The role of Cardiac CT

Transcription

1 Detection of Coronary Artery Disease Anatomy or perfusion? The role of Cardiac CT Multimodality Working Group of Cardiovascular Imaging (Nuc C,CCT &, CMR) Hellenic Cardiology Society Seminars, Thessaloniki, 2014 Eleni C Vourvouri, Cardiologist, PhD, FESC CT Coronary Angiography Department Medical Center Express Service Thessaloniki

2 NO CONFLICTS OF INTEREST

3 Key Clinical Questions in clinical test evaluation Diagnostic question Prognostic question Therapeutic question

4 Key Clinical Questions in clinical test evaluation Diagnostic question Prognostic question Therapeutic question

5 CT Coronary Angiography -CT coronary angiography - lumen -CT-plaque Imaging - identification - characterization

6 Volume Rendering Curved Multiplanar Reconstruction cmpr Maximum Intensity Projection MIP

7 MPS vs. STRESS ECHO MPS vs. CTCA Meta-analysis including 17 studies, 1405 pts, in which MPS was directly compared to Stress echocardiography MPS: pooled data from 50 studies,6971 pts. Mean prevalence of CAD 75% CTCA: pooled sens. Spec. In series totaling 1653 pts Mean prev. of CAD 63% Schinkel AFL et al, Eur Heart J 2003 Carli MF, Hachamovitch R, Circulation 2007

8 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

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

10 Uncertain Prior Results (sequential testing 90 Days)

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

12 New or worsening symptoms (Follow- up Testing)

13 Key Clinical Questions in clinical test evaluation Diagnostic question Prognostic question Therapeutic question

14 CT Coronary Angiography Calcium score-coronary artery calcification Predictive value

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

16 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

17 Asymptomatic

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

19

20 CONFIRM REGISTRY Coronary CT Angiography EvaluatioN For Clinical Outcomes ~ 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 Hadamitzky M, et al, JACC 2013;62:468-76

21 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

22

23 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

24 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

25 Key Clinical Questions in clinical test evaluation Diagnostic question Prognostic question Therapeutic question

26 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 EISNER trial Early Identification of Subclinical Atherosclerosis by Noninvasive Imaging Research

27 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

28 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

29 CONFIRM (COronaryCT Angiography EvaluatioN For Clinical Outcom 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

30 Differences in Prevalence, Extent, Severity, and Prognosis of CoronaryArtery Disease Among Patients With and Without Diabet Undergoing CoronaryComputed Tomography Angiography Results from 10,110 individuals from the CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes): an InteRnational Multicenter Registry OBJECTIVEdWe examined the prevalence, extent, severity, and prognosis of coronary artery disease (CAD) in individuals with and without diabetes (DM) who are similar in CAD risk factors. CONCLUSIONSdCompared with matched non-dm individuals, DM individuals possess higher prevalence, extent, and severity of CAD. At comparable levels of CAD, DM individuals experience higher risk of mortality compared with non-dm individuals. JS Rana et al, Diabetes Care 35: , 2012

31 Differences in Prevalence, Extent, Severity, and Prognosis of CoronaryArtery Disease Among Patients With and Without Diabetes Undergoing CoronaryComputed Tomography Angiography Results from 10,110 individuals from the CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes): an InteRnational Multicenter Registry Rana J S et al. Dia Care 2012;35:

32 Anatomy or perfusion?

33 Predicting Outcome in the COURAGE Trial Coronary Anatomy Versus Ischemia 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 JACC Cardiovasc Interv Jan 9. pii: S (13) doi: /j.jcin [Epub ahead of print]

34 PURPOSE 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

35 Predicting Outcome in the COURAGE Trial Freedom From Death, Myocardial Infarction, or Non ST-Segment Elevation Acute Coronary Syndrome by Anatomic Burden 621 patients Clinical endpoints: Death, MI, NSTE-ACS 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 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).

36 Percent of Ischemic Myocardium No significant relationship with the outcome of death/mi/nste-acs was detected (p = 0.75). The percent of ischemic myocardium is calculated as described in the text and represents the burden of reversible ischemia at baseline.

37 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

38 Conclusions 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 CCTA, both plaque burden and stenosis, particularly in proximal segments carry incremental prognostic value In the Courage Trial, coronary anatomy versus Ischemia, anatomic burden of coronary disease was a consistent predictor of death, MI, NSTE-ACS, whereas ishemic burden was not

39 THANK YOU