1996 New Technologies for Cardiac CT Geoffrey D. Rubin, MD, MBA, FACR, FNASCI Duke University
New Technology The Long View Levels of Efficacy Endpoint Examples 1: Technical Imaging resolution 2: Diagnostic Accuracy Sensitivity/specificity 3: Diagnostic Thinking Pre- and post-test changes in subjectively determined outcome 4: Therapeutic Effects on choice of therapy 5: Patient Outcome Impact of test information on morbidity, mortality, and QALYs 6: Societal Cost-benefit/effectiveness for society Frybach & Thornbury. Med Decis Making 1991;11:88-94
Reporting Templates Cardiac CT CT Scanner Contrast Injector Advanced Visualization and Analysis Software
Reporting Templates Evidence Base Cardiac CT CT Scanner Contrast Injector Evidence Base Advanced Visualization and Analysis Software
So What s New in 2015? Acquisition Technologies Advanced Visualization/Analysis Evolution of Dual Source FFRCT Wide Area Detector CT Perfusion Maps Multi-layer detector for spectral Evidence Base CT ED Clinical Trials Contrast dose and delivery Stable chest pain trials Iterative Reconstruction FFRCT Trials
So What s New in 2015? Acquisition Technologies Advanced Visualization/Analysis Evolution of Dual Source FFRCT Wide Area Detector CT Perfusion Maps Multi-layer detector for spectral Evidence Base CT ED Clinical Trials Contrast dose and delivery Stable chest pain trials Iterative Reconstruction FFRCT Trials
So What s New in 2015? 3D Printing Information Technology Visualization ACRSelect decision support Planning Graft creation PACS, RIS, reporting system, EMR integration Image Sharing Transcatheter Valve Prostheses Aortic Mitral Univ College Dublin
Contrast Delivery Management System Centralized server PACS/RIS integration Protocol management Recording and archive of injection parameters Performance metrics for resource utilization, operations, safety
Dual-energy (spectral) CT Technologies Applications Dual source Contrast medium dose reduction Fast kv switching Metal artifact reduction Dual layer detector Material decomposition Serial single-energy scans Calcium iodine separation 4D Cardiac most challenging, but gains are being made
Dual-energy (spectral) CT Carrascosa et al, Eur J Radiol 2015
Dual-energy (spectral) CT Virtual Unenhanced True Unenhanced Virtual 50 kev Pinho et al, Eur Radiol 2013; 23:351
Dual-energy (spectral) CT Rodriguez-Granillo et al, Card Diagn Ther 2015; 5:79
Coronary CTA Evidence Base Acute Coronary Syndrome ROMICAT II high risk plaque predicts ACS independent of % stenosis Puchner et al, JACC 2014; 64:684 Chest pain in outpatients PROMISE SCOT-HEART PLATFORM
10,003 patients with new onset chest pain (not ACS) randomized to standard functional testing or CCTA Pragmatic trial design 64-row CT scanners CTA Functional CTA Strategy Strategy Strategy Nuclear CTA Stress 93.8% 67.5% 0.9% Stress Echo2.9% 22.4% 93.7% Patients followed for median of 2.0 (range 1.0-4.2) yrs. Exercise No Test ECG3.1% 10.2%% 4.9%
PROMISE Outcomes Primary Composite End Point Death (any cause) MI Hospitalized for unstable angina Major procedural complications
PROMISE Outcomes CT Strategy (N=4996) Functional-Testing Strategy (N=5007) P Value Primary Composite End Point 3.3% 3.0% 0.75 Cardiac Catheterization 12.2% 8.1% Catheterization showing no obstructive CAD 3.4% 4.3% 0.02 Revascularization 6.2% 3.2% <0.001
SCOT-HEART David Newby, PI Lancet 2015; 385: 2383 91 4,146 patients with chest pain randomized to standard care or standard care + CCTA Pragmatic trial design 64-row or 320-row CT scanners Patients followed for median of 1.7 (range 0.1-4.1) years
SCOT HEART: Invasive Procedures Median 1.7 Years of Follow-up Coronary Angiography Coronary Revascularisation 25 HR 1.06 [0.92-1.21], P=0.451 HR 1.20 [0.99-1.45], P=0.061 Proportion of patients with an event (%) 20 CTCA 15 10 5 Standard Care Proportion of patients with an event (%) 15 10 Cumulative incidence, % 5 15% 10% 5% CTCA Standard Care strata AllocatedTreatment=2 AllocatedTreatment=1 CTCA Standard Care 0 2073 1249 634 227 2073 1263 660 226 CTCA Standard Care 0 0% 2073 1386 733 270 2073 1413 755 276 0 500 1000 1500 Time, days 0 1 2 3 0 1 2 3 Follow Up Follow Up (years) (years)
SCOT Heart: Clinical Outcomes Median 1.7 Years of Follow-up CHD Death & Non-Fatal MI CHD Death, Non-Fatal MI & Stroke 5 5% HR 0.62 [0.38-1.01], P=0.053 5 5% HR 0.64 [0.41-1.01], P=0.056 Proportion of patients with an event (%) 4 3 2 1 Cumulative incidence, % 4% 3% 2% 1% Standard Care CTCA strata AllocatedTreatment=2 AllocatedTreatment=1 Proportion of patients with an event (%) 4 3 2 1 Cumulative incidence, % 4% 3% 2% 1% Standard Care CTCA strata AllocatedTre AllocatedTre 0 CTCA Standard Care 0% 2073 1571 853 323 2073 1550 837 316 0 500 1000 1500 Time, days 0 CTCA Standard Care 0% 2073 1569 851 321 2073 1547 835 315 0 500 1000 1500 Time, days 0 1 2 3 Follow Up (years) 0 1 2 3 Follow Up (years)
SCOT Heart: Conclusions Regarding CCTA Increases dx of CHD Does not affect short-term anginal symptoms May increase coronary revascularization (9.7 vs 11.2%, 1.5% increase) May reduce MI (1.3 vs 2.0%, 0.7% reduction)
398,978 pts w/ suspected CAD to Cath (663 U.S. hospitals over 4 years) 37.6% had obstructive CAD 39.2% were normal N Engl J Med 2010;362:886-95
Non-Obst. CAD Obstructive CAD No ICA PLATFORM Trial Eur Heart J. 2015 NI Test Planned ICA Planned Usual Care FFRCT Usual Care FFRCT 100% 100% Key Results 90% 90% FFRCT vs. U.C. 27% 80% 80% No No cath in 61% 70% 70% 73% events 60% 60% at 90 Same % (+) caths 50% 50% days 40% 40% 6x less (-) caths 30% 30% 27% 20% 12% 18% 20% No sig increase in 10% 10% 12% downstream cath 0% 0% n=100 n=104 n=187 n=193 P = 0.95 P < 0.0001
Summary Cardiac CT Technology Think Long Think Broad Think Value patient imager
Technology I Want to be Discussing Heart rate independent cardiac motion-free acquisition Automated optimized protocol definition based on CT measured biometrics (wt, body contour/composition, HR, ) Comprehensive preprocessing with integrated volume rendering, MPR, & annotated quantization of stenosis and plaque character. Automated prior exam analysis for assessment of all non-normal findings Comprehensive intuitive data display with pre-population of reporting template