Eleni C Vourvouri, Cardiologist, PhD, FESC

CT Coronary Angiography Department

Medical Center Express Service

Thessaloniki

The role of CT Coronary Angiography in

year 2014

13rd North Hellenic Cardiology Congress

Thessaloniki , 29-31/5/ 2014

NO CONFLICTS OF INTEREST

• Coronary Calcification (CAS)

• Non-invasive Coronary Angiography• 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 Coronary veins pre-procedure

CT – Cardiac Applications

CT – Coronary Angiography

-CT coronary angiography

- lumen

-CT-plaque Imaging

- identification

- characterization

Schematic drawing of the development of coronary arteriosclerosis including positive remodelling during plaque burden increase and the listing of invasive and non-invasive

methods concerning their ability to detect signs of atherosclerosis starting with endothelial dysfunction and ending with signs of ischaemia in the EKG. Modified according to Erbel et

al.86.

Erbel R , and Budoff M Eur Heart J 2012;33:1201-1213

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

0 = no calcification

>0–100 = mild coronary calcification

>100–400 = moderate calcification

>400–1000 = severe calcification

>1000 = extensive calcification

Classification of coronary artery calcification

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

Assessment of clinically silent atherosclerotic disease

and established and novel risk factors for predicting

myocardial infarction and cardiac death in healthy

middle-aged subjects: Rationale and design of the

Heinz Nixdorf RECALL Study

Axel Schmermund, MD,a Stefan Mohlenkamp, MD, et l and Raimund Erbel,

MD,

for the Heinz Nixdorf Recall Study Investigative Group Essen, Bochum,

Herdecke, Mulheim, Cologne, and Dusseldorf, Germany

Am Heart J

2002;144:212-8

Risk Factors, Evaluation of Coronary Calcium and Lifestyle

Coronary Risk Stratification, Discrimination, and

Reclassification Improvement Based on Quantification

of Subclinical Coronary Atherosclerosis

The Heinz Nixdorf RECALL Study

Erbel R et al, JACC 2010

CAC scoring results in a high reclassification rate

in the intermediate-risk cohort, demonstrating the benefit of

imaging of subclinical coronary atherosclerosis

IMPACT OF CORONARY ARTERY CALCIUM

SCANNING ON CORONARY RISK FACTORS AND

DOWNSTREAM TESTING: A PROSPECTIVE

RANDOMIZED TRIAL

Alan Rozanski, MD, FACC, Heidi Gransar, MS, Leslee J. Shaw, PhD, FACC, Johanna Kim,

MPH, Lisa Miranda-Peats, MPH, Nathan D. Wong, PhD, Jamal S. Rana, MD, PhD, Raza

Orakzai, MD, Sean W. Hayes, MD, John D. Friedman, MD, MPH, Louise Thomson, MBChB,

Donna Polk, MD, James Min, MD,FACC, Matt Budoff, MD, FACC, and Daniel S. Berman,

MD, FACC

J Am Coll Cardiol. 2011

EISNER trialEarly Identification of Subclinical Atherosclerosis

by Noninvasive Imaging Research

2137 volunteers with CAD risk factors and no history of cardiac disease

Randomization into “scan group” and “no scan group”

4 year follow-up

Systolic blood pressure, LDL-cholesterol, weight loss,

Framingham Risk Score

CAC scanning was associated with superior

CAD risk factor control without increasing

downstream medical testing

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%

MSCT Coronary Angiography

Plaque imaging

What could MSCT do in this field?

Plaque Dimensions

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)

Vulnerable Plaque Features on Coronary CT

Angiography as Markers of Inducible Regional

Myocardial Hypoperfusion from Severe Coronary

Artery Stenoses

Haim Shmilovich, MDa,*, Victor Y Cheng, MDa,b,*, Balaji K Tamarappoo, MD, PhDa, Damini

Dey, PhDa,b, Ryo Nakazato, MD, PhDa, Heidi Gransar, MSca, Louise EJ Thomson, MBChB,

MRCPa,b, Sean W Hayes, MDa,b, John D Friedman, MDa,b, Guido Germano, PhDa,b, Piotr

J Slomka, PhDa,b, and Daniel S Berman, MDa,b

aCedars-Sinai Heart Institute and the Departments of Imaging and Medicine, Cedars-Sinai

Medical Center, Los Angeles, California, USA

bDepartment of Medicine, David Geffen School of Medicine, University of California, Los

Angeles,California, USA

Atherosclerosis. 2011

Presence of low attenuation plaque and positive remodeling

in severely stenotic plaques on Coronary CTAngiography

is strongly predictive of myocardial hypoperfusion

These findings were independent of stenosis severity

and indicate that plaque content and morphology

may be useful in assessing

the hemodynamic significance of severe stenosis

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

Diamond and Forrester Pre-Test Probability of Coronary Artery Disease by Age, Sex, and Symptoms∗

Age

(years)Sex Typical/Definite Angina Pectoris Atypical/Probable Angina Pectoris Nonanginal Chest Pain

≤39 Men Intermediate Intermediate Low

Women Intermediate Very low Very low

40–49 Men High Intermediate Intermediate

Women Intermediate Low Very low

50–59 Men High Intermediate Intermediate

Women Intermediate Intermediate Low

≥60 Men High Intermediate Intermediate

Women High Intermediate Intermediate

High: >90% pre-test probability. Intermediate: between 10% and 90% pre-test probability. Low: between 5% and 10% pre-test

probability. Very low: <5% pre-test probability.

∗

Modified from the ACC/AHA 2002 Guideline Update for Exercise Testing (30a).

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).

Asymptomatic

Hadamitzky M et al, Eur Heart J 2013

Pundziute G et al, JACC 2007

CONFIRM REGISTRYCoronary CT Angiography EvaluatioN

For Clinical Outcomes

Hadamitzky M, et al, JACC 2013;62:468-76

~ 20.000 patients, f/up 2.3 years

Number of proximal segments with mixed or calcified plaque

Number of proximal segments with a stenosis > 50%.

Smaller study 1584 pts, f/up 5.6 years

Best predictors for death: severity of CAD and number of plaques

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

PatentIntima

Hyperplasia Occluded

MSCT Coronary AngiographyStent imaging

Stent size matters!

MSCT Coronary Angiography

Stent Imaging

G. B. John Mancini, MD,* Pamela M. Hartigan, PHD,y Leslee J. Shaw, PHD,z

Daniel S. Berman, MD,x Sean W. Hayes, MD,x Eric R. Bates, MD,k David J. Maron, MD,{

Koon Teo, MD,# Steven P. Sedlis, MD,** Bernard R. Chaitman, MD,yy

William S. Weintraub, MD,zz John A. Spertus, MD,xx William J. Kostuk, MD,kk

Marcin Dada, MD,{{ David C. Booth, MD,## William E. Boden, MD***

Vancouver, British Columbia, Canada; West Haven and Hartford, Connecticut; Atlanta, Georgia;

Los Angeles, California; Ann Arbor, Michigan; Nashville, Tennessee; Hamilton and London, O

Predicting Outcome in the COURAGE Trial

Coronary Anatomy Versus Ischemia

JACC Cardiovasc Interv. 2014 Jan 9. pii: S1936-8798(13)01715-9. doi:

10.1016/j.jcin.2013.10.017. [Epub ahead of print]

1. To explore the relative and potentially synergistic prognostic importance

of anatomic burden and ischemic burden for the prediction of death, MI,

non STE- ACS while on OMT

2. To determine whether a combination of anatomic and ischemic burden

would identify patients who would benefit from an initial PCI management

strategy

PURPOSE

The number of patients pertaining to each colored curve are shown per year of follow-up. The atherosclerotic burden of

disease was determined using the graduated scale shown in Table 1. The clusters of 0-5, 6-13 and 14-17 correspond to

traditional vessel disease designations of 0/1, 2 and 3 vessel disease, respectively. Angiographic burden of disease was

significantly predictive of death/MI/NSTE-ACS (p = 0.001).

621 patients

Clinical endpoints:

Death, MI, NSTE-ACS

Predicting Outcome in the COURAGE Trial

Freedom From Death, Myocardial Infarction, or Non–ST-Segment Elevation Acute Coronary Syndrome by Anatomic Burden

Percent of Ischemic Myocardium

The percent of ischemic myocardium is calculated as described in the text and represents the burden of

reversible ischemia at baseline.

No significant relationship with the outcome of death/MI/NSTE-ACS was detected

(p = 0.75).

Atherosclerotic burden vs ischemic myocardium

Proportion of Patients With Death, Myocardial Infarction or Non–ST-Segment Elevation Acute Coronary Syndrome by

Ischemic Myocardium and Atherosclerotic Burden of Disease

Ishemia may be most important in those with

more severe atherosclerotic burden

Outcome does not worsen consistently with increasing ischemic burden

except in the subset of patients with the highest degree of atherosclerotic

burden p = 0.03

ISCHEMIA trial(International Study of Comparative

Health Effectiveness with Medical

And Invasive Approaches)

8000 pts with at least moderate ischemia to PCI+OMT vs OMT

CCTA to exclude pts with minimal atherosclerotic disease or LM

Study will define the incremental contribution of ischemia to atherosclerotic

burden for prognostication and selection of an optimal management strategy

Future

Future

DISCHARGE study

Five-year study of individuals with chest pain-

3500 patients across Europe

German Radiological Society with a grant of 6 million

Euro from the EU

Goal:to investigate when and for whom cardiac CT

has more benefits than cardiac cathetirization

The New Target:

Anatomy meets Ischemia

Novel techniques

MPI CCTA- Myocardial Perfusion Imaging Coronary CT Angiography

FFR- CT

Future

High value of CTCA in sequential or follow-up testing

in symptomatic patients

Take Home Message

CAC has been validated as a powerful tool for

cardiovascular risk assessment

CTCA has high negative predictive value for obstructive CAD.

After a negative CTCA no other test is needed

In asymptomatic patients CAC may be appropriate

in intermediate and high- risk individuals

and either stress or anatomic imaging (CTCA)

in higher-risk individuals

Valuable information about Plaque characteristics

Coronary CT angiography

What is important is to make

the right exam to the right patient, the

right time and according to local

availability and expertise

THANK YOU