Cardiology Update 2011 Davos Switzerland CT coronary angiographyassets.escardio.org/.../Gamperli-CT-coronary-angiography.pdf · 2011-04-27 · CT coronary angiography: From past to

CT coronary angiography

Cardiology Update 2011

Davos Switzerland

An alternative to angiography?

Oliver Gaemperli, MD

Cardiovascular Center

University Hospital Zurich

Switzerland

[email protected]

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: [email protected]