cardiac imaging: yesterday, today and tomorrow...cardiac imaging: yesterday, today and tomorrow...
TRANSCRIPT
Cardiac Imaging: Yesterday, Today and Tomorrow
Matthew J. Budoff, MD, FACC, FAHAProfessor of Medicine
Endowed Chair of Preventive CardiologyHarbor-UCLA Medical Center, Torrance CA
Conflict of Interest: GE paid consultant
YESTERDAY
• Functional Imaging constituted 95%+ of all work ups for CAD
• Performance of nuclear, stress echo and ETT were adequate, as intermediate and high risk patients were being tested
• LOW threshold to send to cardiac catherization
Sensitivity and Specificity of Non-invasive Tests for the Diagnosis of CAD*
Sensitivity and Specificity of Non-invasive Tests for the Diagnosis of CAD*
Diagnostic Test
Sensitivity% (range)
Specificity% (range)
# Studies # Patients
TMT 68 77 132 24,027
Planar MPI 79(70-94)
73(43-97)
6 510
SPECT 88(73-98)
77(53-96)
8 628
Stress echo 76(40-100)
88(80-95)
10 1174
* NEJM Vol. 344, No. 24 June 14, 2001
TODAY• More statins, preventive therapies,
changing prevalence of obstructive disease
• Less smoking, more diabetes, more women being studied
• More COURAGE to treat medically
Rozanski JACC 2013
Rozanski Conclusions
“CAC scanning, with or without treadmill exercise electrocardiography, could serve as potentially low-cost alternative to more expensive imaging tests for the initial workup of relatively lower-risk diagnostic patients.”
DATA TAKEN FROM “THE DAWN OF A NEW ERA -NON-INVASIVE CORONARY IMAGING” R. ERBEL HERZ 1996; 21, 75-77
DIAGNOSTIC SENSITIVITY
0% 20% 45% 60% 70% 90%
INVASIVE MODALITIES
STRESS ECG $300STRESS ECHO $900
PET SCANNING $2200Coronary Calcium with CT $295
NON-INVASIVE MODALITIES
INTRAVASCULAR ULTRASOUND $3,000CORONARY ANGIOGRAPHY $5,000
STRESS THALLIUM $1600
$150
The best predictor of a life threatening illness is the early
manifestation of a life threatening illness
Sir Geoffrey RoseCardiac Epidemiologist
Known for “The Rose Principle”
Coronary Artery Scanning
SEVERECALCIFICATION
Diagnostic accuracy Outcome• Schuijf JD et al. Am Coll Cardiol. 2006;19:2508-
14.
• Mollet NR et al. Eur Heart J. 2007;28:1872-8.
• Dewey M et al. Eur Heart J. 2007;28:2485-90.
• Ravapati G et al. Am J Cardiol. 2008:101;774-5.
• Nieman K et al. Heart. 2009;95:1669-75.
• Pundziute G et al. Coron Artery Dis. 2009;20:281-7.
• Øvrehus KA et al. Am J Cardiol. 2010;105:773-9.
• Maffei E et al. Heart. 2010;96:1973-9.
• Hamirani YS et al. J Comput Assist Tomogr. 2010;34:645-51.
• Tandon V et al. Eur Hear J. 2012;33:776-82.
• Weustink AC et al. Int J Cardiovasc Imaging.
2012;28:675-84.
• Min JK et al. Am J Cardiol. 2008;102:672-8.
• Cheezum MK et al. J Cardiosvasc ComputTomogr. 2011;5:101-9.
• Shreibati JB et al. JAMA. 2011;306:2128-36.
• Tandon V et al. Eur Hear J. 2012;33:776-82.
• Hachamotvitch R et al. J Am Coll Cardiol. 2012;59:462-74.
• Min JK et al. J Cardiovasc Comput Tomogr. 2012;6:274-83.
• Nielsen LH et al. Eur Heart J CardiovascImaging. 2013;14:449-55.
CTA vs Functional Meta Analysis AHA 2013
Diagnostic accuracy - Nielson EHJI 2014
Sensitivity: CCTA 98% vs. XECG 67%, (p < 0.001)
Sensitivity: CCTA 99% vs. SPECT 73%, (p = 0.001)
Specificity: CCTA 82% vs. XECG 46%, (p < 0.001)
Specificity: CCTA 71 % vs. SPECT 48%, (p = 0.14)
Obstructive CAD at Cath: NCDR 2005-2007 376,430 pts without CAD/MI or prior PCI/CABG Undergoing diagnostic cath to R/O CAD 59% of patients with positive stress tests had no obstructive CAD on
invasive angio (False positive), 73% with equivocal test result
Patel MR, Peterson ED, Dai D, Brennan JM, Redberg RF, Anderson HV, Brindis RG, Douglas PS. NEJM. 2010 Mar 11;362(10):886-95
SCCT 201514
Non-Invasive Functional Testing Prior to Angiography
Cury et al, JCCT 2014.Patel et al, Am Heart J 2014.
CONVERSELY, 70% of all CCTA had obstructive disease, still 30% false positives
Data from an analysis of more than 385,000 patients at over 1,100 US hospitalsPATEL M NCDR AHJ 2014
45% 44% 45% 45%
Non-obstructive CADObstructive CAD
SPECT Stress Echo Exercise Stress Test CMR
EVINCI STUDYCirc 2015
• So Anatomical Testing is more accurate than Functional Testing
• What about CV outcomes?
CTA vs Functional Meta AnalysisMyocardial infarction
Nielson EHJI 2014
SPARC STUDYHlatky JACC April 2014
P<0.0001
PROGNOSIS: Exercise Testing vs CTA
Pontone JACC 2013
“CTA may be a better diagnostic tool and may play a key role in prognostic stratification”
PROMISE NEJM 2015
PROMISE TRIAL
PROMISE TRIALPrimary Endpoint – Death, MI, and UA
Coronary CTA: Obstructive CAD >70%
C-Index: 0.72 (95% CI: 0.68, 0.77) 0.64 (95% CI: 0.59, 0.69) p=0.014
Net Reclassification Index (NRI)
Reclassification is based on the change (continuous) in the estimated risk probability.
Anatomical Testing Functional Testing
FRS plus Test Results vs. FRS Alone
Proportion of Events
correctly Reclassified
Proportion of Non-events correctly
Reclassified
NRI (95% Bootstrap CI)
Proportion of Events
correctly Reclassified
Proportion of Non-events correctly
ReclassifiedNRI (95%
Bootstrap CI)
Death/MI/UA 0.18 0.49 0.67 (0.49, 0.86) -0.37 0.76 0.40 (0.24, 0.56)
CV death/MI/UA 0.32 0.55 0.88 (0.68, 1.00) -0.27 0.76 0.49 (0.31, 0.68)
CV death/MI 0.41 0.07 0.47 (0.19, 0.74) -0.55 0.75 0.20 (0.02, 0.41)
PROMISE
• Discriminatory ability of coronary CTA was significantly better than functional testing (c-index: 0.73 (95% CI: 0.69, 0.77) vs. 0.64 (95% CI: 0.59, 0.69); p=0.011).
• Net Reclassification Index: CCTA 0.70 (95%: 0.52, 0.89) and Functional 0.40 (95%: 0.24, 0.56).
• CCTA provided higher discrimination, reclassification and more robust event prediction
SCOT HEARTLancet 2015
• 4,146 patients (mean age: 57 years, 56% male) who presented with chest pain due to suspected coronary artery disease
• Changes in diagnosis occurred in 25% of patients receiving CTCA and only 1% of pts receiving standard protocol (P < .001).
• after 3 years, the proportion of patients with events was reduced by 50% in the CTCA group (~2.5% vs ~1.7%, P = .015).
Future of Cardiac Imaging
• More emphasis on early atherosclerosis and aggressive medical/lifestyle management
• Less emphasis on obstruction and stenting• Continued decline, probably rapidly, of
functional testing – concerns of cost, accuracy and radiation
So, We can Continue what we are doing….
CT ANGIOGRAM = LARGE SOFT PLAQUE, INSTITUTE STATIN, ASPIRINLIFESTYLE….
Or with CTAWe can do better!!
FUNCTIONAL TEST RESULT =NORMAL STUDY, Reassure patient
• Superior test performance– false negative test results/untreated CAD
• coronary events• Better detection of non-obstructive CAD
• Improved preventive treatment and adherence
– Longer ‘warranty’ period with fewer repeat tests • hospitalizations during follow up
Why is CTA-Superior?Why is CTA-Superior?
NICE ALGORITHM
Testing and Costs Go Down after implementation of NICE – BMJ
2015
SYMPTOMATIC ALGORITHM
Low Pretest Probability (0-50%)
High Pretest Probability
Intermediate Pretest Probability(50-80%)
UK NICE Guidelines 2016
Where does Stress Nuclear and Stress Echocardiography fit into chest pain evalution in new guidelines?
What About FFR-CT?
FFR 0.94
FFRCT 0.93
LAD stenosis 70-90%
FFRCT Model
Per-Patient Diagnostic Performance vs. CT
Nørgaard et al, JACC 2014: ePub ahead of print; DOI: 10.1016/j.jacc.2013. 11.043
%
CT (>50%) FFRCT (≤ 0.80)
* **
*p<0.001
Platform Study – Douglas et al
35
CONSERVE Trial – ESC 2016
CONSERVE RESULTS
CONSERVE
0.9 mSv1.3 mSv 2.0 mSv
1.2 mSv
1.3 mSv(interquartile range 0.8-1.9)
Current CCTA dose is significantly reduced
Source: Labounty, Leipsic, Earls, Min et al. AJC 2010
Multicenter study of 449 patients undergoing CCTA after implementation of a standardized image acquisition protocol that employed prospective gating, reduced tube voltage, lower
tube current and reduced Z-axis coverage
Annual BackgroundRadiation
Conclusions
• With increasing accuracy and decreasing radiation exposure, CT angiography will become the dominant method to evaluate coronary artery disease
• For Preventive-minded physicians, the ability to see atherosclerosis will enhance patient selection and improve adherence