Comparison of 64 slice multi detector CT vs 128 slice multi detector CT for acute chest pain evaluation in the chest pain unit
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1 Comparison of 64 slice multi detector CT vs 128 slice multi detector CT for acute chest pain evaluation in the chest pain unit Poster No.: C-0642 Congress: ECR 2010 Type: Topic: Authors: Keywords: Keywords: DOI: Scientific Exhibit Cardiac - CT O. Goitein, E. Konen, Y. Eshet, R. Beigel, A. Hamdan, E. Di Segni, S. Matetzky; Tel Hashomer/IL 128 MDCT, cardiac CT, chest pain triage Cardiac, CT /ecr2010/C-0642 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 17
2 Purpose Background : Purpose : CCTA used daily in acute chest pain triage Radiation is not negligible & has been addressed as a potential patient hazard CCTA using prospective ECG gating -"step & shoot" (S&S) enables significant dose reduction, albeit requiring low steady HR The introduction of 128 MDCT opens new possibilities for S&S To determine whether the routine use of 128 VS 64 MDCT can increase the proportion of patients scanned using S&S shoot" technique and therefore decrease the related radiation exposure Page 2 of 17
3 Images for this section: Fig. 0: Prosepctivly gated ECG: the tube current is triggered only during diastole (red tracing) Radiology, Sheba Medical Center - Tel Hashomer/IL Page 3 of 17
4 Methods and Materials S&S was performed whenever possible; S&S inclusion criteria : 128 MDCT: stable heart rate (HR) < 70/min and weight < 140 Kg 64 MDCT: stable heart rate (HR) < 60/min and weight < 110 Kg 15 coronary segmnets visually evaluated for image quality (scale of 1-5) An estimated radiation dose was recorded per patient Subjects and Methods 128 MDCT (ICT SP Philips): Consecutive 116 patients Mean age 49y 68% M; 32% F Mean HR 57 bpm Mean BMI MDCT (Brilliance 64 Philips): Consecutive 116 patients (during the period immediately preceding 128 MDCT installation) Mean age 50y 65% M; 35% F Mean HR 58 bpm Mean BMI 28.3 S&S ± 5% tolerance A new S&S option available for 128 MDCT Page 4 of 17
5 Allows prospective axial scanning in 3 diastolic phases : 70, 75, 80% of the R-R interval Page 5 of 17
6 Images for this section: Fig. 0: coronary arteries; 15 segment model according to AHA AHA Coronary artery disease reporting system, Circulation, 1975 Fig. 0: S&S with 5% tolerance also known as "padding". The tube current is triggered during diastole, allowing the reconstruction of three diastolic phases: 70%, 75%, and 80% of the R-R interval Radiology, Sheba Medical Center - Tel Hashomer/IL Page 6 of 17
7 Results Results: Effective dose: Average msv 128 MDCT (N=116) S&S single phase 3.2 (N=21) 4 (N=56) S&S 5% tolerance 5.11 (N=79) NA RG 15.2 (N=1) 23 (N=7) Average msv 64 MDCT (N=116) DM (40,70-80 %) 14.3 (N=8) 14.4 (N=32) DM (70-80 %) NA 10.6 (N=9) S&S twice 5.7 (N=1) 6.9 (N=1) S&S & DM 14.8 (N=6) 17.6 (N=8) DM twice NA 27 (N=3) Table legend: S&S: "Step and shoot" single diastolic phase (70% of the R-R interval); S&S 5% tolerance: "Step and shoot" with three diastolic phases (70,75, 80,% of the R-R interval); RG: retrospective gating CCTA without dose modulation (full exposure during the entire R-R interval);dm (40-80%): retrospective gating CCTA with dose modulation (full exposure during 40-80% of the R-R interval); DM (70-80%): retrospective gating CCTA with dose modulation (full exposure during 70-80% of the R-R interval); S&S twice: "Step and shoot"was acquired first and was non diagnostic, then followed by another "Step and shoot"; S&S and DM (40-80%): "Step and shoot"was acquired first and was non diagnostic, then followed by DM (40-80%); DM (40-80%) twice: dose modulation was acquired first and was non diagnostic, then followed by the same repeated technique. "Step and shoot" performed in 84% of the 128 MDCT group "Step and shoot" performed in 49% of the 64 MDCT group (p< ) Average image quality score 4.6± MDCT group VS 4.7± MDCT group (p= 0.08) Page 7 of 17
8 Images for this section: Fig. 0: Average effective radiation for the different scanning techniques in both 128 MDCT and 64 MDCT groups. DLP: Dose length product mgy/cm2; S&S single phase: "Step and shoot" only 75% of R-R; S&S 5% tolerance: Step and shoot 70%,75%,80% of R-R; RG: retrospective gating; DM (40,70,75,80 %): Dose modulation for 40%,70%,75%,80% of R-R; DM (70,75,80 %): Dose modulation for 70%,75%,80% of R-R; S&S twice: Step and shoot twice due to study failure; S&S & DM: Step and shoot followed by dose modulation due to study failure; DM twice: dose modulation twice due to study failure. Radiology, Sheba Medical Center - Tel Hashomer/IL Page 8 of 17
9 Fig. 0: Curved multiplanar reformations of the RCA (64 MDCT): significant stenosis in the proximal and Mid RCA. Radiology, Sheba Medical Center - Tel Hashomer/IL Page 9 of 17
10 Fig. 0: Coronary angiography: significant stenosis in the proxiaml RCA. Radiology, Sheba Medical Center - Tel Hashomer/IL Page 10 of 17
11 Fig. 0: Curved multiplanar reformations of RCA (128 MDCT): significant stenosis in the proximal RCA. Radiology, Sheba Medical Center - Tel Hashomer/IL Page 11 of 17
12 Fig. 0: coronary angiography: significant stenosis in the proximal and Mid RCA. Radiology, Sheba Medical Center - Tel Hashomer/IL Page 12 of 17
13 Conclusion Conclusions: Patient tailored CCTA reduces the radiation exposure significantly 128 MDCT allows lowering tube voltage to 100 KvP lead to a significant dose reduction with no decrease in image quality The mean radiation dose 6.2±5 128 MDCT VS 10.4±7 msv for 64 MDCT 128 MDCT scanner facilitates the utilization of "step and shoot" technique thereby deceasing the related radiation significantly, without hampering image quality Page 13 of 17
14 References References: 1. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation 2007;116:e Hendel RC, Patel MR, Kramer CM, et al. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/ SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology. Journal of the American College of Cardiology 2006;48: Beigel R, Oieru D, Goitein O, et al. Usefulness of routine use of multidetector coronary computed tomography in the "fast track" evaluation of patients with acute chest pain. The American journal of cardiology 2009;103: Gallagher MJ, Ross MA, Raff GL, Goldstein JA, O'Neill WW, O'Neil B. The diagnostic accuracy of 64-slice computed tomography coronary angiography compared with stress nuclear imaging in emergency department low-risk chest pain patients. Annals of emergency medicine 2007;49: Rubinshtein R, Halon DA, Gaspar T, et al. Impact of 64-slice cardiac computed tomographic angiography on clinical decision-making in emergency department patients with chest pain of possible myocardial ischemic origin. The American journal of cardiology 2007;100: Carbonaro S, Villines TC, Hausleiter J, Devine PJ, Gerber TC, Taylor AJ. International, multidisciplinary update of the 2006 Appropriateness Criteria for cardiac computed tomography. Journal of cardiovascular computed tomography 2009;3: Page 14 of 17
15 7. Earls JP. How to use a prospective gated technique for cardiac CT. Journal of cardiovascular computed tomography 2009;3: Earls JP, Schrack EC. Prospectively gated low-dose CCTA: 24 months experience in more than 2,000 clinical cases. The international journal of cardiovascular imaging Gutstein A, Dey D, Cheng V, et al. Algorithm for radiation dose reduction with helical dual source coronary computed tomography angiography in clinical practice. Journal of cardiovascular computed tomography 2008;2: Pontone G, Andreini D, Bartorelli AL, et al. Diagnostic accuracy of coronary computed tomography angiography: a comparison between prospective and retrospective electrocardiogram triggering. Journal of the American College of Cardiology 2009;54: Morin RL, Gerber TC, McCollough CH. Radiation dose in computed tomography of the heart. Circulation 2003;107: Austen WG, Edwards JE, Frye RL, et al. A reporting system on patients evaluated for coronary artery disease. Report of the Ad Hoc Committee for Grading of Coronary Artery Disease, Council on Cardiovascular Surgery, American Heart Association. Circulation 1975;51: Shim SS, Kim Y, Lim SM. Improvement of image quality with beta-blocker premedication on ECG-gated 16-MDCT coronary angiography. Ajr 2005;184: Smith-Bindman R, Lipson J, Marcus R, et al. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Archives of internal medicine 2009;169: Einstein AJ, Henzlova MJ, Rajagopalan S. Estimating risk of cancer associated with radiation exposure from 64-slice computed tomography coronary angiography. Jama 2007;298: Einstein AJ, Moser KW, Thompson RC, Cerqueira MD, Henzlova MJ. Radiation dose to patients from cardiac diagnostic imaging. Circulation 2007;116: Hausleiter J, Meyer T, Hadamitzky M, et al. Radiation dose estimates from cardiac multislice computed tomography in daily practice: impact of different scanning protocols on effective dose estimates. Circulation 2006;113: Hausleiter J, Meyer T, Hermann F, et al. Estimated radiation dose associated with cardiac CT angiography. Jama 2009;301: Johns HE CJ. The Physics of Radiology, 4th ed: Charles C. Thomas, 1983 Page 15 of 17
16 20. Bischoff B, Hein F, Meyer T, et al. Impact of a reduced tube voltage on CT angiography and radiation dose: results of the PROTECTION I study. Jacc 2009;2: Page 16 of 17
17 Personal Information Orly Goitein MD Page 17 of 17
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