Why? Cardiac CT. Cardiac CT - State of the Art 3/7/2013. Cardiovascular disease in the USA

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1 MGH Cardiac CT Program - Acknowledgement Cardiac CT - State of the Art Suhny Abbara, MD Associate Professor of Radiology, Harvard Medical School Director, Cardiovascular Imaging Fellowship, Massachusetts General Hospital Director of Education, MGH Cardiac MRCT Program Suhny Abbara Thomas J Brady Rajiv Gupta Udo Hoffmann Mannudeep Kalra Fred Mamuya Ahmed Tawakol Ricardo Cury Stephan Achenbach Shawn Teague Maros Ferencik Jonathan Dodd Leon Shturman Fabian Bamberg Ron Blankstein Carolyn Taylor Andrew Blum Chun-Ho (Leo) Yun Brian Ghoshharja David Okada Ian Rogers Khuram Nasir Quynh Truong John Nichols Ricardo Benenstein Christopher Schlett Mat Gilman Amit Mehndiratta Nikhil Goyal Sanjeeva Kalva Terry Healy Seth Kligerman SAbbara@Partners.org Disclosures Medical Advisory Board Member Perceptive Informatics, Partners Imaging, Magellan Healthcare Consultant / Editing / Authoring (honoraria): EZEM, Siemens Medical Systems Amirsys, Inc., Elsevier Research: NIH, Bracco, Bayer Healthcare, Siemens BOD: SCCT, CBCCT Why? Cardiac CT Contrast not FDA approved for coronary CTA Cardiovascular disease in the USA Leading cause of death ~64 million Americans have some form of the disease Economic burden ~ $133 billion American population ages Obesity epidemic continues increase in future prevalence hospitals ACC National Cardiovascular Data Registry Pts with no Hx of CAD: No CAD (<20% stenosis) 39.2% Non obstructive (<50%) 60% CONCLUSIONS: Better strategies for risk stratification are needed to inform decisions and to increase the diagnostic yield of cardiac catheterization N Engl J Med Mar 11;362(10):

2 Pubmed cited articles by years (((((("cardiac CT") OR "cardiac CTA") OR "coronary CT") OR "coronary MDCT") OR "coronary CTA") AND "20xx 200xx+1"[Publication Date] Not all articles captured! CT Literature on Stenosis Accuracy for Stenosis Detection MDCT Invasive angio vs. 17/18 segments / per artery / per patient analysis +/- Non-evaluable segments (calcium, motion) Accuracy values: sensitivity, specivity, PPV, NPV S Achenbach Reasons for Non Evaluability Meta-analysis extensive calcification motion artifact 27 studies N=2024 pts 16, 32, 40, 64-slice Prevalence of CAD: 63% 4.2% non-evaluable excluded 64-slice: Sensitivity 87% Specificity 96% Very high NPV Pooled Sensitivity 0.81 JACC. 2006;48; Pooled Specificity

3 Accuracy for Stenosis Detection META-ANALYSES Sens. Spec. NPV PPV Gopalakrishnan Cardiol in Rev 2008 PER SEGMENT 91% 96% 98% 78% PER PATIENT 96% 90% 96% 93% Mowatt Heart 2008 PER SEGMENT 90% 97% 99% 76% 64 Slice CT Meta PER PATIENT Analyses99% 89% 100% 93% High negative predictive value Positive predictive value not quite as high S Achenbach International Multicenter Trial (MEDIC) 6 internat. sites, n=415, year old Pts Who? intermediate likelihood for coronary stenosis scheduled for invasive angiography DSCT prior to cath Agatston score >800 excluded How scanned? No beta blockers, spiral mode Blinded central core laboratory readings How analyzed? No excluded nonevaluable segments Accuracy of DSCT in Patients with Intermediate Pre test Likelihood of CAD Initial Results of the MEDIC Trial. Achenbach,, Abbara,.. Hausleiter J. SCCT 2011 Denver, CO, 2011 International Multicenter Trial (MEDIC) ccta vs. subsequent PCI (n = 71) or bypass surgery Mean (n=12) : radiation dose: 5.9 msv Sensitivity = 95% (83/87) Specificity = 91% (299/328) PPV = 74% (83/112) Results NPV = 99% (299/303) CT did not predict revascularization 4 times (all single vessel disease): 2 x LAD stenoses < 50% in QCA 1 x peripheral LAD stenosis 1 x diagonal branch lesion Accuracy of DSCT in Patients with Intermediate Pre test Likelihood of CAD Initial Results of the MEDIC Trial. Achenbach,, Abbara,.. Hausleiter J. SCCT 2011 Denver, CO, 2011 International Multicenter Trial (MEDIC) Accuracy by heart rate - no difference Heart Rate n Sensitivity Specificity PPV NPV All > > % (106/111) 98% (42/43) 94% (64/68) 100% (25/25) 95% (289/304) 95% (97/102) 95% (193/203) 94% (67/71) Achenbach,, Abbara, et al. SCCT 2012, Baltimore, MD 88% (106/121) 89% (42/49) 87% (64/74) 86% (25/29) 98% (289/294) 99% (97/98) 98% (193/197) 100% (67/67) Multi-Center Accuracy Trials (Stenosis) by CT Per patient analysis ccta vs QCA, stenoses > 50% n Sensitivity Specifity NPV Prevalence ACCURACY % 83% 99% 25% Meijboom % 64% 96% 68% CORE % 90% 83% 56% CORE-64 Multicenter Trial Prediction of Revascularization within 30days of cath MDCT: AUC=0.84 QCA: AUC=0.82 Unevaluable NEGATIVE 1 Budoff et al, JACC 2008; 2 Meijbom et al, JACC 2008 ; 3 Miller et al, NEJM 2008 per patient analysis Miller et al. New Engl J Med 2008;359:

4 Diagnosis of obstructive CAD Imperfect Gold Standard? Test Sensitivity Specificity Exercise ECG treadmill 1 68% 77% Exercise Echo treadmill 2 86% 81% Dobutamine Echo 2 ~85% ~85% Exercise nuclear treadmill 3 87% 73% Pharmacologic nuclear 3 89% 75% Cardiac CTA 4 95% 83% 1. ACC/AHA 2002 Guideline Update for Exercise Testing 2. ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography 3. ACC/AHA/ASNC Guidelines for the Clinical Use of Cardiac Radionuclide Imaging 4. ACCURACY study, presented at 2008 ACC Scientific Sessions Courtesy Stephan Achenbach, MD R/o Stenoses in Symptomatic Patients 421 patients with stable chest pain and positive SPECT ( intermediate risk ): 64 slice CT 78 Pt: Coronary angiography (50 revasc., 1MI, 1 ) 343 Pt: Medical 15 month FU: 6 Coronary Angiographies 1 Revascularization Close to Zero event rate after ruling out coronary stenoses by CT in symptomatic patients Stable Chest Pain Hadamitzki et al, ijacc 2009 Lesser et al, Cath Card Interv 2007 Danciu et al, Am J Cardiol 2007 Schussler et al, Am J Cardiol 2009 Ostrom et al, JACC 2008 Abidov et al, J Nucl Cardiol 2009 Chow et al, JACC 2010 Acute Chest Pain Rubinshtein et al, AJC 2007 Hollander et al, Ann Emerg Med 2009 Am J Cardiol 2007 Correlation to Ischemia Coronary CT angiography normal no coronary stenosis Prognostic Value of cct >50% stenosis controlled for age, family history, dyslipidemia, (not calcium score) Endpoint: all cause mortality 1.00 CT is good at ruling out, Coronary CT shows stenosis not necessarily ischemia Cumulative Survival n = 1127 But not at predicting ischemia. Min et al. J Am Coll Cardiol 2007;50: Years after CT 4

5 CONFIRM Registry (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry) Subjects Without Chest Pain Syndrome Risk-adjusted event-free survival after CTA CAD stratified by severity of disease and number of diseased arteries Symptomatic Pts ***Even if we don t find obstructive disease, the total amount of disease and number of vessels affect survival and number of events.**** N= 2,538 Cho, Min. Circulation 126(3), 17 July 2012 Ostrom,, Budoff. J Am Coll Cardiol 2008;52: ED 130 million ED visits Acute Chest Pain 3 million non cardiac Discharge 8 mil chest pain 5 million Rule Out cardiac cause Workup +/- CT? 40,000 MI 54 3 h substernal pain, pain relief after nitro negative 1 st Troponin / CK-MB - non-diagnostic EKG 54 3 h substernal pain, pain relief after nitro negative 1 st Troponin / CK-MB - non-diagnostic EKG RCA LAD Occlusion 5

6 Functional Information from Cardiac CT 54 3 h substernal pain, pain relief after nitro negative 1 st Troponin / CK-MB - non-diagnostic EKG Culprit Lesion in LAD LV RV Perfusion Defect Myocardial Akinesis ± LV thrombus Cardiac Biomarkers Acute Chest Pain Without CT: 103 admitted Only 13% had ACS With CT: 29 admitted ( 72%) 48% had ACS 74 safely discharged Zimmermann, NEMJ 2000 TIMING IS IMPORTANT USA: ~1 in 10 admitted positive 14 ACS+ to 1 in 2? 6

7 Acute vs. chronic MI Chronic MI R/o Stenoses in Symptomatic Patients 486 acute chest pain patients in ER, low TIMI score Length of Hospital Stay n=1000 (501CTA, 40 to 74years) Courtesy U. Hoffmann 64 slice CT >5 minutes of CP <24h prior to ED presentation, SR 84% discharged home after normal CT No history of CAD No events in 30 days (vs. 7) 1 year (481 pts): 1 unclear death, no MI Mean LOS + SD (hrs) All CCTA 23.2 ± 37.0 Standard ED Eval 30.8 ± 28.0 p-value Final Dx not ACS 17.2 ± ± 19.5 < Final Dx ACS 86.3 ± ± Ann Emerg Med 2009 Acad Emerg Med 2009 Primary Outcome - Length of Hospital Stay Courtesy U. Hoffmann Secondary Endpoints - Safety 62% 8.6 hours 26.7 hours Safety Missed ACS (n, %) Peri-procedural Complications (n, %) CCTA N=501 0 (0) 2 (0.4) Standard ED Eval N=499 0 (0) 0 (0) p-value Follow-up at 28 days MACE (n, %) 2 (0.4) 5 (1.0) % Peri-procedural Complications Peri-operative bleeding after re-implantation of an anomalous coronary artery Increase in creatinine after renal stone and hydronephrosis 7

8 Costs of Care Costs* CCTA mean ± SD Standard ED Eval mean ± SD % Diff p-value ED # 2,053 ± 1,076 2,532 ± 1,346-19% < CTA for low risk Patients with Possible ACS N=1392 multicenter, randomized controlled study Outcome at Index visit Hospital 1950 ± 6,817 1,297 ± 5, % 0.17 Total 4,004 ± 6,907 3,828 ± 5,289 +5% 0.72 cost per pt (US$) in a subset of 650 pts from 5 centers # includes observation unit Litt et al, NEJM 2012, Mar 26. ACRIN CTA for low risk Patients with Possible ACS Outcome at 30 day f/u CT-STAT Prospective, comparative-effectiveness multicenter trial Randomization to CCTA (n = 361) or MPI (n = 338) Time to diagnosis 54% reduction CTA 2.9 h vs. MPI 6.3 h Costs of care 38% reduction CTA $2,137 vs. MPI $3,458 No difference in outcome/mace Litt et al, NEJM 2012, Mar 26. Goldstein,.., Raff. JACC. Sep CT for Systematic Triage of Acute Chest Pain Patients to Treatment Changes in Radiation Doses past 10 Years 61yof, BMI 31 Effective Dose 1.3 msv msv MGH Radiation Dose for ALL PATIENTS (all indications, BMI, includes ca-scoring, perfusion DE) 2005: 12.4 msv 2011: 3.6 msv Lowest dose: 0.3mSv cardiac CT chest CT SPECT cath Thallium s/r 8

9 Anomalous Coronary Arteries Malignant RCA Anomaly Ropers D et al, AJC 2001 Deibler AR et al, Mayo Clin Proc 2004 Datta J et al, Radiology 2005 van Ooijen PM et al, Eur Radiol 2004 Memisoglu et al, Cath Card Interv 2005 Manghat NE et al, Heart 2005 Schmid M et al, Int J Cardiol 2006 Ao PA R L Dodd JD et al, AJR 2007 N... and many case reports Yeon Hyeon Choe, MD, Samsung Medical Center, Seoul, Korea Other Coronary CTA Indications Coronary Anomalies 19 yom Kawasaki Disease Multiple RCA aneurysms Multiple Aneurysmosis Yeon Hyeon Choe, MD, Samsung Medical Center, Seoul, Korea B Desjardins, EA Kazerooni. AJR 2004; 182:

10 Atherosclerotic aneurysm Coronary Artery to Pulmonary Artery Fistula Miller, Boxt, Abbara. Cardiac Imaging - The requisites. 3 rd edition Miller, Boxt, Abbara. Cardiac Imaging - The requisites. 3 rd edition Bypass Grafts 10

11 Diagnostic Performance of 64 Slice Technology Vein graft Vein graft Diagonal branch Marginal branch Meyer et al. JACC 2007;49: Courtesy Koen Nieman Courtesy Koen Nieman 1/4 11

12 Graft Aneurysms 2/4 3/4 Graft Aneurysms Graft Aneurysms 4/4 Unusual Grafts Unusual Grafts 12

13 3/7/2013 Cardiomyopathy Diagnostic Accuracy of 16-cCT in DCM sensitivity, specificity, PPV, NPV Disease of the heart muscle (myocardium) Decreased ventricular pump function Systolic or diastolic dysfunction Decreased Ejection Fraction (EF) May have ischemic or non-ischemic causes DCM (n=61: 44 normal coronaries, 17 CAD): 99%, 96.2%, 81.2%, 99.8% 86.1%, 96.4% Control (n=139): 86.1%, 96.4%, Andreini et al. JACC, 49 (20): Diagnostic Accuracy of cct in DCM Ischemic DCM Case Idiopathic DCM 67 yom with history of nonischemic dilated cardiomyopathy Worsening of SOB over past months CT to exclude possibility of CAD Andreini et al. JACC, 49 (20):

14 3/7/2013 Utility of Cardiac CT in Concentric LV hypertrophy hypertensive cardiomyopathy HOCM SAM / Wall thickness / Fibrosis LV Non-compaction ARVD RV volume / function / aneurysms/ fatty infiltration Hemochromatosis Increased myocardial attenuation (non contr. CT) Sarcoidosis Patchy mesocardial / sub-epicardial DE Kanao et al. JCAT 2005:29:745-8 Williams TJ, et al. Clin Radiol Apr;63(4): Apical Hypertrophy Williams TJ, et al. Clin Radiol Apr;63(4): Midventricular Hypertrophy 14

15 Isolated Ventricular Noncompaction Distinct cardiomyopathy 2 intrauterine arrest of myocardial compaction Two layers of abnormal LV wall Thin compact epicardial layer Thick endocardial layer with prominent fine trabeculations and deep recesses Morbidity & mortality in young - middle aged Heart failure, thromboembolism, ventricular arrhythmia Oechslin et al. JACC 2000;36: Higher incidence of WPW in Japanese children Ichida et al. JACC 1999;34: LV Noncompaction Echo: ratio of >2.0 noncompacted / compacted myocardium in systole (Jenni et. al. HEART 2001;86:666-71) CMR: ratio of >2.3 in diastole Sensitivity 86%, Specificity 99% PPV 75%, NPV 99% (Peterson et. al. JACC 2005) LV non-compaction LV Noncompaction Ratio of trabeculated to compact myocardium 2.3 diagnostic Measurements must be orthogonal to LV wall Williams TJ, et al. Clin Radiol Apr;63(4): Thank You! SAbbara@Partners.org 15