Eleni C VourvouriCardiologist, PhD, FESC

Euromedica Geniki Kliniki,

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

CT Coronary Angiography -

Indications:

From the guidelines to clinical practice

Multimodality Working Group of Cardiovascular Imaging

(Nuc C, CCT CMR)

Hellenic Cardiology Society Seminars, Thessaloniki, 2017

NO CONFLICTS OF INTEREST

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

• 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

“Appropriateness Criteria“

Budoff M et al. Circulation 2006

1. Patients with low to intermediate likelihood of CAD:

Class IIa, B

2. Follow-up of percutaneous coronary intervention:

Class III, C

3. Follow-up after bypass surgery: Class IIb, C

4. Anomalous coronary arteries: Class IIa, C

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

Symptomatic

A = appropriate

M = may be appropriate

R = rarely appropriate

Uncertain Prior Results (sequential testing 90 Days)

Abnormal Prior Test/Study (sequential testing 90 Days)

New or worsening symptoms (Follow- up Testing)

Post revascularization

(PCI or CABG)

Symptomatic

Post revascularization

(PCI or CABG)

Asymptomatic

Asymptomatic

CORONARY CT ANGIOGRAPHY

What does it offer to the cardiologist?

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

Shaw Radiology 2003;228:826

EBCT Calcium score modifies Framingham Risk Score:

predicted mortality at 5 years

10.377 high-risk asymptomatic individuals

Mean 53 yrs, male: 60%

0.01

0.06

0.04

0.02

0Low Risk

N=1.302

Intermediate Risk

N=5.876High risk

N=3.194

0.08

<10

11 - 100

101-400

401 - 1000

> 1000

Framingham Risk stratification

0.12

0.14

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

Hadamitzky M et al, Eur Heart J 2013

Pundziute G et al, JACC 2007

CONFIRM REGISTRYCoronary CT Angiography EvaluatioN

For Clinical Outcomes

Min J , JCCT 2011

Dynamic registry of >32,000 consecutive patients,

12 sites in 6 countries (US, Canada, Germany, Switzerland,

Italy & Korea)

Database locked in 2010

Kaplan Meier for MORTALITY-FREE

Survival

Kaplan Meier for MACE-FREE

Survival

PLAQUE CHARACTERIZATION

The value of the additional information

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

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

CT characteristics of a stable plaque

RI= 0,87

CT characteristics of a high risk plaque

Positive remodelling

Low attenuation

Spotty calcification

Plaque modulation, as part of risk modification, is a feasible strategy

2016

All-cause mortality benefit of coronary revascularization

vs. medical therapy in patients without known coronary

artery disease undergoing coronary computed

tomographic angiography: results from CONFIRM

(COronaryCT Angiography EvaluatioN For

ClinicalOutcomes: An InteRnational MulticenterRegistry)

James Min et al, Eur Heart J , 2012

CONFIRM REGISTRYCoronary CT Angiography EvaluatioN

For Clinical Outcomes

15 223 patients

F/up 2.1 y

Clinical

endpoints:

all cause

mortality

High risk CAD:

2-vessel with

prox LAD, prox

LAD, 3-vessel,

LM CAD

CONFIRM (COronaryCT Angiography EvaluatioN For Clinical Outcomes:

An InteRnational MulticenterRegistry

CONCLUSIONS

Tremendous growth in EVOLUTION of cardiovascular computed tomography

Numerous MULTICENTER TRIALS and REGISTRIES about clinical value

of CCTA

HIGH DIAGNOSTIC AND PROGNOSTIC VALUE

PLAQUE CHARACTERIZATION

•High risk plaques or : positive remodelling and low attenuation

and spotty calcification

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

specific ishemia

•The combination of atherosclerotic plaque characteristics (PR,

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

specific ischemia

Conclusions

There are significant discrepancies between

discharge prescription of statin

and ASA with the presence and extent of CAD

Physican knowledge of CCT results to improved alignment

of aspirin and statin with the presence and severity of CAD

Use of statin results in substantial reduction

in low attenuation plaque volume

Future research examining how CCTA truly affects

prescription behavior of

preventive medical therapy and downstream outcomes

A broader implementation of a CCTA guided strategy

in clinical practice could improve patient management

Conclusions

THANK YOU