Cardiology Update 2011 Davos Switzerland CT coronary angiographyassets.escardio.org/.../Gamperli-CT-coronary-angiography.pdf · 2011-04-27 · CT coronary angiography: From past to
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CT coronary angiography
Cardiology Update 2011
Davos Switzerland
An alternative to angiography?
Oliver Gaemperli, MD
Cardiovascular Center
University Hospital Zurich
Switzerland
oliver.gaemperli@usz.ch
The beatles greatest gift….
„Abbey Road“ (1969)
EMI Studios, Abbey road, London
……Is to science
First commercial CT head
scanner: EMI 1010
Sir Godfrey Hounsfield, 1971
EMI Central Research Laboratory,
Heathrow, London
CT coronary angiography: From past to present…
1971
Sir Godfrey Hounsfield
1st CT scanner
1983
Dynamic Spatial
Reconstructor (DSR)
1895
Wilhelm C.
Roentgen
1986
Electron
beam CT
1989
Fir
st
sp
iral
CT
1998
4-slice CT
2002
16-slice CT
2005
64-slice CT
2006
Dual-source CT,
320-slice CT
Cardiac CT
• Stable and unstable CAD
• Stents and coronary bypasses
• LV-Function and volumes
• Cardiac veins / Coronary anomalies
Established clinical applications
Emerging fields
• Assessment of coronary plaques
• Myocardial perfusion and scar imaging
Cardiac CT
• Stable and unstable CAD
• Stents and coronary bypasses
• LV-Function and volumes
• Cardiac veins / Coronary anomalies
Established clinical applications
Emerging fields
• Assessment of coronary plaques
• Myocardial perfusion and scar imaging
CTCA: an alternative to angiographyComparison of both methods
Multidetector CTA Diagnostic CA
Temporal Resolution 83 – 165 ms 33 ms (30f/s)
Spatial resolution 0.4 (isotropic) (3D) 0.16 mm 1) (2D)
Radiation 0.9 – 21.5 mSv 2 – 16 mSv
Contrast agent 60-80 mL 50-70 mL
Time expenditure 30 min 24 h
Costs 700 CHF 15,000 – 20,000 CHF
1) Otero HJ, Steigner ML, Rybicki FJ. Radiol Clin North Am 2009;47: 79
64-Slice CT for Diagnosis of Coronary Artery Disease:
A Systematic Review
Stein PD et al. The American Journal of Medicine (2008) 121, 715-725
N Sens Spec PPV NPV LR+ LR-
Overall(Patient-based)
2045 98 88 93 96 8.0 0.03
LMA 883 100 99 91 100 136.8 0.0
LAD 2716 93 95 84 98 17.6 0.08
LCX 2338 88 95 76 98 19.5 0.13
RCA 2424 90 96 83 98 21.0 0.11
Accuracy of 64-slice CTA along the length of the coronary artery
Am J Med 2008;121:715
Proximal Mid DistalSens/Spec
95 / 93LR+/LR-
12.9 / 0.05
Sens/Spec
94 / 90LR+/LR-
9.7 / 0.07
Sens/Spec
80 / 97LR+/LR-
23.2 / 0.2
Multicentric diagnostic coronary CTA studies
Sens Spec PPV NPV Nonevaluable
segments (%)
CATSCAN JAMA. 2006;296:403-411
16-slice CT
238 patients
89 65 13 99 29
CORE 64 N Engl J Med 2008;359:2324-36
64-slice CT
291 patients
85 90 91 83† 1 *
ACCURACY JACC 2008;52:1724–32
64-slice CT
230 patients
95 83 64 99 1
Meijboom et al. JACC 2008;52:2135–44
64-slice CT
360 patients
99 64 86 97 0
*patients with CACS>600 not
included
†Intention-to-diagnose analysis with nonevaluable
segments rated “negative”
CTCA for Early Triage of Patients with Acute Chest pain
The ROMICAT trial. JACC 2009
Patient:
A.H. 1946 ♀chest pain, no previously known risk
factors
BP 190/110 mmHg
Negative enzymes
Non-specific T flattening
Any
Plaque
Coronary
stenosis
Sens
(%)
100 77
Spec
(%)
54 87
NPV
(%)
100 98
PPV
(%)
17 35
Diagnostic accuracy for the
detection of ACS
CTCA in patients with acute chest pain reduces ED time and cost expenditure
Safety 100% in both groups
CTCA SOC P
Time to
diagnosis (h)
3.4 15.0 <0.001
ED costs ($) 1,586 1,872 <0.001
Repeat
evaluations
for recurrent
chest pain
2/99
(2.0%)
7/99
(7.0%)
0.10
Goldstein et al. JACC 2007;49:863
Stents!
Maintz et al. Eur Radiol 2006
Cobalt-
chromium
Cobalt-
chromiumCobalt-
chromium
Cobalt alloy
+ titanium
Tantalum
Gold
coatingGold
coatingNitinol
Platinum
markers
Platinum
markersPlatinum
markers Gold
markersNitinolTantalum
Tantalum Cobalt-
chromium
Tantalum
Cypher:
0.14mm
Palmaz-Crown:
0.091mm
Diagnostic accuracy of EBCT and MSCT in the Evaluation of coronary stents
CT technique and
study
No. of
Patients
No. of
stents
Stent location Stent caliber
(mm)
No. of
assessable
stents
Criteria for patency Sens
(%)
Spec
(%)
EBCTPump et al. 202 321 LM, RCA, LAD,
LCX, bypass
grafts
Dynamic study, distal
run-off
78 98
Knollman et al. 117 152 2.5-3.0 144 Dynamic study, distal
run-off
72 60
4-slice CTKruger et al. 20 32 RCA, LAD, LCX 32 Distal run-off
Maintz et al. 29 47 3-5 38 Distal run-off 100 100
Ligabue et al. 48 72 RCA, LAD, LCX 53 Distal run-off 100 100
16-slice CTSchuijf et al. 22 68 2.25-5 50 Distal run-off 78 100
Cademartiri et al. 51 76 >2 74 Lumen visualization 84 99
Gilard et al. 29 29 LM 27 Lumen visualization 100 92
Gilard et al. 143 232 LM, RCA, LAD,
LCX
4.0 122 Lumen visualization 86 100
3.0 54 100
Kitagawa et al. 42 61 42 Lumen visualization
Hong et al. 19 26 2.25-5 26 Contrast enhancement
measurement
Ohnuki et al. 16 20 >3 19 Pixel count method 75 88
Diagnostic accuracy of EBCT and MSCT in the Evaluation of coronary stents
CT technique and
study
No. of
Patients
No. of
stents
Stent location Stent caliber
(mm)
No. of
assessable
stents
Criteria for patency Sens
(%)
Spec
(%)
40-slice CTGaspar et al. 65 111 LAD, LCX, RCA,
SVG
N/A 106 Lumen visualization 89 81
64-slice CTv Mieghem et al (16+64 slice CT)
74 4 pts LM N/A 162 Lumen visualization 100 91
Rist et al. 25 46 45 Lumen visualization 75 92
Rixe et al. 64 102 ≥2.5 59 Lumen visualization 86 98<3mm 1 (8%) - 100
3mm 33 (58%) 83 96
≥3.5mm 35 (78) 100 100
Cademartiri et al. 182 192 LM, RCA, LAD,
LCX
≥2.5 178 Lumen visualization 95 93
Ehara et al. 81 125 LM, RCA, LAD,
LCX
N/A 110 Lumen visualization 91 93
Dual source CTPflederer et al. 112 150 ≥3mm 135 Lumen visualization 84 95
3mm 65 (81%) 80 96
≥3.5mm 70 (100%) 89 93
Pugliese et al. 100 178 LM, RCA, LAD,
LCX
≥2.25mm Lumen visualization 94 92
However….
The distal anastomosis can be difficult to assess due to metal artefacts from clips
Disease progression in the native vessels may be difficult to evaluate due to extensive calcification
Increased CT coverage of the entire thorax results in higher radiation exposure and contrast agent use
U=Uncertain
I=Inappropriate
Prognostic value of 64-slice CTAA systematic review and metaanalysis
Int J Cardiovasc Imaging 2010
Epub ahead of print
10 studies
5,675 patients
FU 21 months
0
2
4
6
8
10
12
14
16
18
Normal CTA Non-obstructive
CAD
Obstructive
CAD
Cumulative
MACE rate (cardiac death,
nonfatal MI,
revasc)
during
Follow-up
[%]
Prognostic value of 64-slice CTAA systematic review and metaanalysis
Int J Cardiovasc Imaging 2010, Epub ahead of print
10 studies
5,675 patients
FU 21 months
0.5%
3.5%
16%
CT provides additional prognostic value over classical risk factors
Hadamitzky et al Circ Cardiovasc Imaging
1937 patients with suspected CAD undergoing CCTA were followed up for a median of 31 months. Endpoint was the occurrence of cardiac events (cardiac
death, nonfatal myocardial infarction, unstable angina requiring hospitalization and coronary revascularisation later than 90 days after CCTA).
Clinical Clinical +
MSCT ≥50%
Clinical +
MPI
Clinical +
MPI +
MSCT ≥50%
Clinical +
MPI +
MSCT ≥50% +
MSCT non-calcified
P<0.05
P<0.05
P<0.05
van Werkhoven JM, et al. JACC 2009;53:623
P<0.05
n=517
MSCT stenoses and plaque composition provide incremental prognostic value over clinical variables, MPI and CACS
Multivariate model correcting for CACS and baseline clinical variables
4.4
13.115.8
20.5
30.4
0
5
10
15
20
25
30
35
Glo
bal
χ2
Cost-Effectiveness of CTCAComparison of costs and outcome in matched patients with suspected CAD
CTCA
(n=1,938)
SPECT
(n=7,752)P
Costs$467 (95% CI, $99 - $984) lower
for CTCA<0.001
Invasive
angiography6.2% 9.5% <0.05
Revasc
(surg/perc)2.1% 1.6% NS
Post-test MI 0.4% 0.6% NS
Min et al. Am J Cardiol 2008;102:672
Limitations of CT coronary angiography
• Calcifications
• Cardiac Motion
• Low signal-to-noise ratio
The diagnostic accuracy of CTCA is decreased by heart rate >70 bpm,
BMI >30 kg/m2, calcium score >400
Patient selection and preparation is crucial! (betablockers, nitrates)
Can CT replace angiography?
No!
Conventional coronary angiography is an invasive procedure offering the possibility for ad hoc/planned coronary
revascularization (unmatched by CT)
Invasive coronary angiography has evolved from a diagnostic procedure to an interventional procedure, as such it should be
reserved for patients in whom an intervention is likely
Can CT replace diagnostic angiography?
It already has!(to a certain extent)
Chow et al. Circ Cardiovasc Imaging. 2009 Jan;2(1):16-23
University of Ottawa
Heart Institute
Impact of CTCA
on utilization of invasive coronary angiography
Thank you
Oliver Gaemperli, MD
Cardiovascular Center,
University Hospital Zurich,
Switzerland
Email: oliver.gaemperli@csc.mrc.ac.uk
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