The role of CT Coronary Angiography in year rd North Hellenic Cardiology Congress Thessaloniki, 29-31/5/ Eleni C Vourvouri,

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1 The role of CT Coronary Angiography in year rd North Hellenic Cardiology Congress Thessaloniki, 29-31/5/ 2014 Eleni C Vourvouri, Cardiologist, PhD, FESC CT Coronary Angiography Department Medical Center Express Service Thessaloniki

2 NO CONFLICTS OF INTEREST

3 CT Cardiac Applications 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

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

5 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:

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

7 Classification of coronary artery calcification 0 = no calcification >0 100 = mild coronary calcification > = moderate calcification > = severe calcification >1000 = extensive calcification

8 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

9 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 Risk Factors, Evaluation of Coronary Calcium and Lifestyle Am Heart J 2002;144:212-8

10 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

11 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

12 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

13 First Author Technique Patients Not evaluable Sensitivit y Specificity Negative Predictive Value Leschka 64-slice CT % 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 % 95% 100% Mühlenbru 64-slice CT 51-87% 95% 98% Meijboom 64-slice CT % 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 % 94% 99%

14 MSCT Coronary Angiography Plaque imaging What could MSCT do in this field?

15 Plaque Dimensions

16 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

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19 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

20 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

21 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

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

23 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 Men High Intermediate Intermediate Women Intermediate Low Very low 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).

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26 Acute Chest Pain 64 STAT randomized trial Acute Chest Pain in ED Goldstein et al. JACC Feb 2007;49:863

27 Goldstein et al. J Am Coll Cardiol 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). CCTA (n=99) SOC (n=98) Reduced diagnostic time by 77% (3.4 hr vs 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)

28 Asymptomatic

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 ~ 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

32 Uncertain Prior Results (sequential testing 90 Days)

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

34 New or worsening symptoms (Follow- up Testing)

35 Post revascularization (PCI or CABG) Symptomatic

36 Post revascularization (PCI or CABG) Asymptomatic

37 MSCT Coronary Angiography Stent imaging Patent Intima Hyperplasia Occluded

38 Stent size matters! MSCT Coronary Angiography Stent Imaging

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40 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]

41 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

42 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).

43 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.

44 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

45 Future 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

46 Future DISCHARGE study Five-year study of individuals with chest pain 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

47 Future The New Target: Anatomy meets Ischemia Novel techniques MPI CCTA- Myocardial Perfusion Imaging Coronary CT Angiography FFR- CT

48 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 High value of CTCA in sequential or follow-up testing in symptomatic patients

49 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

50 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

51 THANK YOU