Computed tomography coronary angiography in patients with suspected coronary artery disease

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1 Computed tomography coronary angiography in patients with suspected coronary artery disease Prof. Dr. Stephen Schröder, EC, FESC Department of Cardiology Klinik am Eichert Göppingen Germany

2 -No conflicts of interest to declare-

3 Unclear Chest pain, Suspicion of CAD Ex-ECG, Echo Pretest Probability for having a significant stenosis Low (<10%) Interm.(10-80%) High (>80%) CAC-Scoring: Low risk CT-Angiography / CAC 1 SPECT ²/ Stress-Echo/-CMR No Stenosis Proximal highgrade Stenosis Plaque unclear relevance Ischemia? CAC <30 u. <75% Perc. CAC 30 o. 75% Perc. Normal low- moderate Severe (>0 - <10%) 3 (>10%) Medic. Prevention Medic. Prevention Yes 4 Stable, tolerable symptoms No 1: No CTA with extensive CAC 2: PTP> 50% directly SPECT? 3: High PTP& Ischemia <10% : CTA Invasive diagnostics ± Revascularisation 4: according to e.g. COURAGE-Trial

4 Unclear Chest pain, Suspicion of CAD (Ex-ECG, Echo) Pretest Probability for having a significant stenosis Low (<10%) Interm.(10-80%) High (>80%) CAC-Scoring: Low risk CT-Angiography / CAC SPECT ²/ Stress-Echo/-CMR No Stenosis Proximal highgrade Stenosis Plaque unclear relevance Ischemia? CAC <30 u. <75% Perc. CAC 30 o. 75% Perc. Normal low- moderate Severe (>0 - <10%) 3 (>10%) Medic. Prevention Medic. Prevention Yes 4 Stable, tolerable symptoms No 1: No CTA with extensive CAC 2: PTP> 50% directly SPECT? 3: High PTP& Ischemia <10% : CTA 4: according to e.g. COURAGE-Trial Invasive diagnostics ± Revascularisation

5 Suspicion of CAD Current clinical practice v.buuren, Horstkotte. Kardiologe 2009; 3:

6 Suspicion of CAD Current clinical practice Number of Cath- labs in Germany v.buuren, Horstkotte. Kardiologe 2009; 3:

7 Suspicion of CAD Invasive cath as standard of reference Rare but possible complications

8 Cardiac-CT The alternative in coronary imaging Imaging of the coronaries with high quality v v

9 Cardiac-CT Rapid technical improvements 4-slice CT / slice CT 2010 Dewey et al. Circulation 2009; 120: de Graf, Bax et al. Eur Heart J 2010; 31: Chou et al. Eur Heart J 2010; 31:

10 Cardiac-CT Major indications Exclusion of significant stenosis (CT- Angiography) Risk stratification (Calcium Scoring)

11 Cardiac-CT Major indications Exclusion of significant stenosis (CT- Angiography) Risk stratification (Calcium Scoring) x

12 Cardiac-CT Straight forward: Fast 1. Patient preparation : 4 Min 2. CT-Scan: 5 Min -> specific Scan app 1-15 sec 3. Image reconstruction: 1 Min 4. Interpretation: 5 Min Total: ~15 Min

13 Cardiac-CT Cost effective Cardiac CT ~ 550 Euro (currently no reimbursement by public insurances ) Conventional Angio ~ 650 Euro

14 Cardiac-CT Results from multi-center trials Imaging of the coronaries with high diagnostic accuracy Results from Multicenter Studies Prev Pat Nr Sensitivity Specificity PPV NPV Core 64 * Accuracy Rotterdam * * Miller et al., NEJM 2008, 359: * Meijboom et al., JACC 2008, 52: Budoff et al., JACC 2008, JACC 2008;52:

15 Cardiac CT Relevant for predicting prognosis! Registry data of 1127 pts, 16-Slice CT because of chest pain, FU: 15 months, End-point: Death. Min et al., JACC 2007, 50:

16 Cardiac CT Relevant for predicting prognosis! Register Data 1256 Pat.!, 64-slice CT because of chest pain, FU: 18 Months, End point: Death, MI, unstable Ap with hospital admission 0.6 vs 1,8% Hadamitzky et al et al., JACC Cardiovasc Imaging 2009; 2:

17 Cardiac CT Relevant for predicting prognosis! Severity of CAD Coronary Atherosclerosis LV-EF Chow et al., JACC 2010; 55:

18 Cardiac CT Relevant for predicting prognosis! Imaging of different stages of atherosclerosis

19 Cardiac-CT Different stages of atherosclerosis 441 Pat. FU 32 ± 15 months 44 events in 40 pts Russo et al, Cir.Cardiovasc Imaging 2010; 3:

20 Cardiac-CT Scientific evidence High diagnostic accuracy in detecting significant CAD Cardiac CT is of prognostic relevance

21 Cardiac CT Comprehensive information! Stenosis detection Plaque detectionmorphology Ventricular morphology /geometry (Viability) / Perfusion Valve morphology Function

22 Cardiac CT Exclusion of significant CAD! Exclusion of CAD! With information on cardiac function, valvular and cardiac morphology, evaluation of extra-cardiac pathologies, perfusion defects No evidence of CAD Suspicion of CAD NO Coronary Imaging Non Invasive Coronary Imaging Invasive Coronary Imaging As gate-keeper No further Coronary imaging Invasive Coronary imaging

23 Cardiac CT Exclusion of significant CAD! Intermediate Pretest probability for having a significant stenosis Leber et al. Eur Heart J 2007; 28:

24 Cardiac CT Exclusion of significant CAD! Intermediate Pretest probability for having a significant stenosis n=90 Leber et al. Eur Heart J 2007; 28:

25 Cardiac CT Exclusion of significant CAD! Indication confirmed by international experts in all large cardiac societies

26 Cardiac CT Limitations Exact quantification of stenoses severity Meijboom et al., JACC 2008, 52:

27 Cardiac CT Limitations Need for radiation 10,0 9,0 8,0 7,0 6,0 5,0 4,0 3,0 2,0 1,0 0,0 EKG-pulsing 20%, 120kV 330mAs MinDose 4% 120kV 330mAs EKG-pulsing 20%, 100 kv 330mAs EKG-pulsing 20%, 100 kv 220mAs Cardio Sequence 120 kv Cardio Sequence 100 kv Courtesy of H.Alkhadi, Zürich

28 Cardiac CT Limitations Significant improvements in reducing radiation!

29 Cardiac CT Limitations msv Courtesy, Dr. Ropers, Univ of Erlangen

30 Unclear Chest pain, Suspicion of CAD Ex-ECG unclear or negative, Echo: LV- function normal Pretest Probability for having a significant stenosis Low (<20%) Interm (20-70%) High (>70%)

31 Cardiac CT In clinical practice How to evaluate pretest- probability for a significant stenosis? Morise et al. Am J Med 1997; 102:

32 Cardiac CT In clinical practice

33 Unclear Chest pain, Suspicion of CAD Ex-ECG unclear or negative, Echo: LV- function normal Pretest Probability for having a significant stenosis Low (<20%) Interm (20-70%) High (>70%) Calcium- Score CTA Stress-ECHO, -MRT, SPECT Non significant stenosis Prox. stenosis <30 > 30 Unclear/ Severe stenosis No angina, Ischemia < 10% Angina and/or Ischemia >10% < 50. Percentile > 50. Percentile Medical therapy Ischemia- Dx Medical therapy Ischemia- Dx Invasive Diagnostics

34 Cardiac CT Exclusion of significant CAD! Clinical Case 51, thoracic discomfort/ pain under stress, active smoker, hypertension, fam. Disposition (mother) Exercise ECG-> ascending ST- inferior without pain Coronary Calcium Scoring -> Presence of CAD? Haberl et al., JACC 2001;37:

35 Cardiac CT Exclusion of significant CAD! Clinical Case 51, thoracic discomfort/ pain under stress, active smoker, hypertension, fam. Disposition (mother) Exercise ECG-> ascending ST- inferior without pain Invasive Coronary Angiography -> Significant, stenotic CAD? Diagnosis Non stenotic CAD, treatment: Medical therapy-> ASS, statin, ACE-inhibitor, ß-blocker

36 Coronary imaging is feasible with high accuracy in selected patient groups: Risk stratification = Calcium Score and Exclusion of significant Stenosis (CAD) = CT- Angiography Cardiac CT Summary! Strength Additional information, Comprehensive look at the heart Limitations Evaluation of morphology, no functional imaging (low!) Radiation, iodinated contrast, reimbursement

37 Thank you very much for your attention!

38 Cardiac-CT Major indications Coronary Calcifications as a hint for the entire plaque burden

39 Cardiac-CT Major indications Coronary Calcifications as a hint for the entire plaque burden Correlation 1:5 Rumberger et al. Circulation 1995; 92:

40 Cardiac-CT Coronary calcium and prognosis Relation between Plaque burden und Mortality N= asymp. persons Age 53 years 40% women Risk adjusted mortality Shaw et al., Radiology 2003;228:

41 Cardiac-CT Coronary calcium and prognosis MESA-Trial: Population based, n=6814, age: years, 4 ethnic groups, no diagnosed CAD at inclusion, follow-up: 3.5 years Detrano et al. NEJM 2008: 358: