CT CORONARY CT CORONARY ANGIOGRAPHY ANGIOGRAPHY INDICATIONSINDICATIONS

Wednesday 19/10/11Wednesday 19/10/11

Dr Alistair BeggDr Alistair BeggSA Heart Ashford HospitalSA Heart Ashford Hospital

CT CORONARY CT CORONARY ANGIOGRAPHYANGIOGRAPHY

CT CORONARY CT CORONARY ANGIOGRAPHYANGIOGRAPHY

CT CORONARY CT CORONARY ANGIOGRAPHYANGIOGRAPHY

CT CORONARY CT CORONARY ANGIOGRAPHYANGIOGRAPHY

CT CORONARY CT CORONARY ANGIOGRAPHYANGIOGRAPHY

INDICATIONSINDICATIONS

Noninvasive Noninvasive Coronary Artery Coronary Artery Imaging:Imaging:

Current Clinical Current Clinical ApplicationsApplications

Cardiac Society of Cardiac Society of Australia and New Australia and New Zealand GuidelinesZealand Guidelines

Heart Lung and Heart Lung and Circulation July 2011Circulation July 2011

Appropriate Appropriate indications indications 1.Chest pain 1.Chest pain

evaluation – evaluation – intermediate intermediate pretest probability pretest probability of CAD where the of CAD where the patient is unable patient is unable to exercise or the to exercise or the ecg is ecg is uninterpretable eg uninterpretable eg LBBBLBBB

Normal coronary Normal coronary arteriesarteries

Appropriate Appropriate indicationsindications 2.Chest pain evaluation-2.Chest pain evaluation-

uninterpretable or equivocal uninterpretable or equivocal stress test or stress imagingstress test or stress imaging

Appropriate Appropriate indicationsindications 3.Evaluation of chest pain (ED) if 3.Evaluation of chest pain (ED) if

intermediate pretest probability intermediate pretest probability with no ecg changes or cardiac with no ecg changes or cardiac enzyme elevationenzyme elevation

Tight LAD stenosisTight LAD stenosis

Appropriate Appropriate indicationsindications 4.Evaluation of suspected 4.Evaluation of suspected

coronary anomaliescoronary anomalies

Left main arising from Left main arising from RCARCA

Appropriate Appropriate indicationsindications 5.Evaluation of CAD in new onset 5.Evaluation of CAD in new onset

heart failureheart failure

Appropriate Appropriate indicationsindications 6.Assessment of complex 6.Assessment of complex

congenital heart disease congenital heart disease especially in regards to both especially in regards to both coronary/great vessels and coronary/great vessels and cardiac chambers and valvescardiac chambers and valves

Atrial switch operation Atrial switch operation (Mustard operation)for (Mustard operation)for transposition of great transposition of great arteriesarteries

Appropriate Appropriate indicationsindications 7.Evaluation of pulmonary vein 7.Evaluation of pulmonary vein

anatomy prior to radiofrequency anatomy prior to radiofrequency ablation for atrial fibrillationablation for atrial fibrillation

Appropriate Appropriate indicationsindications 8.Coronary vein mapping prior to 8.Coronary vein mapping prior to

placement of biventricular placement of biventricular pacemaker pacemaker

Appropriate Appropriate indicationsindications 9.Repeat CABG – internal 9.Repeat CABG – internal

mammary artery and coronary mammary artery and coronary artery mappingartery mapping

Appropriate Appropriate indicationsindications 10.Technically difficult or limited 10.Technically difficult or limited

images from echocardiogram or images from echocardiogram or MRI in particular relating to MRI in particular relating to cardiac masses ( tumour or cardiac masses ( tumour or thrombus) and evaluation of thrombus) and evaluation of pericardial conditions pericardial conditions (mass,pericarditis,post cardiac (mass,pericarditis,post cardiac surgery)surgery)

Appropriate Appropriate indicationsindications 11.Preoperative coronary 11.Preoperative coronary

assessment prior to noncoronary assessment prior to noncoronary cardiac surgery.The CTA finding cardiac surgery.The CTA finding of a stenosis > 50% or highly of a stenosis > 50% or highly calcified plaque that precludes calcified plaque that precludes assessment of stenosis severity assessment of stenosis severity will necessitate invasive coronary will necessitate invasive coronary angiographyangiography

Appropriate Appropriate indicationsindications 12.Cardiac transplant follow up12.Cardiac transplant follow up

INappropriate INappropriate indicationsindications 1.Asymptomatic patients1.Asymptomatic patients

INappropriate INappropriate indicationsindications

2.High pretest probability including 2.High pretest probability including positive stress testspositive stress tests

INappropriate INappropriate indicationsindications 3.Positive cardiac enzymes or ST 3.Positive cardiac enzymes or ST

elevation on ECGelevation on ECG

INappropriate INappropriate indicationsindications 4.Instent evaluation especially 4.Instent evaluation especially

stents <3.0mmstents <3.0mm

Special situationsSpecial situations- Emergency department - Emergency department chest painchest pain

>60% ED chest pain is noncardiac>60% ED chest pain is noncardiac Numerous studiesNumerous studies Show high NPV 97-100%Show high NPV 97-100% Show poor PPV 47-52%Show poor PPV 47-52% Versus nuclear imageing is Versus nuclear imageing is

faster/cheaper/less repeat faster/cheaper/less repeat presentationspresentations

Excellent negative Excellent negative predictive valuepredictive value

Special situationsSpecial situationsCoronary stentsCoronary stents CORE 64 trial showed PPV 57% CORE 64 trial showed PPV 57%

and NPV 80% if stent <3.0mmand NPV 80% if stent <3.0mm If left main stent > 4.0mm is 98% If left main stent > 4.0mm is 98%

accurateaccurate Routine use of CTCA for instent Routine use of CTCA for instent

restenosis NOT recommendedrestenosis NOT recommended

Special situationsSpecial situationsCoronary bypass Coronary bypass graftsgrafts Excellent accuracy for graftsExcellent accuracy for grafts 100% NPV100% NPV 92%PPV92%PPV Native coronaries very calcified Native coronaries very calcified

and diseased,hard to quantitateand diseased,hard to quantitate Useful if invasive angiography has Useful if invasive angiography has

failed to assess a graft or patencyfailed to assess a graft or patency Can use to plan repeat CABGCan use to plan repeat CABG

Coronary bypass Coronary bypass graftsgrafts

Special situationsSpecial situationsChronic total Chronic total occlusions occlusions Useful to assessUseful to assess Chronic total occlusion if Chronic total occlusion if

considering PCIconsidering PCI Assess occlusion Assess occlusion

length,stump,calcificationlength,stump,calcification

Diagnostic accuracyDiagnostic accuracy

Better if segments > 2.0mm Better if segments > 2.0mm diameterdiameter

Better for left main 91-100% sens Better for left main 91-100% sens and 100% specificand 100% specific

Worse for mid- RCA 81% sens 95% Worse for mid- RCA 81% sens 95% spec spec

100% NPV if low-medium risk group100% NPV if low-medium risk group 89% NPV if high pretest probability89% NPV if high pretest probability

Diagnostic accuracyDiagnostic accuracy

Diagnostic accuracyDiagnostic accuracy

Diagnostic accuracyDiagnostic accuracy

Diagnostic accuracyDiagnostic accuracy

Diagnostic accuracyDiagnostic accuracy

Heart 2010;96:1973-19Heart 2010;96:1973-19

Cost effectiveness of Cost effectiveness of CTCACTCA MSAC (medical services advisory MSAC (medical services advisory

committee) advised that based on committee) advised that based on cost of $3035 invasive vs $1020 cost of $3035 invasive vs $1020 noninvasive coronary noninvasive coronary angiographyangiography

Cost effective strategy if Cost effective strategy if symptomatic and up to 65% symptomatic and up to 65% pretest risk of CAD pretest risk of CAD

Preparation for CTCAPreparation for CTCA

Recent UEC to avoid nephrotoxicityRecent UEC to avoid nephrotoxicity Aim HR 50-55 by giving Metoprolol 50 mg Aim HR 50-55 by giving Metoprolol 50 mg

night before and 50 mg morning of scannight before and 50 mg morning of scan Fast 4 hours,avoid caffeine on day of testFast 4 hours,avoid caffeine on day of test Atrial fibrillation should be treated ? Atrial fibrillation should be treated ?

Cardiovert before , and ideally avoided for Cardiovert before , and ideally avoided for CTCACTCA

Usually no sedation requiredUsually no sedation required

CT CORONARY CT CORONARY ANGIOGRAPHYANGIOGRAPHY

CT CORONARY CT CORONARY ANGIOGRAPHYANGIOGRAPHY

Medicare rebateMedicare rebate

57360       57360       

COMPUTED TOMOGRAPHY OF THE CORONARY ARTERIES COMPUTED TOMOGRAPHY OF THE CORONARY ARTERIES performed on a minimum of a 64 slice (or equivalent) performed on a minimum of a 64 slice (or equivalent) scanner, where the request is made by a specialist or scanner, where the request is made by a specialist or consultant physician, and: consultant physician, and:

a)     the patient has stable symptoms consistent with coronary a)     the patient has stable symptoms consistent with coronary ischaemia, is at low to intermediate risk of coronary artery ischaemia, is at low to intermediate risk of coronary artery disease and would have been considered for coronary disease and would have been considered for coronary angiography; or angiography; or

b)     the patient requires exclusion of coronary artery anomaly b)     the patient requires exclusion of coronary artery anomaly or fistula; or or fistula; or

c)     the patient will be undergoing non-coronary cardiac c)     the patient will be undergoing non-coronary cardiac surgery surgery

Radiation safetyRadiation safety

Radiation safetyRadiation safety

Radiation safetyRadiation safety

SummarySummary

CT CORONARY CT CORONARY ANGIOGRAPHYANGIOGRAPHY

CT CORONARY CT CORONARY ANGIOGRAPHYANGIOGRAPHY Questions and comments?Questions and comments?