score

≤ 10

11 – 100

101 – 400

401 – 1000

> 1000

NP

5946

2044

1432

632

332

All-cause death %

1.0

2.6

3.8

6.3

12.3

Relative Risk Ratio

---

2.5

3.6

6.2

12.3

Shaw Radiology 2003;228:826

Linear Scale of Progressively Higher Event Rates

Hundred of peer-reviewed manuscripts

Hadamitzky M et al, Eur Heart J 2013

Pundziute G et al, JACC 2007

Kaplan Meier for MORTALITY-FREE

Survival

Kaplan Meier for MACE-FREE

Survival

APPROPRIATE USE CRITERIA

ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS

2013 Multimodality Appropriate Use Criteria for the Detection and Risk

Assessment of Stable Ischemic Heart Disease

A Report of the American College of Cardiology Foundation Appropriate Use

Criteria Task Force, American Heart Association, American Society of

Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society

of America, Heart Rhythm Society, Society for Cardiovascular Angiography and

Interventions, Society of Cardiovascular Computed Tomography, Society for

Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons

Journal of the American College of Cardiology

2014 by the American College of Cardiology

Foundation

Appropriateness Indications

• Evaluation of patients with Chest Pain and uninterpretable ECG or

inability to exercise

• Evaluation of patients with Chest Pain and non diagnostic stress tests

• Evaluation of patients with cardiovascular risk factors and atypical symptoms

• Congenital Heart Disease

• Coronary Anomaly (suspicion)

• Prior to redo cardiac surgery

• In the emergency room for acute chest pain in pts with low to intermediate risk

Maybe in asymptomatic high risk patients

Post revascularization

(PCI or CABG)

Symptomatic

Post revascularization

(PCI or CABG)

Asymptomatic

PLAQUE CHARACTERIZATION

Plaque Type

Calcified

Partly calcified

“Mixed“

Non-calcified

Motoyama, JACC 2007

Schuijf et al, Acad Radiol 2007

Hoffmann, AJC 2006

Post-hoc Analysis of Plaques in ACS:

- More non-calcified components than stable lesions

- Positive Remodeling (87%)

-- “Spotty“ calcification

- Lower CT attenuation (< 30 HU)

Atherosclerotic plaque characteristics-APCS

Positive Remodelling RI (Remodelling Index) >=1,10

Low attenuation plaque: HU <30

Spotty calcification < 3mm

RI=Maximum

Reference

Maximun

Reference

CCTA

STRENTH AND WEAKNESS

First

AuthorTechnique Patients

Not

evaluable

Sensitivit

ySpecificity

Negative

Predictive

Value

Leschka 64-slice CT 67 -- 94% 97% 99%

Leber 64-slice CT 59 7% 73% 97% 99%

Ehara 64-slice CT 69 8% 90% 94% 95%

Raff 64-slice CT 70 12% 86% 95% 98%

Fine 64-slice CT 66 4% 95% 96% 92%

Ropers 64-slice CT 82 4% 95% 93% 99%

Mollet 64-slice CT 52 2% 99% 95% 99%

Nikolaou 64-slice CT 72 10% 86% 95% 97%

Schlosser 64-slice CT 61 100% 95% 100%

Mühlenbru 64-slice CT 51 - 87% 95% 98%

Meijboom 64-slice CT 104 - 92% 91% 99%

Schuijf 64-slice CT 60 - 85% 98% 99%

Oncel 64-slice CT 80 - 96% 98% 99%

Herzog 64-slice CT 50 - 89% 92% 97%

Ehara 64-slice CT 69 8% 90% 94% 95%

Shabestari 64-slice CT 143 2% 94% 97% 97%

Cademartii 64-slice CT 72 0% 100% 98.6% 100%

Hausleiter 64-slice CT 114 8% 92% 92% 99%

Meijboom 64-slice CT 254 - 88% 94% 99%

Andreini 64-slice CT 200 3% 99% 96% 100%

MPS vs. STRESS ECHO MPS vs. CTCA

Meta-analysis including 17 studies,

1405 pts, in which MPS was directly

compared to Stress echocardiography

Schinkel AFL et al,

Eur Heart J 2003

MPS: pooled data from

50 studies,6971 pts. Mean

prevalence of CAD 75%

CTCA: pooled sens. Spec.

In series totaling 1653 pts

Mean prev. of CAD 63%

Carli MF, Hachamovitch R,

Circulation 2007

-Gold standard for diagnosis of lesion-specific ischemia

-Improves event-free survival and cost effectiveness

FFR <0,80 lesion specific ischemia

FFR -Fractional flow reserve

1. DISCOVER-FLOW(Diagnosis of Ischemia-Causing Stenoses Obtained Via

Noninvasive Fractional Flow Reserve) Study

2. De FACTO

(Determination of Fractional Flow Reserve by

Anatomic Computed Tomographic Angiography

FFR CT

DISCOVER-FLOW(Diagnosis of Ischemia-Causing Stenoses Obtained Via

Noninvasive Fractional Flow Reserve) Study

103 patients with suspected or known CAD ,

4 centers (Korea, Latvia, USA)

FFR-CT produced sensitivity and negative predictive value similar

to CT alone but much higher scores for specificity (82%vs 40%)

and positive predictive value (74%vs 47%)

-FFRCT improved diagnostic accuracy (20%) in

discrimination of hemodynamically significant

lesions due to higher sensitivity and specificity

-for intermediate lesions improvement in

sensitivity

De FACTO

(Determination of Fractional Flow Reserve by

Anatomic Computed Tomographic Angiography

Subjects analysed 254

10 participating centers worldwide

Norgaard JACC 2014;63:1145-1155

CCTA Invasive angiography FFR FFRCT= no ischemia

No ischemia

ischemia

Additive diagnostic value of atherosclerotic plaque

characteristics to non-invasive FFR for identification of

lesions causing ischaemia: results from a prospective

international multicentre trial

Ryo Nakazato, MD; Hyung-Bok Park, MD; Heidi Gransar, MSc;

Jonathon A. Leipsic, MD; Matthew J. Budoff, MD; G.B. John Mancini, MD;

Andrejs Erglis, MD; Daniel S. Berman, MD; James K. Min

EuroIntervention 2015 Sep

64–STAT randomized trial

Acute Chest Pain in ED

• Goldstein et al. JACC Feb 2007;49:863

Acute Chest Pain

CCTA (n=99) SOC (n=98)

• Reduced diagnostic time by 77% (3.4 hr vs. 15.0 hr, p<0.001)

• Lower costs ($1586 vs. 1872, p<0.001) [15%]

• Fewer repeat evaluations for CP (2% vs. 7%)

• Nondx 5% with newer CT scans

• Both approaches 100% safe (2-years)

Goldstein et al. J Am Coll Cardiol 2007.

Exclusion of CAD in acute chest pain

CCTA immediately excluded or identified CAD as cause of

CP in 75% patients (67 normal cors, 8 severe CAD).

Fifty percent of patients with acute chest pain and low to

intermediate likelihood of

ACS are free of CAD by CT and have no ACS.

ROMICAT II, U Hoffmann

Pulmonary Embolism

Coronary Artery

Aortic Dissection

RCA & LAD Stenosis

53 year old male with chest pain

CONCLUSIONS

• Tremendous growth in evolution of cardiovascular computed tomography

• Numerous multicenter trials and registries about clinical value of CCTA

CAC and CCTA improve selection of patients for preventive care-

Pharmacotherapy and Lifestyle Modification

All of the data suggest that CCTA is superior or at least equivalent to other

non-invasive tests

CTCA has high negative predictive value for

obstructive CAD. After a negative CTCA no other test

is needed

High value of CTCA in sequential or follow-up testing

in symptomatic patients

In asymptomatic patients CAC may be appropriate

in intermediate and high- risk individuals and either

stress or anatomic imaging (CTCA) in higher-risk

individuals

Conclusions 1

PLAQUE CHARACTERIZATION

•High- risk plaques = positive remodelling, low attenuation

and spotty calcification

•FFR -CT : novel non- invasive method for determining lesion-

specific ishemia

Increases accuracy, specificity and PPV of CCTA

•The combination of atherosclerotic plaque characteristics (PR,

LAP, SC) and FFR-CT may improve identification of lesion

specific ischemia

Conclusions 2

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