Gunjan Gholkar MD Metro Heart and Vascular Objectives Show lots of pretty pictures Raise awareness of current indications and clinical scenarios for which to consider CT angiography Interpretation of reports ID: 911642
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Slide1
Multi-Slice CT for Coronary Calcium Scoring and Coronary Angiography
Gunjan
Gholkar
MD
Metro Heart and Vascular
Slide2Objectives
Show lots of pretty pictures
Raise awareness of current indications and clinical scenarios for which to consider CT
angiography
Interpretation of reports
Review
strengths and limitations of
MSCT
Slide3Pretest Probability
Diamond – Forrester
Duke clinical score
Slide4Test Selection According to Pretest Probability of CAD
Slide5Indications of Coronary CTA
Ruling out
significant luminal
stenoses
in stable patients with suspected coronary
stenoses
, but intermediate pretest likelihood of
disease
High negative predictive value and thus allows one to reliably rule out presence of coronary stenosis.
Aim is to avoid unnecessary invasive testing
Most useful in low to intermediate risk
High false positive rate in very low risk patients.
Sensitivity decreases in very high pretest probability patients.
Slide6Indications of Coronary CTA
Ruling
out coronary artery disease in acute chest
pain
ER patients with normal enzymes ,
ekg
and low likelihood of CAD.
Patient with new LBBB
Slide7Special situations- Emergency department chest pain
>60% ED chest pain is
noncardiac
.
Numerous studies
Show high NPV 97-100%
Show poor PPV 47-52%
Versus nuclear imaging is faster/cheaper/less repeat presentations.
Slide8Indications of Coronary CTA
3. Equivocal
stress test or persistent symptoms despite negative stress test
Slide9Indications (Contd.)
Prior
to non-coronary cardiac surgery (valve or congenital repair
)
Evaluation of coronary artery disease in new onset heart failure
.
Suspected
coronary
anomalies
Cardiac
transplant
evaluation
Determine patency of bypass grafts
Slide10Case 1
43 year old man commenced a new exercise program
Left side chest discomfort on exertion
Cholesterol 6.0, LDL 3.6, HDL 1.3
No smoking, diabetes, HT or family history of IHD
BMI 26 kg/m2
Medications – none
Resting ECG – normal
What next ?
Slide11Functional Test
Objectively negative stress echocardiogram – 13 minutes
However, vague left sided chest pain at peak exercise
“Is my heart OK ?”
Slide12CIA Mar 08
LAD
Slide13Patients to undergo electrophysiologic
intervention (AF ablation,
BiV
pacing
)
Aortic diseases
Pericardial disease
Congenital heart diseases
Indications (Contd.)
Slide14Aortic Coarctation Visualized by 16-Row Detector MSCT
Fröhlich, G et al.
Circulation
. 2005;112:e81.
Slide15Pulmonary Vein Stenosis
Vasamreddy et al.
Heart
Rhythm
(2004) 1, 78-81
.
Slide16Pericardial Calcification
Multi-Slice CT Scanning Superior to MRI
Hoffmann et al.
Circulation
108 (7): 48e Figure IG1
Slide17Left Main Arising from right Cusp
Slide18The Great Promise of MSCT
The “Triple Rule-Out”
Slide19Normal coronary arteries
Slide20Tight LAD stenosis
Slide21Indications (Contd.)
Assessment of complex congenital heart disease especially in regards to both coronary/great vessels and cardiac chambers and valves.
Slide22Slide23Surgical planning
The use of MDCT in surgical planning before cardiothoracic surgery, particularly for reoperations, is increasingly recognized.
Preoperative scans can evaluate the proximity of mediastinal structures to the sternum( i.e. aorta, right ventricle, bypass grafts); the degree of aortic calcification( i.e. to guide cannulation sites); and concomitantly provide information about cardiac morphology( e.g. presence of a ventricular aneurysm).
Ongoing studies are evaluating whether this added information might reduce intraoperative and perioperative complications.
Slide24Special Situations- Coronary Stents
Core 64 trial showed PPV 57% and NPV 80% if stent < 3.0mm
If left main stent > 4.0mm is 98% accurate
Routine use of CTCA for
instent
restenosis is NOT recommended.
Slide25Cardiac morphology/function
Contrast enhanced MDCT can provide high resolution morphologic images of cardiac chambers.
It can also provide accurate assessment of right and left ventricular systolic function.
Other imaging modalities such as echocardiography , MRI which do not require radiation exposure are preferred for cardiac morphology.
Slide26Inappropriate indications
Asymptomatic patients
High pretest probability including positive stress tests.
Positive cardiac enzymes or ST elevation on ECG.
Instent
evaluation especially stents < 3.0 mm.
Slide27Contraindications
Slide28Relative contraindications
Slide29Slide30Slide31Slide32Case 2
48 yr old man
Consistent exertional bilateral arm tightness
“like the compression of a blood pressure cuff”
Hyperlipidemia. Father and brother IHD in their 50s. On no medical therapy at time of presentation
Negative Stress Echo after 12 minutes of Bruce protocol. No symptoms with stress test
Worrying symptoms and CV risk factors, but negative functional test
Slide33Outcome
This patient had a concerning history and risk factor profile. He declined the offer of an invasive angiogram given his negative stress test. He agreed to have a CT coronary angiogram which detected severe proximal LAD disease which required revascularisation.
Slide34Volume rendered image of Coronary CT
Severe LAD and Diagonal branch stenosis
Slide35Coronary
artery calcium scoring
Slide36Coronary Calcification
Proven robust technique in identifying at risk population
Coronary Calcium Score >100 or >75
th
pecentile
identifies a CAD equivalent
Coronary Calcium scores are given in all patients undergoing CTA except graft patients and some stent
patients.
Slide37Diagnostic accuracy
CTCA vs Invasive coronary angiography
Visualize
wall in addition to lumen
ICA may not detect positive remodeling and underestimate plaque burden
Slide382010 ACCF/AHA Guidelines for assessment of cardiovascular risk in asymptomatic adults.
Slide39Clinical applications
Slide40Slide41The Calcium Scale
The calcium scale is a linear scale with 4 calcium score categories:
0 none
1–99 mild
100–400 moderate
>400 severe
Slide42Slide43Interpretation of CTA
Calcium score
Severity of stenosis and coronary segments.
Type of plaque
Non-cardiac findings
Slide44Recommended Quantitative Stenosis Grading
0
Normal: Absence of plaque and no luminal stenosis
1
Minimal: Plaque with
<25
%
stenosis
2
Mild: 25%–49%
stenosis
3
Moderate: 50%–69% stenosis
4 Severe: 70%–99%
stenosis
5 Occluded
Slide45CTA Limitations
Rapid (>80 bpm) and irregular HR
High calcium scores (>800-1000)
Stents
Contrast requirements (Cr > 2.0 mg/dl)
Small vessels (<1.5 mm) and collaterals
Obese and uncooperative patients
RADIATION EXPOSURE
Slide46Thank you
Slide47