ROSI AMRILLA F MD INTRODUCTION Coronary artery disease CAD is a pathological process characterized by atherosclerotic plaque in the epicardial arteries whether obstructive or nonobstructive Anatomical the coronary artery lumen and wall can be evaluated by Coronary CT Angiography coronary ID: 930847
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Slide1
Functional and anatomical imaging of coronary artery disease ; How to choose the right modality
ROSI AMRILLA F, MD
Slide2INTRODUCTION
Coronary artery disease (CAD) is a pathological process characterized by atherosclerotic plaque in the epicardial arteries, whether obstructive or non-obstructive
Anatomical the coronary artery lumen and wall can be evaluated by Coronary CT Angiography (coronary CTA) and Invasive Coronary Angiography (ICA)
Coronary CTA is the preferred test in patients with a lower range of clinical likelihood of CAD, no previous diagnosis of CAD, and characteristics associated with a high likelihood of good image quality
It detects subclinical coronary atherosclerosis, but can also accurately rule out both anatomically and functionally significant CAD
Slide3INTRODUCTION
If the
stenoses
are not functionally significant, non-invasive or invasive functional testing is recommended for further evaluation
Several multicenter clinical trials have demonstrated the diagnostic superiority of Coronary computed tomography Angiography - Fractional Flow Reserve (FFR-CT) over traditional coronary CTA for the diagnosis of functionally significant coronary artery disease
Juhani
Knuuti
et al.
2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes: The Task Force for the diagnosis and management of chronic coronary syndromes of the European Society of Cardiology (ESC),
European Heart Journal
, Volume 41, Issue 3, 14 January 2020, Pages 407–477
Slide4Risk assessment of coronary artery disease
A simple predictive model can be used to estimate the
pre-test probability (PTP)
of obstructive CAD based on age, gender and nature symptoms
The likelihood of obstructive CAD is influenced by the prevalence of the disease in population
Slide5Assessment of pre-test probability and clinical likelihood of CAD
50% of patients previously classified as having an intermediate likelihood of obstructive CAD were reclassified to a PTP <15% according to the new PTP
Studies have shown that outcomes in patients classified with the new PTP <15% is good (annual risk of cardiovascular death or MI is <1%)
PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial
The true observed prevalence of obstructive CAD has been <5% in patients who had a PTP <15% according to the 2013 version of these Guidelines.
!
Juhani
Knuuti
et al.
2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes: The Task Force for the diagnosis and management of chronic coronary syndromes of the European Society of Cardiology (ESC),
European Heart Journal
, Volume 41, Issue 3, 14 January 2020, Pages 407–477
Slide6Coronary CTA is recommended as
the initial test to diagnose CAD in symptomatic patients
in whom obstructive CAD cannot be excluded by clinical assessment alone
Juhani
Knuuti
et al.
2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes: The Task Force for the diagnosis and management of chronic coronary syndromes of the European Society of Cardiology (ESC),
European Heart Journal
, Volume 41, Issue 3, 14 January 2020, Pages 407–477
Slide7Juhani
Knuuti
et al.
2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes: The Task Force for the diagnosis and management of chronic coronary syndromes of the European Society of Cardiology (ESC),
European Heart Journal
, Volume 41, Issue 3, 14 January 2020, Pages 407–477
Slide8Coronary CTA GoalsAnatomical Imaging
Plaque Characterization (
Eg
, Vulnerable Plaque)
Coronary Stenosis
Functional ImagingCoronary Flow Reserve
Slide9INDICATION OF CORONARY CTA
Coronary arteries for atherosclerosis or anomalies;
Noncoronary pathology including the great vessels, chambers, myocardium, valves, or pericardium;
Cardiac chamber function, including ejection fraction and chamber volumes;
Low-to-intermediate risk symptomatic patients presenting with symptoms of stable angina or acute chest pain
Discordant or inconclusive stress tests
Leipsic J,
Abbara
S, Achenbach S, et al. SCCT guidelines for the interpretation and reporting of coronary CT angiography: A report of the Society of Cardiovascular Computed Tomography Guidelines Committee.
J Cardiovasc
Comput
Tomogr
. 2014;8(5):342-358. doi:10.1016/j.jcct.2014.07.003
Slide10Dewey M.
Cardiac CT
. Vol 53. I. Berlin - New York: Springer Heidelberg Dordrecht; 2013. doi:10.1007/978-3-642-14022-8
A negative test (normal CTA) has a 98% chance of revealing normal coronary arteries on invasive angiography
Slide11Assessment of Event Risk
Slide12High event risk
Definition
!
Juhani
Knuuti
et al.
2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes: The Task Force for the diagnosis and management of chronic coronary syndromes of the European Society of Cardiology (ESC),
European Heart Journal
, Volume 41, Issue 3, 14 January 2020, Pages 407–477
Assessment of event risk
is recommended in every patient being evaluated for suspected CAD or with a newly diagnosed CAD, as
it has major impacts on therapy decisions
In patients with established CCS, the risk of
annual cardiac mortality
is used to describe the event risk
Assessment of Event Risk
Slide13Shmilovich H, MDa,*, Cheng VY, Tamarappoo BK, et al. Vulnerable Plaque Features on Coronary CT Angiography as Markers of Inducible Regional Myocardial
Hypoperfusion
from Severe Coronary Artery
Stenoses
. Atherosclerosis. 2011 December ; 219(2): 588–595.
Presence of low attenuation plaque and positive remodelling in severely stenotic plaques on CCTA is
strongly predictive of myocardial hypoperfusion
and may be useful in assessing
the hemodynamic significance of such lesions
Assessment of Event Risk
Slide14Likewise CTA can also identify nonobstructive plaque and high-risk plaque (HRP)
seen on intravascular ultrasound
Obstructive plaque, nonobstructive plaque, and HRP are
independent predictors of major adverse coronary events (MACE)
and have the potential to guide management decisions
High-risk features include: Low attenuation plaque (less than 30 Hounsfield Units), Positive remodeling, Spotty calcificationThe “napkin ring sign”
Assessment of Event Risk
Bittner DO, Mayrhofer T,
Budoff
M, et al. Prognostic Value of Coronary CTA in Stable Chest Pain: CAD-RADS, CAC, and Cardiovascular Events in PROMISE.
JACC Cardiovasc Imaging
. 2020;13(7):1534-1545
Slide15Spotty calcium, defined as punctate calcium within a plaque;
“napkin ring sign”, defined as central low attenuation plaque with a peripheral rim of higher CT attenuation (arrows);
Positive remodeling, defined as the ratio of outer vessel diameter at the site of plaque divided by the average outer diameter of the proximal and distal vessel greater than 1.1, or Av/[(
Ap
þ
Ad)/2] >1.1; and
Low attenuation plaque, defined as non-calcified plaque with internal attenuation less than 30 HU. Please note that a combination of two or more high-risk features is necessary to designate the plaque as high-risk for CAD-RADS.
High-risk plaque features on coronary CTA
Slide16Slide17Either a functional or anatomical test can be used to establish a diagnosis of obstructive CAD
Information on both anatomy and ischaemia is needed for revascularization decision
Slide18Coronary computed tomography angiography -Fractional flow reserve (FFR-CT)
Min JK. Diagnostic
Accuray
of Fractional Flow Reserve from Anatomical CT Angiography. JAMA. 2012; 308: 1237-1245.
The diagnostic performance of FFR-CT has been evaluated in 3 prospective, multicenter clinical trials using measured FFR as the reference standard and blinded core laboratory controls:
DISCOVER- FLOW
(Diagnosis of Ischemia-Causing
Stenoses
Obtained Via Noninvasive Fractional Flow Reserve),
DeFACTO
(Determination of Fractional Flow Reserve by Anatomic Computed Tomographic Angiography), and
NXT
(Analysis of Coronary Blood Flow Using CT Angiography: Next Steps).
Slide19Coronary computed tomography angiography -Fractional flow reserve (FFR-CT)
Minetal
. Noninvasive Fractional Flow Reserve From CT. JACC: Cardiovascular Imaging Vol. 8, No. 10, 2015 October2015:1209–22
Slide20Coronary computed tomography angiography - Fractional flow reserve (FFR-CT)
Min JK. Diagnostic
Accuray
of Fractional Flow Reserve from Anatomical CT Angiography. JAMA. 2012; 308: 1237-1245.
Slide21Coronary computed tomography angiography -Fractional flow reserve (FFR-CT)
J. Leipsic et al. AJR 2015; 204:W243–W248
Slide22Clinical Applications and Interpretation of FFR CT
FFR-CT has been shown capable of identifying ischemia which stem from coronary lesions that do not meet definitions of “angiographically severe”
(intermediate
stenoses
, diffuse atherosclerosis)
The primary role of FFR-CT as an alternative to invasive FFRFFR-CT provides superior diagnostic performance over coronary CTA alone
Clinical decision-making should involve additional information such as patient history, medication use, anatomy, location of
stenoses
, vessel size, and suitability for revascularization
Slide23SUMMARY
Coronary CTA is recommended as
the initial test to diagnose CAD in symptomatic patients
in whom obstructive CAD cannot be excluded by clinical assessment alone
If the
stenoses are not functionally significant, non-invasive or invasive functional testing is recommended for further evaluationFFR-CT, as an alternative to invasive FFR has been shown capable of identifying ischemia which stem from coronary lesions that do not meet definitions of “angiographically severe”
Slide24THANK YOU
Slide25Diagnostic performance of cardiac imaging to diagnose ischaemia-causing coronary artery disease
MRI had the highest performance for diagnosis of
ischaemia
-causing CAD, with lower performance for SPECT and stress ECHO
Slide26Coronary computed tomography angiography -Fractional flow reserve (FFR-CT)
Koetal
. Feasibility and Accuracy of CT-FFR. JACC: Cardiovascular imaging, Vol. 10, No. 6, 2017 June 2017:663–73
Slide27Clinical Applications and Interpretation of FFR CT
FFR-CT showed diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of 83.0%, 66.7%, 88.6%, 66.7%, and 88.6% (Koo BK et al)
Clinical decision-making should involve additional information such as patient history, medication use, anatomy, location of
stenoses
, vessel size, and suitability for revascularization
Slide28Diagnostic performance of cardiac imaging to diagnose ischaemia-causing coronary artery disease
Perfusion stress MRI has a sensitivity of 89.1% (95% CI, 84–93%) and specificity of 84.9% (95% CI, 76.6–91.1%) on a patient basis and a sensitivity of 87.7% (95% CI, 84.4–90.6%) and specificity of 88.6% (95% CI, 86.7– 90.4%) on a coronary territory basis (Ravi R. Desai and Saurabh Jha)
Slide29INTRODUCTION
Coronary artery plaques were identified via invasive coronary angiography (ICA), using visual assessment of vessel stenosis
Oftentimes the stenosis lesions are not hemodynamically significant
Fractional flow reserved (FFR) is a measured of the ratio of maximal blood flow through the coronary artery distal to a stenotic lesion to the normal maximal blood flow
Invasive FFR measured in the cardiac catheterization-lab using a pressure wire and administering an intracoronary or intravenous vasodilator to produce maximal hyperemia
Slide30TEXT SLIDE - TITLES
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No text shadows on any text
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Grube
E. et al,
Am Journal
Cardiol
2006;
“
in press
”
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Slide33DCA
n = 381
Stent
n = 372
P Value
Late loss (mm)
25.0
13.0
0.28
Binary restenosis
26.7
22.1
0.24
- Optimal DCA (%)
16.2
22.1
0.39
-TVR
25.0
23.0
21.0
12-Month TVF
(death, MI, TVR) (%)
23.9
21.5
0.48
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Slide35PHOTO & BULLETED TEXT
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