coronary ct angiography: state of the art

3/7/2013

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Cardiac CT - State of the Art

Suhny Abbara, MD

Associate Professor of Radiology, Harvard Medical School

Director, Cardiovascular Imaging Fellowship, Massachusetts General HospitalDirector of Education, MGH Cardiac MRCT Program

[email protected]

Suhny AbbaraThomas J BradyRajiv GuptaUdo Hoffmann Mannudeep Kalra Fred Mamuya Ahmed Tawakol

Ricardo Cury Stephan AchenbachShawn Teague

Maros Ferencik Leon Shturman Ron BlanksteinAndrew BlumBrian GhoshharjaIan Rogers Quynh TruongRicardo BenensteinMat GilmanNikhil GoyalTerry HealySeth Kligerman

MGH Cardiac CT Program - Acknowledgement

Jonathan DoddFabian Bamberg Carolyn TaylorChun-Ho (Leo) YunDavid OkadaKhuram NasirJohn NicholsChristopher SchlettAmit MehndirattaSanjeeva Kalva

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

Contrast not FDA approved for coronary CTA

Why ?Cardiac CT

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

N Engl J Med. 2010 Mar 11;362(10):886-95

• 2004 – 2008

• 663 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 …

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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

vs.

MDCT Invasive angio

17/18 segments / per artery / per patient analysis

+/- Non-evaluable segments (calcium, motion)

Accuracy values: sensitivity, specivity, PPV, NPV

Accuracy for Stenosis Detection

S Achenbach

Reasons for Non Evaluability

extensive calcification motion artifact

JACC. 2006;48;1896-1910

27 studies

N=2024 pts

16, 32, 40, 64-slice

Prevalence of CAD: 63%

4.2% non-evaluable

�excluded

Meta-analysis

Pooled Specificity 0.93

Pooled Sensitivity 0.81

64-slice:Sensitivity 87%Specificity 96%Very high NPV

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Accuracy for Stenosis Detection

64 Slice CT Meta Analyses

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%

PER PATIENT 99% 89% 100% 93%

High negative predictive value

Positive predictive value not quite as highS Achenbach

International Multicenter Trial (MEDIC)

• 6 internat. sites, n=415,

• 30-80 year old Pts

– intermediate likelihood for coronary stenosis

– scheduled for invasive angiography

• � DSCT prior to cath

• Agatston score >800 excluded

• No beta blockers, spiral mode

• Blinded central core laboratory readings

• 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

Who?

How scanned?

How analyzed?

cCTA vs. “subsequent PCI (n = 71) or bypass surgery (n=12)”:Sensitivity = 95% (83/87) Specificity = 91% (299/328) PPV = 74% (83/112)NPV = 99% (299/303)CT did not predict revascularization 4 times (all single vessel disease):2 x LAD stenoses < 50% in QCA1 x peripheral LAD stenosis 1 x diagonal branch lesion


Results

Mean radiation dose: 5.9 mSv

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 Achenbach,, Abbara, et al. SCCT 2012, Baltimore, MD

Heart Rate n Sensitivity Specificity PPV NPV

All 41596%

(106/111)95%

(289/304)88%

(106/121)98%

(289/294)

≤ 60 14598%

(42/43)95%

(97/102)89%

(42/49)99%

(97/98)

> 60-75 27094%

(64/68)95%

(193/203)87%

(64/74)98%

(193/197)

> 75 92100%

(25/25)94%

(67/71)86%

(25/29)100%

(67/67)


Accuracy by heart rate - no difference

Multi-Center Accuracy Trials (Stenosis) by CT

Per patient analysiscCTA vs QCA, stenoses > 50%

1 Budoff et al, JACC 2008; 2 Meijbom et al, JACC 2008 ; 3 Miller et al, NEJM 2008

n Sensitivity Specifity NPV Prevalence

ACCURACY1 230 95% 83% 99% 25%

Meijboom2 360 99% 64% 96% 68%

CORE 643 291 85% 90% 83% 56%

Prediction of Revascularization

Miller et al. New Engl J Med 2008;359:2324-36

within 30days of cath

MDCT: AUC=0.84QCA: AUC=0.82

Unevaluable � NEGATIVE

CORE-64 Multicenter Trial

per patient analysis

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Diagnosis of obstructive CAD

Test Sensitivity Specificity

Exercise ECG treadmill1 68% 77%

Exercise Echo treadmill2 86% 81%

Dobutamine Echo2 ~85% ~85%

Exercise nuclear treadmill3 87% 73%

Pharmacologic nuclear3 89% 75%

Cardiac CTA4 95% 83%

1. ACC/AHA 2002 Guideline Update for Exercise Testing2. ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography

3. ACC/AHA/ASNC Guidelines for the Clinical Use of Cardiac Radionuclide Imaging4. ACCURACY study, presented at 2008 ACC Scientific Sessions

Imperfect Gold Standard?

Courtesy Stephan Achenbach, MD

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

R/o Stenoses in Symptomatic Patients

Am J Cardiol 2007

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

„Close to Zero“ event rate after ruling out coronary stenoses by CT in symptomatic patients

CT is good at ruling out,

But not at predicting ischemia.

Correlation to Ischemia

Coronary CT angiography

normal � no coronary

stenosis

Coronary CT shows stenosis

� not necessarily ischemia

Min et al. J Am Coll Cardiol 2007;50:1161-70

controlled for age, family history, dyslipidemia, (not calcium score)Endpoint: all cause mortality

Prognostic Value of cCT >50% stenosis

n = 1127

Years after CT

0.85

0.95

0.90

1.00

Cu

mu

lati

ve S

urv

ival

1.5

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CONFIRM Registry (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry)

Subjects Without Chest Pain Syndrome

Cho, … Min. Circulation 126(3), 17 July 2012

Risk-adjusted event-free survival after CTA

***Even if we don’t find obstructive disease,

the total amount of disease and number of vessels affect survival and number of events.****

CAD stratified by severity of disease and number of diseased arteries

Symptomatic Pts

N= 2,538

Ostrom , …, Budoff. J Am Coll Cardiol 2008;52:1335-1343

Acute Chest Pain

ED 130 million ED visits

8 mil chest pain

Dis

charg

e

40,000 MI

3 million �“non cardiac”

5 million “Rule Out” cardiac cause

Work

up

+/-

CT

?

54♂ 3 h substernal pain, pain relief after nitronegative 1st Troponin / CK-MB - non-diagnostic EKG

54♂ 3 h substernal pain, pain relief after nitro

negative 1st Troponin / CK-MB - non-diagnostic EKG

RCALAD Occlusion

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Functional Information from Cardiac CT

Perfusion Defect

RV

LV

54♂ 3 h substernal pain, pain relief after nitro

negative 1st Troponin / CK-MB - non-diagnostic EKG

Myocardial Akinesis

± LV thrombus

Culprit Lesion in LAD

Cardiac BiomarkersCardiac Biomarkers

TIMING IS IMPORTANT

Zimmermann, NEMJ 2000

Acute Chest Pain

14 ACS+

Without CT:103 admittedOnly 13% had ACS

USA:~1 in 10admitted positive

With CT:29 admitted (↓72%)48% had ACS74 safely discharged

↓to 1 in 2?

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Acute vs. chronic MI Chronic MI

486 acute chest pain patients in ER, low TIMI score

64 slice CT

84% discharged home after normal CT

No events in 30 days (vs. 7)

1 year (481 pts): 1 unclear death, no MI

Ann Emerg Med 2009Acad Emerg Med 2009

R/o Stenoses in Symptomatic Patients Length of Hospital Stay

Courtesy U. Hoffmann

Mean LOS + SD (hrs)

CCTA Standard ED Eval

p-value

All

Final Dx not ACS

Final Dx ACS

23.2 ± 37.0

17.2 ±24.6

86.3 ±72.2

30.8 ± 28.0

27.2 ± 19.5

83.8 ±61.3

0.0002

<0.0001

0.87

• n=1000 (501CTA, 40 to 74years)

• >5 minutes of CP <24h prior to ED presentation, SR

• No history of CAD

Primary Outcome - Length of Hospital Stay

8.6 hours 26.7 hours

62%

21%

Courtesy U. Hoffmann

Secondary Endpoints - Safety

CCTAN=501

Standard ED EvalN=499

p-value

SafetyMissed ACS (n, %) Peri-procedural Complications (n, %)

0 (0)2 (0.4)

0 (0)0 (0)

-

0.25

Follow-up at 28 daysMACE (n, %) 2 (0.4) 5 (1.0) 0.37

Peri-procedural Complications

• Peri-operative bleeding after re-implantation of an anomalous coronary artery• Increase in creatinine after renal stone and hydronephrosis

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•cost per pt (US$) in a subset of 650 pts from 5 centers

# includes observation unit

Costs of Care

Costs*CCTA

mean ±±±± SDStandard ED Eval

mean ±±±± SD% Diff p-value

ED# 2,053 ±±±± 1,076 2,532 ±±±± 1,346 -19% <0.0001

Hospital 1950 ±±±± 6,817 1,297 ±±±± 5,316 +50% 0.17

Total 4,004 ±±±± 6,907 3,828 ±±±± 5,289 +5% 0.72

CTA for low risk Patients with Possible ACS

• N=1392 multicenter, randomized controlled study

Litt et al, NEJM 2012, Mar 26. ACRIN

Outcome at Index visit

CTA for low risk Patients with Possible ACS

Litt et al, NEJM 2012, Mar 26.

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

Goldstein,.., Raff. JACC. Sep 2011. CT for Systematic Triage of Acute Chest Pain Patients to Treatment

Changes in Radiation Doses past 10 Years

0

5

10

15

20

25

30

35

40

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

cardiac CT chest CT SPECT

cath Thallium s/r

mSv

61yof, BMI 31 � Effective Dose 1.3 mSv

MGH Radiation Dose for ALL PATIENTS (all indications, BMI, includes ca-scoring, perfusion DE)

2005: 12.4 mSv2011: 3.6 mSv

Lowest dose: 0.3mSv

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AnomalousCoronaryArteries

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

Dodd JD et al, AJR 2007

... and many case reports

Malignant RCA Anomaly

R

L

N

AoPA

Yeon Hyeon Choe, MD, Samsung Medical Center, Seoul, Korea

Other Coronary CTA IndicationsCoronary Anomalies

19 yom

Kawasaki Disease

Yeon Hyeon Choe, MD, Samsung Medical Center, Seoul, Korea

Multiple RCA

aneurysms

Multiple Aneurysmosis

B Desjardins, … EA Kazerooni. AJR 2004; 182:993-1010

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Atherosclerotic aneurysm

Miller, Boxt, Abbara. Cardiac Imaging - The requisites. 3rd edition

Coronary Artery to Pulmonary Artery Fistula

Miller, Boxt, Abbara. Cardiac Imaging - The requisites. 3rd edition

Bypass Grafts

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Diagnostic Performance of 64 Slice Technology

Meyer et al. JACC 2007;49:946-50

Vein graft

Vein graft

Marginal branch

Diagonal branch

Courtesy Koen Nieman

Courtesy Koen Nieman 1/4

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2/4 3/4

Graft Aneurysms

4/4

Graft Aneurysms Graft Aneurysms

Unusual Grafts Unusual Grafts

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Cardiomyopathy

• 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

sensitivity, specificity, PPV, NPV

• DCM (n=61: 44 normal coronaries, 17 CAD):

– 99%, 96.2%, 81.2%, 99.8%

• Control (n=139):

– 86.1%, 96.4%, 86.1%, 96.4%

Andreini et al. JACC, 49 (20): 2044 - 2050

Diagnostic Accuracy of 16-cCT in DCM

Diagnostic Accuracy of cCT in DCM

Ischemic DCM Idiopathic DCM

Andreini et al. JACC, 49 (20): 2044 - 2050

Case

• 67 yom with history of nonischemic dilated

cardiomyopathy

• Worsening of SOB over past months

• CT to exclude possibility of CAD

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Utility of Cardiac CT in

• 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

Concentric LV hypertrophy hypertensive cardiomyopathy

Williams TJ, et al. Clin Radiol. 2008 Apr;63(4):464-74.

Apical Hypertrophy


Midventricular Hypertrophy

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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;36:493-499

• Higher incidence of WPW in Japanese children

Ichida et al. JACC 1999;34:233-40

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 Noncompaction

LV non-compaction

• Ratio of trabeculated to compact myocardium ≥ 2.3 diagnostic

• Measurements must be orthogonal to LV wall


LV Noncompaction

Thank You!

[email protected]

coronary ct angiography: state of the art

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