Calcium Scoring and Cardiac CT John C. Finley, MD, FACC, FASE Medical Director, CT Department; Alaska Heart and Vascular Institute February 9, 2018
1. Calcium Scoring 2. CT Coronary Angiography 3. Use in EP Procedures 4. TAVR 5. Evaluation of valves 6. Functional and ischemia testing 7. Congenital disease, masses 8. Future uses: Mitral valve percutaneous procedures
I HAVE ENTHUSIASM ABOUT CALCIUM SCORING Yet I seldom order the test. Why not? (A test question for the audience)
EBCT and CALCIUM SCORING Supermarkets in southern California Later analysis by the larger community of physicians Acceptance of calcium scoring by reputable organizations Varying proposals as to its use
IT IS A MEDICAL TEST 1. Ordered by a provider 2. Serves a purpose in diagnosis and/or treatment of an individual. 3. The perceived risk of the test is outweighed by the benefit. 4. In this day and age, cost may be a consideration.
PROCESS OF ATHEROSCLEROSIS Fatty/ cholesterol infiltration Inflammation Placque formation Scarring Calcification
MYOCARDIAL INFARCTION..\Pictures\pic MI.jpg
PLAQUE RUPTURE VULNERABLE PLAQUE When? Where? Why?
WHAT DOES THE CALCIUM SCORE REFLECT? Not really a risk factor but a manifestation of well/long established disease Is a marker for overall severity of atherosclerotic disease Not surprisingly, the more calcium, the more likely the individual is to have a manifestation of the disease in the future
ARTHUR AGATSTON The calcium score is based upon measurement of how densely calcified and of how much calcification is found on a low-radiation CT scan of the heart. This value is reproducible and the same from place to place
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WHY NOT DO A CORONARY CALCIUM SCORE? No reason to do one if atherosclerosis already is diagnosed; the person already falls into the high risk category There is a small amount of radiation involved The cost is $105 hereabouts. Some insurers pay for it
CALCIUM SCORES IN 55 YEAR OLD PERSON 1-10 minimal disease 11-100 moderate disease 101-400 increased risk >400 extensive disease >1,000 25% probability of myocardial infarction within 1 year
survival and Ca score.jpg
APPROVED REASONS TO DO A CORONARY CALCIUM SCORE? (Depends on who you ask) ACC/AHA: may be appropriate in asymptomatic, intermediate or high risk patients (Wolk, Michael et al JACC 2014;63:380-406) Possibly CAC may be helpful in trying to exclude significant disease in low risk patients with atypical symptoms : very unlikely someone with a score of 0 has significant disease Some advocate use as part of an initial risk assessment evaluation
ACC/AHA 2013 Lipid Guidelines CAC>300 or CAC>75th% when adjusted for age and gender suggests statin therapy needed (Stone, Neil et al. JACC 2014;63:2890-2932)
PRESENTLY NOT VIEWED AS HELPFUL: Serial studies Use in established coronary disease
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Cath Correlation Cath View Stenosis in proximal RCA 76-year-old female. Cath View Two stenotic lesions in LAD and circumflex.
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Suspected CAD (with no beta blockers) 67-year-old male patient complaining of chest discomfort with a family history of heart disease. 3D view clearly showing patent LAD as well as obtuse marginals. Patent RCA in volume rendered 3D view Patent circumflex as well as outstanding visualization of the coronary sinus Vessel probed view of the circumflex confirming no apparent lesions.
Chest Pain Left main- Distal heterogeneous calcified and noncalcified lesion. Volume-rendered view showing apex of heart LAD- Proximaltird with irst diagonal artery 74-year-old male with chest pain and shortness of breath RCA- Proximal occlusion, distal RCA supplied by a branch from the first marginal Patient diagnosed with severe arteriosclerosis. Referred for bypass and drug therapy.
Mildly Aberrant L Main CA
20% LAD Stenosis
Anomalous RCA 36-year-old female who has chest pain when exercising. Confirmed with stress echo Cath correlation demonstrating RCA anomaly RCA seen arising from left coronary sinus and tracks on front of the aorta, behind the pulmonary trunk. Volume rendered view showing anomaly very easily Potentially fatal congenital abnormality easily viewed on Aquilion Cardiac CT
Dual Stent Follow-up 73-year-old male with two stents placed prior to CT. Precise stent placement produces appearance of single stent upon quick inspection. Exam completed in 11 second breath-hold and 100ml of contrast. Volume rendered 3D image allowing visualization and localization of calcium (white) and stent (blue) Curved planar reformats of entire LAD. Patent stent lumen and area of non-calcified plaque with stenosis can be easily visualized distal to the two stents. VR and Orthogonal CPR images of LAD providing assessment and localiztaion of stenosis and calcified plaque distal to the two stents CPR of the two stents. Note that the edges are touching.
Coronary Occlusion Bypass Graft Heart rate at 100bpm throughout study. Distal graft (mammary artery) from aorta to distal LAD. Occluded from its origin. Patient referred for revascularization. 72-year-old male Proximal graft (saphenous vein) open.
Atrial Mass Assessment 46-year-old female. Several presyncol episodes after a change in position. Several episodes of sharp left-side chest pain, most recently five days prior to admission. Patient referred for CTA after atrial mass noted on ultrasound. Multiphase CT confirms finding. Found to be benign myxoma. Patient underwent successful surgical resection of the left atrial myxoma No evidence of significant obstructive coronary disease or extra-luminal arteriosclerosis
Congenital Defect Follow-up of Fontan circulation operation (inferior vena cava attached to pulmonary vein) RCA seen arising from left coronary sinus and tracks on front of the aorta, behind the pulmonary trunk. Fontan circulation follow-up 31-year-old male with one ventricle During the operation, surgeons left metal epicardic electrodes for future application of pacemaker. Fistula of the right coronary artery and a mild aortic coarctation
Kawasaki Disease Follow-up (pediatric) Contrast 100cc, heart rate 81bpm No aneurysm seen with Aquilion in any of the coronaries 14-year-old female Rotating Volume Rendered View
Descending Thoracic Aorta
INDICATIONS FOR CT CORONARY ANGIOGRAM 1. First line test in chest pain with intermediate likelihood of CAD. 2. Inconclusive stress test 3. Continued chest pain without explanation despite prior stress test result 4. Clarify findings of invasive angiogram 5. R/O CAD in cardiomyopathy, valve surgery in young person
MORE INDICATIONS FOR CCTA 6. To exclude disease instead of doing an invasive coronary angiogram 7. Acute chest pain in the ED 8. To evaluate possible coronary anomalies 9. To evaluate patency of bypass graft or of stent 10. Post-transplant follow up. 11. In future: to evaluate vulnerable plaque
2013 ACCF/AHA Appropriate use Criteria (CCTA) 1. Intermediate probability CAD and uninterpretable ECG or unable to exercise 2. Non-Diagnostic or abnormal exercise ECG or stress test within prior 90 days 3. Continued concern for CAD with normal or abnormal treadmill testing or abnormal stress imaging 4. New diagnosis systolic congestive heart failure JAMA Vol 63, No. 4, 2014
WHY NOT DO CARDIAC CT? 1. High likelihood of needing cardiac intervention requiring invasive angio 2. Renal disease (contrast) 3. Rapid or irregular heart rate (decreased likelihood of good study) 4. Weight may be an issue 5. Young women a consideration
PROSPECTIVE GATING Z Sun: Cardiovascular Diagnosis and Therapy
Prospective Gating Z Sun: Cardiovascular Diagnosis and Therapy
Helical Scannng
256 slice 256 slice scanner
https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&r etmode=ref&cmd=prlinks&id=22300689
Age Counts Peck, Donald and Samel, Ehsan (ACR)
Cardiac Test Doses (historically) https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pu bmed&retmode=ref&cmd=prlinks&id=22300689
Effective Radiation Doses Past 20 Calcium Scores AVERAGE DOSE: 0.5 msv RANGE of DOSES: 0.1-1.3 msv Average dose for PET/CT stress test 2.8 msv
RADIATION
FLASH
o.7 msv coronary angiogram
FLASH
Myocardial Perfusion Scan
FUNCTIONAL IMAGING func
INDICATIONS FOR CARDIAC CT 1. Pre-ablation therapy to evaluate L.A. when cardiac MR is contraindicated. 2. Intracardiac mass. 3. Congenital heart disease 4. Pre-operatively to assist surgeon (Ex: past RIMA; where is it) 5. Pericardial disease
Pulmonary Vein Ablation Therapy Heart rate 90bpm. CT saved hours off pulmonary vein ablation planning. Easy-to-measure pulmonary veins and ostiums. Use of CT for pulmonary vein ablation therapy planning. Interior view of pulmonary veins. Volume rendering of pulmonary veins.
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MORE RECENT INDICATIONS New Interventional Cardiology Options: TAVR Mitra-Clip Interventional Mitral and Tricuspid valve replacement is coming.
Aortic Valve Stenosis
Distance to Coronary Artery
75cc Fast Pre-TAVR Studies
Thrombus 1 year p-tavr
Same case
Mitral Bioprosthesis
Mitral Bioprosthesis in Diastole
Abbott Mitra-Clip
CTA vs Echo: ECHO: Has Doppler. Moving images. No radiation. No IV. More available CT: Images very detailed. Can image coronary arteries Can manipulate images later. Is always a 3-D image Sees more than just the heart. Can quantitate calcium.
CT versus MRI MRI Time consuming, uncomfortable, single slices. Can t use with some metal devices. Subspecialized. Can evaluate flow. Doesn t give ionizing radiation. Gold standard for RVEF, evaluation of infiltrative disease, scar, viability. CT A brief experience for patient. More easily available. A permanent 3 D image which can be manipulated later Can t determine flow. Does give radiation. X-ray contrast allergy possible Both give contrast which is potentially nephrotoxic
SUMMARY 1. Calcium Scores 2. CT coronary angio 3. EP applications 4. Interventional Cardiology uses 5. Evaluation of valves, congenital disease, masses 6. Functional studies 7. Coming: Studies for ischemia 8. New scanners provide lower dose radiation