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? Clinical Applications of Coronary CT Computed Angiography:?.
- Wednesday, April 27, 2022 Zoom meeting
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Introduction
- Good morning
- Honor
- Thanks
- Ravin –
- Go back along way
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- Nail on the Head
- Two of the disciplines that have inspired me and made my career so rewarding
- Heart
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- remarkable anatomy physiology
- Has intrigue adventure drama and romance
- Unlike the brain that just sits and thinks
- the heart moves -it has rhythm it has sound
- Shakespeare mentions it more than 1200 times
- We celebrate it and what it means to people every year on Valentine’s day
- My Teachers Go back a long way
- Ongoing pursuit to find the underlying principles that govern complexity
- Parts
- Size
- Shape
- Position
- Character
- Time
- The Common Vein
- Whichever technology is able to fulfill these elements wins the prize
- And I believe it is CT(at least for the diagnosis of CAD) and and I hope to convince you too
- Ongoing pursuit to find the underlying principles that govern complexity
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- CT scan and I also go back a long way
- were born just 6 years apart
- Nail on the Head
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- It was advent of CT and its application that inspired me to
- hang up my triple headed Tycos
At the time the perception of radiology was that
Working in a Dark Room
Subjectivity Dominated
But even in that world it gave birth to people like Dotter, Seldinger and Judkins
However it was my introduction to CT that sold Radiology to me
Nietsche – German philosopher
Believer in Perspectivism
Mother in Law Rosalie Fisher – Physicist
Looking at the the Pixel/Voxel from Many Angles
Gave numbers to the pixels
(just like the the 0 and 1 of computer science)
Enabled Objectivity – Ability to Accurately Measure
Applying the Segmental Approach to Complex Structures
So for example looking at these liver cells
Cell Size 10 to 100 µm
And most of the time in clinical practice we use subjectivity
and on that basis we give the structure under evaluation
In the world of digital technology the cell = the pixel/voxel = about 1mm
The pixel has a number embedded within it
This methodology is therefore able to provide objectivity, enabled by better measurement provided by better tools (computer algorithms)
- CT scan
- because of the nature of its acquisition
- it has the element of objectivity
Familiar to all is the Hounsfield Number relating to the density
Blooming Artifact
At the Vessel Level
- Coronary Artery
- diameter 3-4mm
- wall thickness ranges from 0.55 to 1.0 m
- intima and adventitia.2mm – .3mm
- … and the vessels is moving
Subjectivity
Consensus in the Trials
- ACCURACY, Core-64 multicenter Study, CONFIRM Study, PROMISE Study, SCOT Heart Study Summary
- revealed that we had a tool with high sensitivity and low specificity
- However over over the last 10 years or so we have developed new tools that are able to enhance and better use the information within the voxels which are
- readily applied because of the innate and sound basis of the digital acquisition of the information
- Advances include
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- improved resolution
- reduced radiation
- faster times of acquisition
- computational algorithms that are able to
- infer function from structure (FFR CT )
- methodology to characterize the tissues in the arterial wall
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using the digital information inside the voxels
The New Tools – “Game Changers”, “Paradigm Shift”
- Faster Acquisition –
- 256 to 320- 640 detectors
- 640-slice CT scanner can image the entire heart in less than one third of a second
- 256 to 320- 640 detectors
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- 640 slice CT scanner uses 80% less radiation
- Computerized Algorithms and AI
Calcium Score and Coronary CTA
- Acceptance and Recommendations by the Societies
- Class 1 recommendations
- 2016 Britain
- 2019 Europe
- ESC guideline
- 2021 US
- Class 1 recommendation
- patients with stable and acute chest pain
- (Narula J, et al 2021 Expert Consensus Document)
- Class 1 recommendation
Fractional ?ow reserve derived from CT – FFR CT
- Normal = 1.0
- Abnormal <0.75-0.80
- generally considered to be associated with myocardial ischemia
CT Perfusion
- CT Perfusion
- Core 320 Study Summary
- core 320 study Pub Med Link Full Text
- PERFECTION Study
- PERFECTION Study CTp vs FFR CT (Pub Med)
- Core 320 Study Summary
Plaque Characterization
Bittner D et al Coronary Computed Tomography Angiography?Specific Definitions of High-Risk Plaque Features Improve Detection of Acute Coronary Syndrome
Results From the ROMICAT II Trial
Circulation Cardiovascular Imaging Vol 11 No.8 Coronary
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- Abdelraman et al JACC 2020
- What we have learned is that we should approach
- Chest Pain – like we approach
- OA
- ie as a mostly a chronic illness
- We must approach Acute MI for its sneak attack methodologies
- high suspicion for a hidden enemy
- like pathological fracture
Understanding of atherosclerosis
History of Atherosclerosis
“….acquire so thick a covering that it contracts the passage of the blood .”
“I have found there stones in the vessels”
“The tunics of the vessels behave in man as in oranges, in which the peel thickens and the pulp diminishes the older they become. And if you say that it is the thickened blood which does not flow through the vessels, this is not true, for the blood does not thicken in the vessels because it continually dies and is renewed.?
Atherosclerosis
CT-015-lo-res-scaled.jpg
Atherosclerosis starts as a fatty infiltration in the intimal and subintimal layer progressing in size stimulating the formation of fibrous tissue to create the so called fibrofatty plaque. Dystrophic calcification resultsAshley Davidoff MD
thecommonvein.net
CT-016-lo-res-scaled.jpg
As the plaque grows , either as a fibrofatty plaque or a calcified plaque or a mixture and it slowly encroaches on the lumen causing progresive narrowing of the vessel and results in time wit decreased perfusionAshley Davidoff MD
thecommonvein.net
The Fatty Plaque with thin cap and neovascularity is a land mine waiting to explode
The Vulnerable Plaque
CT and Vulnerable Plaque – IVUS
Patient with Psoriasis, Atherosclerotic Disease Before and After Biologic Therapy
Conclusion and Summary
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I saw it for myself in Washington DC
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It is definitely on their minds
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Saw the writing on the walls (floor) of the
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National Airport
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Between Concourse B and C
Digital Make Up of the Coronary Artery
Concern for Lipid Infiltration into the Vessels
Concern for the Vulnerable
Focus to Treat and Help the Vulnerable Before it was too Late
Advancing Computerised Evaluation of Flow Dynamics
Remembering the Role of Shear Stress
Concern for Shortfalls of Energy Delivery
Attention to Myocardial Perfusion
Approaching a Problem from Many Angles to get to the Truth
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- Evaluation of stable chest pain often
- requires diagnostic testing with the
- goals of
- detecting coronary artery disease (CAD) and
- non obstructive
- obstructive
- assessing the risk of a
- future major adverse cardiovascular event (MACE),
- death,
- myocardial infarction, or
- unstable angina
- future major adverse cardiovascular event (MACE),
- detecting coronary artery disease (CAD) and
- Evaluation of stable chest pain often
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Background and History
- Ravin
- My Teachers
- History of CT
- Coronary CTA – History
- Evaluation of Structure Why do we see things
- Contrast Resolution
- Spatial resolution
- Temporal Resolution
- History of CTA of the coronary arteries
- CT Anatomy
- Embryology
- History of Atherosclerosis
- Atherosclerosis
- Image Quality
- What is easy for us
- What is hard for us
- Blooming Artifact
- Penetrating Heavy Calcium
- Wall Characterization
- Artifacts
- Partial Volume Artifact
- Beam Hardening
- What is new?
- What is hard for us
- see web image 258 Anatomic imaging is very sensitive as to who may have a CV event down the line Functional image not so much or who may nothave an event
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Indications
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First Line Study (Narula J, et al 2021 Expert Consensus Document)
- Chest pain no known CAD presenting with
- Stable Typical Pain
- Atypical Chest Pain
- thought to represent a possible anginal equivalent
- Chest Pain with known CAD presenting with
- Stable Typical Pain
- Atypical Chest Pain
- thought to represent a possible anginal equivalent
- Unclear or inconclusive stress test results.
- When considering evaluation for revascularization strategies
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- ISCHEMIA Trial
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- Selected asymptomatic high risk individuals
- Rarely appropriate
- very low risk symptomatic patients, e.g., <40 years of age with non-cardiac symptoms (chest wall pain, pleuritic chest
pain) - low- and intermediate risk asymptomatic patients
- very low risk symptomatic patients, e.g., <40 years of age with non-cardiac symptoms (chest wall pain, pleuritic chest
- Risk Stratification
- A strong family history of early heart disease.
- Multiple other risk factors for coronary artery disease (hypertension, diabetes, cholesterol abnormality, smoking)
- Ruling out significant luminal stenoses in stable patients with suspected coronary stenoses, but intermediate pretest likelihood of disease
- most useful in patients with a low-to-intermediate likelihood of CAD
- patients with left bundle branch block of unknown etiology
- patients with new onset heart failure
- Confounding Cath
- Interesting and important associations in syndromes
- polyarteritis (89H)
- congenital coronary artery disease
- congenital heart disease
- Anomalous coronary origins
- aneurysms
- Plaque characterisation
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Contraindications
- Renal
- Excessive Coronary Calcification
- Relative
- patient?s heart rate,
- body weight, or
- ability to perform a breath-hold,
- contrast or problems with
- vascular access (which may make invasive angiography more prone to complication)?
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Advantages
- high negative predictive value
- Provides high-definition 3-D images of the arteries feeding the heart and blockages at the earliest stages when they can be treated most effectively
- Most accurate noninvasive diagnostic test for coronary artery disease
- Measures both calcified and noncalcified plaques. Noncalcified plaques are more prone to rupture and cause heart attacks than calcified plaques. By assessing both types of plaque, coronary CTA analyzes your risk for a heart attack.
- Monitor the effectiveness of therapy since noncalcified plaques may shrink with effective treatment
- cross-sectional nature permits visualization not only of the contrast-enhanced coronary artery lumen, but also of the vessel wall (if image quality is adequate). In this way, atherosclerotic plaque can become visible, which is undetectable in the invasive coronary angiogram
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Disadvantages
- lacking in
- speci?city ie lot of false positives
- positive predictive accuracy, ie lot of false positives
- which has led to the development of value added CTA strategies like fractional ?ow reserve derived from CT and CT perfusion.
- Radiation
- Goal median <5milliSieverts (15 5-10 years ago)
- NM 10-15 milliSieverst
- Limited temporal resolution can reduce image quality, especially if heart rates are above 60 beats per minute (bpm)
- Since data acquired over several heartbeats are necessary to acquire a complete data set, coronary CTA is not reliably possible in patients with arrhythmias (scanner design concepts with ?256 slices may help overcome this limitation).
- analysis was limited to segments of ?1.5 mm in diameter.
- Also, there is a tendency to overestimate the degree of stenosis in CT as compared with the invasive angiogram,
- extensive calcifications can render image interpretation impossible.
- In patients with a very low pretest likelihood, the false-positive rate may be too high,
- patients with a very high pretest likelihood, sensitivity may not be sufficiently high.
- patients with a high pretest likelihood of disease, performing an invasive, catheter-based coronary angiogram will often be much more appropriate because it offers the option of immediate treatment.
- lacking in
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Aim
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Method
- Patient Preparation and Patient Factors
- Equipment
- Contrast
- Technique
- Gating
- Calcium Score
- When is it too high
- Coronary Evaluation
- Axial
- MPR
- 3D
- Ventricular Evaluation
- LV
- EF
- mass
- LV
- Myocardial Perfusion
- FFR
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Results
- Evolving technology
- Fractional ?ow reserve derived from CT
- Lesion specific stenosis
- Calcific plaque limits
- CT perfusion.
- Global
- Tissue Characterization
- Fractional ?ow reserve derived from CT
- CAD RADS
- Linking reporting to Management Situations
- 1-5
- 2 Atheroscleosis
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Conclusion
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Summary
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Links and References
- TCV
- TCV
- CTA of the Coronary Arteries
- Cases
- 023H Takotsubo Sarcoidosis and a Police Visit
- 028h 83fF Post MI Post Cath LV Contrast
- 047H Acute MI Left Main Occlusion Batwing CXR
- 067H Calcium score >2000
- 068H LV infero-basal aneurysm
- 072H 49M CAD CHF ground glass01 CONFIRM j.jacc.2011.02.074
- 074H 55F-AVM LAD incidental-finding
- 079H Left Main Calcification CTA Negative Angio
- 080H CTA LAD Disease CAth Negative
- 081H CT Heavy Calcification Lung Cancer Screening Discrepant Cath
- 084H coronary artery LAD and Cx separate origins
- 085H Conal artery to PA fistula (AVM)
- 086H Left Main High Grade Stenosis
- 087H RCA aneurysm in young female
- 088H Septic Shock Perforated Ulcer
- 089H Polyarteritis Nodosa and Coronary Artery Aneurysms
- 090H HOCM and Anomalous Origin of RCA from LCA Sinus
- Literature
- Need to review
- patient Stable CAD PAin in out
- CTA
- patient Stable CAD PAin in out
- Videos
- Gary Huang Cardiology University of Washington Has All the Trials Excellent
- Todd Vilines U of Virginia
- Chest Pain Guidelines has 2 videos
- Abdelrahman KM eta al State of the Art Review of CTA ACC
- Collet et al Implementing Coronary CTA in the Cath Lab
- Bhatt et al The Emerging Role of CTA in Stable Angina With ISCHEMIA
- Ahmadi A,Narula J Assessment of Coronary Disease Independent of Symptoms JACC
- Need to review
- Min, J et al A New Decade of Old Questions Steps Toward Demonstrating Efficacy of Physiologic CAD Evaluation by CT JACC
- Stone K.E. History of Coronary CTA
- Narula J, et al2021 Expert Consensus Document on Coronary CTA Society of Cardiovascular CT
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- Leber AW, Knez A, Becker A, et al. Accuracy of multidetector spiral computed tomography in identifying and differentiating the composition of coronary atherosclerotic plaques: A comparative study with intracoronary ultrasound. J Am Coll Cardiol. 2004;43:1241-1247.
- Leber AW, Becker A, Knez A, et al. Accuracy of 64-slice computed tomography to classify and quantify plaque volumes in the proximal coronary system: A comparative study using intravascular ultrasound. J Am Coll Cardiol. 2006;47:672-627.
- Schroeder S, Kopp AF, Baumbach A, et al. Noninvasive detection and evaluation of atherosclerotic coronary plaques with multislice computed tomography. J Am Coll Cardiol. 2001;37:1430-1435.
- Achenbach S, Ropers D, Hoffmann U, et al. Assessment of coronary remodeling in stenotic and nonstenotic coronary atherosclerotic lesions by multidetector spiral computed tomography. J Am Coll Cardiol. 2004;43:842-847.
- Caussin C, Ohanessian A, Ghostine S, et al. Characterization of vulnerable nonstenotic plaque with 16-slice computed tomography compared with intravascular ultrasound. Am J Cardiol. 2004;94:99-100.
- Carrascosa PM, Capuñay CM, Garcia-Merletti P, et al. Characterization of coronary atherosclerotic plaques by multidetector computed tomography. Am J Cardiol. 2006;97:598-602.
- Pohle K, Achenbach S, Macneill B, et al. Characterization of non-calcified coronary atherosclerotic plaque by multi-detector row CT: Comparison to IVUS. Atherosclerosis. 2007;190:174-180.
- Moselewski F, Ropers D, Pohle K, et al. Comparison of measurement of cross-sectional coronary atherosclerotic plaque and vessel areas by 16-slice multi-detector computed tomography versus intra-vascular ultrasound. Am J Cardiol. 2004;94: 1294-1297.
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- Schuijf JD, Beck T, Burgstahler C, et al. Differences in plaque composition and distribution in stable coronary artery disease versus acute coronary syndromes; non-invasive evaluation with multi-slice computed tomography. Acute Card Care. 2007;9: 48-53.
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