Defining Plaque Composition by CTA: The Latest Tool to Monitor Therapy?

Transcription

1 Defining Plaque Composition by CTA: The Latest Tool to Monitor Therapy? John McB. Hodgson, M.D., FSCAI Chairman, Department of Cardiology Geisinger Health System Wilkes Barre,, Pa

2 Disclosure Information John McB. Hodgson MD, FSCAI The following relationships exist related to this presentation: Grant support (GS), consultant (C), speakers bureau (SB), stock options (SO), equity interest (EI): Boston Scientific, RADI, Volcano: GS Volcano : C Technology Solutions Group: EI Boston Scientific, Pfizer, GE Medical : SB Off label use of products will be discussed in this presentation.

3 Leading Causes of Death for All Males and Females United States: 2001 A Total CVD B Cancer C Accidents D E F Chronic Lower Respiratory Diseases Diabetes Mellitus Alzheimer s Disease Source: CDC/NCHS.

4 Progression of atherosclerosis

5 PDAY: Prevalence of Lesions in LAD Age (y) Prevalence (%) Women Men % AHA lesion grade AHA lesion grade Error bar=se. McGill HC Jr, et al. Circulation. 2000;102:

6 512 display 3 mm diameter vessel Resolution = 0.2mm 15 pixels to cover the artery Quantitative Coronary Angiography

7 512 display 3 mm diameter vessel Resolution = 0.5 mm 6 pixels to cover the artery Coronary CT Angiography

8 Detailed coronary anatomy Stent 2 mm Non-calcified Plaque

9 High resolution coronary CTA Coronary Aneurism Non-calcified plaque Courtesy, GE Medical

10 Noncalcified Plaque: CTA vs. IVUS Hounsfield units (HU)

11 CCTA for plaque characterization N=21 ACS, 53 stable pts; non-culprit lesions; 16 slice Kunimasa, et al Circ J 2005;69:

12 IVUS-CTA n=32 pt; 252 sites; 16 slice qualitative IVUS vs.. HU 49 HU 117 HU 88 HU Pohle,, et al Atherosclerosis 2007;190:

13 Detection of Calcified and Noncalcified Plaque: 16 Slice CTA vs IVUS 37 pts; 68 vessels Hypoechoic 78% Hyperechoic 78% Calcified 98% None 92% Leber et al. JACC;2004;43:1241 7

14 Rasouli,, et al Coron Artery Dis 2006; 17:

15 Detection of Vulnerable plaque low density < 68 HU based on IVUS correlation Kunimasa,, et al Circ J 2005;69:1346-5

16 TCFA? MLA 2.8 mm mm 2 Courtesy: Harvey Hecht

17 # of RO Is : 146 # of RO Is : 3 3 MB F > # of RO Is : 1 13 MB F < # of RO Is : 2 8 M i np > # of R O Is : 5 M i np < Type: Collagen # of RO Is : 8 2 Int > # of RO Is : 3 1 Int < # of RO Is : 2 0 MB F > Type: C alcium # of RO Is : 8 MB F < Type: C alcium #of RO Is: 44 F at MaxP > # of RO Is : 3 8 F at MaxP < # of RO Is : 2 6 M a xp > Type: Collagen # of RO Is : 5 M a xp < Type: Collagen # of R O Is : 3 8 Ma xp > #of RO Is: 6 Ma xp < Type: Collagen # of R O Is : 1 1 MB F > # of R O Is : 2 7 MB F < # of RO Is : 1 7 MaxP > # of RO Is : 2 1 MaxP < #of RO Is: 5 #of RO Is: 6 Int < Type: Calcium # of R O Is : 1 7 F at M a xp > Type: Collagen # of R O Is : 1 0 F at M a xp < # of RO Is : 9 F at MaxP > 35.5 Type: Collagen # of RO Is : 8 F at MaxP < 35.5 Type: Collagen #of RO Is: 15 F at Ma xp > # of RO Is : 6 F at Ma xp < Type: N ecrotic # of R O Is : 5 Int > Type: Collagen # of R O Is : 5 Int < Type: Collagen # of R O Is : 5 Ma xp > T yp e: Fib ro -Lipi di c # of RO Is : 1 0 Ma xp < #of RO Is: 5 MBF > Type: Collagen #of RO Is: 5 MBF < Type: FibroLipidic VH-IVUS TREE ROOT Classification Tree Int > Type: Collagen MEDIA FIBROUS FIBROLIPIDIC CALCIUM VH Legend NECROTIC CORE John McB. Hodgson, M.D.

18 Correlation of CT and VH-IVUS N=59 pts, 80 lesions Am Am JJ Cardiol Cardiol 2008;102: ;102:

19 Correlation of CT and VH-IVUS N=59 pts, 80 lesions Am J Cardiol 2008;102:

20 Correlation of CT and VH-IVUS N=59 pts, 80 lesions Am J Cardiol 2008;102:

21 Plaque burden important 3 X Risk Min JACC 2007;50:1161

22 CTA and prognosis 2538 pts; referred by MD; 15 year follow-up; all cause mortality Use of EBCT Ostrom JACC 2008; in press

23 CTA and prognosis CTA + CCS CTA Risk factors Ostrom JACC 2008; in press

24

25 Prevalence of plaque by Risk Factors (RF) % RF 2-3 RF >=4 RF No Plaque Some Plaque Sig Plaque N= 163 symptomatic pts, age 65 Radiol Med. 2008;113:363-72

26 Routine screening-asymptomatic

27 Asymptomatic screening J Am Coll Cardiol 2008;52:357-65

28 Asymptomatic: frequent disease J Am Coll Cardiol 2008;52:357-65

29 Asymptomatic: failure of classic risk factors to identify significant stenoses J Am Coll Cardiol 2008;52:357-65

30 Asteroid Rosuvastatin 40 mg 24 months LDL: 61 mg/dl Volume down 6.8% JAMA 2006;295:epub

31 Effect of Statins on Fibroatheroma Randomized Fluvastatin 60mg/d vs. control (n=80) Fibroatheromas detected by VH-IVUS Re-study at 12 months ESC abstract 2008

32 Reports of the future:

33 Summary Angiography limited to luminal pathology Stress testing by definition cannot find subclinical disease Anatomic plaque quantification now easily possible with CCS, CTA, IVUS, OCT, etc. Plaque modification with medication possible CT adds value for early diagnosis and monitoring (my bias!) Transition to preventative treatment