CT Coronary Angiography - Indications: From the guidelines to clinical practice

Transcription

1 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 Eleni C Vourvouri Cardiologist, PhD, FESC Euromedica Geniki Kliniki, Research Associate, 2nd Cardiology Department, Hippokrateio University Hospital, Thessaloniki

2 NO CONFLICTS OF INTEREST

3 CT-coronary angiography: developments 64 slice MSCT Spiral CT EBCT CA 4-slice MS-CT slice MS-CT 16 slice MS-CT 64 slice MS-CT Dual source Year Cardiac motion Artefacts = (Temp. Resolution) (ms) Breath hold time (s) <10

4 CT-coronary angiography: developments 64 slice MSCT Spiral CT EBCT CA 4-slice MS-CT slice MS-CT 16 slice MS-CT 64 slice MS-CT Dual source Year Cardiac motion Artefacts = (Temp. Resolution) (ms) Breath hold time (s) <10

5 CT Cardiac Applications 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 Coronary veins pre-procedure

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7 Appropriateness Criteria

8 Budoff M et al. Circulation 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

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13 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

14 Symptomatic A = appropriate M = may be appropriate R = rarely appropriate

15 Uncertain Prior Results (sequential testing 90 Days)

16 Abnormal Prior Test/Study (sequential testing 90 Days)

17 New or worsening symptoms (Follow- up Testing)

18 Post revascularization (PCI or CABG) Symptomatic Post revascularization (PCI or CABG) Asymptomatic

19 Asymptomatic

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23 CORONARY CT ANGIOGRAPHY What does it offer to the cardiologist?

24 CT Calcium Score : Predictive Value No calcification Mild Severe Calcium Score NP All-cause death % Relative Risk Ratio > Shaw Radiology 2003;228:826

25 EBCT Calcium score modifies Framingham Risk Score: predicted mortality at 5 years high-risk asymptomatic individuals Mean 53 yrs, male: 60% < > Low Risk N=1.302 Intermediate Risk N=5.876 Framingham Risk stratification High risk N=3.194 Shaw Radiology 2003;228:826

26 Estimation of presence of coronary artery disease 1. Diamond and Forrester model N Eng J Med. 1979;300: Age, Sex, Symptoms 2. Duke clinical score Ann Intern Med 1993;118:81-90 Age, Sex, Symptoms, diabetes, hypertension, dyslipidaemia and smoking

27 Estimation of presence of coronary artery disease 1. Diamond and Forrester model N Eng J Med. 1979;300: Age, Sex, Symptoms 2. Duke clinical score Ann Intern Med 1993;118:81-90 Age, Sex, Symptoms, diabetes, hypertension, dyslipidaemia and smoking 3. New prediction model BMJ 2012;344:E3485 Age, Sex, Symptoms, diabetes, hypertension, dyslipidaemia and smoking Coronary Calcium Score

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29 Hadamitzky M et al, Eur Heart J 2013 Pundziute G et al, JACC 2007

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31 CONFIRM REGISTRY Coronary CT Angiography EvaluatioN For Clinical Outcomes Dynamic registry of >32,000 consecutive patients, 12 sites in 6 countries (US, Canada, Germany, Switzerland, Italy & Korea) Database locked in 2010 Min J, JCCT 2011

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33 Kaplan Meier for MORTALITY-FREE Survival Kaplan Meier for MACE-FREE Survival

34 PLAQUE CHARACTERIZATION The value of the additional information

35 Plaque Type Calcified Non-calcified Partly calcified Mixed

36 Post-hoc Analysis of Plaques in ACS: - More non-calcified components than stable lesions - Positive Remodeling (87%) - Spotty calcification - Lower CT attenuation (< 30 HU) Motoyama, JACC 2007 Schuijf et al, Acad Radiol 2007 Hoffmann, AJC 2006

37 Atherosclerotic plaque characteristics-apc S Positive Remodelling RI (Remodelling Index) >=1,10 Low attenuation plaque: HU <30 Spotty calcification < 3mm

38 RI=Maximum Reference Reference Maximun

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40 Subjects analysed participating centers worldwide Norgaard JACC 2014;63:

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42 No ischemia CCTA Invasive angiography FFR FFR CT = no ischemia ischemia

43 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

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45 CT characteristics of a stable plaque RI= 0,87

46 CT characteristics of a high risk plaque Positive remodelling Low attenuation Spotty calcification

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

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51 2016

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53 CONFIRM REGISTRY Coronary CT Angiography EvaluatioN For Clinical Outcomes 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

54 CONFIRM (COronaryCT Angiography EvaluatioN For Clinical Outcomes: An InteRnational MulticenterRegistry 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

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56 CONCLUSIONS Tremendous growth in EVOLUTION of cardiovascular computed tomogra Numerous MULTICENTER TRIALS and REGISTRIES about clinical value of CCTA HIGH DIAGNOSTIC AND PROGNOSTIC VALUE

57 Conclusions 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

58 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

59 THANK YOU