Computed Tomography Coronary Angiography .pptx

CT Coronary

1. Coronary Computed Tomographic Angiography Dr Rajesh Ponnada Cardiology Resident Apollo Hospital, Visakhapatnam

2. Introduction: scope of the CT Coronary Angiography Evidence base Diagnostic accuracy Guidelines and pre-test probability Clinical indications for coronary CTA Decision making

3. simple exercise treadmill test(ETT ) myocardial blood flow changes functional consequence of reduced myocardial blood flow Anatomic Imaging Combination of anatomic coronary imaging coupled with physiology or perfusion SPECT PET MRI stress echocardiography (SE), CTA FFRCT CTP Gold standard for determining ischemia percent diameter stenosis (DS) Invasive fractional fl ow reserve (FFR) compared to invasive FFR < 0.80, sensitivity 69%, and ICA specificity is 67%

4. Guidelines and pre-test probability (2010) NICE chest pain guidelines (DF) score PTP <10% no further investigations 10 - 29% coronary artery calcium scoring (CACS) 30 - 60% functional imaging 61 - 90% ICA 2016 the NICE guideline group 15 validated PTP models, diagnostic accuracy and costs factor CTA (on a 64-slice CT scanner) in all patients with typical or atypical anginal symptoms strongest negative predictive value comparable positive predictive

5. NICE cohort and, importantly a signi fi cant reduction in downstream ICA , signi fi cant reductioninevents in the NICE cohort SCOT-HEART and PROMISE populations identi fi ed the superiority of the NICE guidelines NICE Medical Technology Assessment Committee (MTAC). FFRCT was a robust and scienti fi cally valid adjunct to CTA

6. 2019 ESC guidelines ESC-DF PTP overestimate vastly the actual prevalence of CAD ≥ 50% (Class l) coronary CTA or non-invasive functional imaging as the initial test to evaluate chest pain, revised ESC-DF PTP table in the 2013 ESC guidelines Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE ) PTP   Pretest probability for patients with suspected obstructive coronary artery disease: re-evaluating Diamond–Forrester for the contemporary era and clinical implications: insights from the PROMISE trial  CTA was recommended (Class lla ) as an alternative to invasive angiography in the setting of an equivocal or non-diagnostic functional imaging test Low clinical CAD likelihood, )

7. Coronary CTA in Native Vessels Stable Coronary Artery Disease, Known /Unknown CAD with stable typical or atypical chest pain , Angina equivalents evaluation for revascularization strategies using the ISCHEMIA Trial Fi rst line test Appropriate to perform CTA selected asymptomatic high risk individuals H igher likelihood of having a large amount of noncalcified plaque Rarely appropriate very low risk symptomatic patients low- and intermediate risk asymptomatic patients Stable Coronary Artery Disease

8. Stable Coronary Artery Disease: Coronary CTA Post Revascularization symptomatic patients with intracoronary stent diameter 3.0 mm symptomatic patients with intracoronary stent diameter 3.0 mm thin stent struts ( < 100 m m) in proximal, non-bifurcation locations Evaluation of patients with prior CABG, particularly if graft patency is the primary objective Visualize grafts and other structures prior to re-do cardiac surgery

9. Stable Coronary Artery Disease: Coronary CTA with FFR or CTP E valuate the functional signi fi cance of intermediate stenoses on CTA ( 30 - 90% diameter stenosis in the setting of multivessel disease Adding FFRCT and stress-CTP to CTA increases speci fi city, positive predictive value, and diagnostic accuracy over regular CTA.

10. Stable Coronary Artery Disease: Coronary CTA in Other Conditions evaluation prior to noncoronary cardiac surgery alternative to other noninvasive tests for evaluation of selected patients prior to noncardiac surgery suspected non-ischemic cardiomyopathy screening of patients for coronary allograft vasculopathy evaluation of coronary anomalies.

11. VERDICT (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography) trial Coronary CTA has good diagnostic accuracy compared with invasive coronary angiography and could be used to rule out significant coronary artery disease in patients with NSTEACS  2,147 patients with NSTEACS Negative predictive value 91%, positive predictive value 88%, sensitivity 97%, and specificity 72%) The RAPID-CTCA (Rapid Assessment of Potential Ischaemic Heart Disease with CTCA;  study presented at the American Heart Association meeting recently demonstrated that coronary CTA reduced the need for invasive angiography in intermediate-risk patients presenting with chest pain to the emergency department, but with no effect on all-cause death or subsequent myocardial infarction.

12. Diagnostic accuracy

13. Reference Most Sensitive and specific Less Sensitive and specific ICA > 50%DS CTA, MRI and PET SPECT and SE invasive FFR 0.80 CTA, MRI and PET Sensitive But CTA least specific CT-FFR and CTP increase the specificity to the level of MRI and PET without loss of sensitivity SPECT and SE

14. Prognostic value and comparison with functional testing Prognostic value of a normal CTA, both for short-term outcomes and longer term mortality Meta-analysis of patients 122,721 patients in 165 studies Result annual event rate CTA normal CTA (without plaque) < 1% stress myocardial perfusion imaging (MPI) Normal Study < 1% normal CTA strongly predicts event free survival even over a 10 year follow up

15. COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter ( CONFIRM) registry predictive of mortality at 2 years presence of obstructive disease number of vessels involved 23,854 patients without known CAD undergoing CTA Meta-analysis of 25,258 patients with suspected or known CAD in 21 studies identi fi ed a similar long term ( > 2.5 years) Similar prognostic value for CTA and stress MPI in the prediction of death and non-fatal myocardial infarction

16. PROMISE ( PROspective Multicentre Imaging Study for Evaluation of chest pain) trial assessed stable symptomatic outpatients referred for non-invasive investigation for suspected CAD 10,003 participants randomized to anatomical testing with CTA Vs functional testing (exercise electrocardiography, stress echocardiography or SPECT 25 months of follow-up there was no difference Subsequent assessment of this study identi fi ed that the discriminatory ability to predict subsequent events was higher for CTA( due to the ability of CTA to detect prognostically important non-obstructive disease

17. CADRADs classi fi cation to the CONFIRM database 19 Graded decrease in event free survival with more severe disease 5-year event-free survival 95% with CAD-RADS 0 69.3% for CAD-RADS 5 PROMISE study 20 showed that increasing severity (CAD-RADs score) continued to have additional prognostic value over and above CAC and ASCVD scores

18. Plaque burden and adverse coronary artery plaque characteristics CT- Leaman score segment involvement score independent predictor of subsequent prognosis Quantitative and Qualitative assessment of plaque characteristics percent atheroma volume (PAV) at baseline was the strongest predictor of progression of non-obstructive disease to obstructive lesions. 25 high volume of noncalcified plaque is one of the strongest parameters for predicting ACS

19. Adverse coronary artery plaque characteristics high risk plaques or vulnerable plaques presence of positive remodeling , spotty calci fi cation, low attenuation plaque ‘ napkin ring ’ sign

20. Computed Tomography versus Exercise Testing in Suspected Coronary Artery Disease (CRESCENT 1), 60 and CRESCENT II 62 Computed Tomography versus Exercise Testing in Suspected Coronary Artery Disease (CRESCENT 1), 60 and CRESCENT II 62 and Min et al. 61 trials directly assessed the in fl uence of CTA on the diagnosis of stable chest pain that was suspected to be due to coronary artery disease CTA was superior to functional testing or standard of care, with the SCOT-HEART trial reporting a 2-fold increase in diagnostic certainty compared to standard of care.

21. Thank you…..