CT angiography Vs Invasive CAG.pptx

CT angiography Vs Invasive CAG.pptx

1. CT Angiography Or Invasive Coronary Angiography For Initial CAD Evaluation ,How To Decide Dr Awadhesh Kr Sharma, DM Cardiology, FACC(USA), FSCAI(USA) Associate Professor LPS Institute of Cardiology, GSVM Medical College, Kanpur (UP)

2. NON-Invasive or Less invasive investigative modalities are the choice of everyone

3. Myths regarding Angiography

4. Google Gyan………..

5. But………….

6. Which one to choose or good in initial CAD evaluation is matter of discussion today……..

7. Introduction CT angiography (CTA) - an accurate, noninvasive alternative to invasive coronary angiography (ICA). CTA is advised in patient with stable chest pain and intermediate pretest probability for obstructive CAD. However, the comparative effectiveness of CT and ICA in the management of CAD to reduce the frequency of major adverse cardiovascular events is uncertain.

8. Invasive Coronary Angiography (ICA) ICA is the reference standard for the diagnosis of obstructive CAD and enables coronary revascularization during the same procedure. However, elective ICA is associated with rare but major procedure-related complications.

9. CTA VS ICA CTA is associated with - More radiation exposure as ICA More contrast volume Require strict rate control (HR<70) Difficult in morbid obese patient Inaccurate to assess severity in heavily calcified vessel Less sensitive in patient with prior Stent due to blooming effect of metallic scaffold

10. Evidences….

11. Evidences…. PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial- As compared with an initial strategy of functional testing (exercise electrocardiography, nuclear stress testing, or stress echocardiography), an initial CT strategy in patients with stable symptoms was associated with similar cardiovascular outcomes at 25 months. SCOT-HEART (Scottish Computed Tomography of the Heart) trial- The use of CT was associated with a significantly lower incidence of major adverse cardiovascular events, which were defined as death from CAD or nonfatal myocardial infarction at 4.8 years (hazard ratio, 0.59)

12. P r e t e s t P r o b a b i l i t i es o f O b s t r u c t i v e C A D i n S y m p t o m a t i c P a t i e n ts A c co r d i n g t o A g e , S e x , a n d Symptoms. 14 C o l o r s c o rr e s p o n d t o th e C l a s s o f R e c o m m e n d a t i o n i n T a b l e 1. C A C i n d i c a t e s c o r o n a ry ar t e r y c a l c i u m ; a n d C A D , c o r o n a r y a r t e r y d i s e a s e .

13. Index of Suspicion That Chest “Pain” Is Ischemic i n O r i g i n o n t h e B a s i s o f C o mm o n l y U s e d D e s c r i p t o rs . 15

14. Stable chest pain 1. No Known CAD: Appropriate as the first line test in stable typical or atypical chest pain , or other symptoms which are thought to represent a possible anginal equivalent (e.g. dyspnoea on exertion, jaw pain). After a nonconclusive functional test , in order to obtain more precision regarding diagnosis and prognosis, if such information will influence subsequent patient management. May be appropriate in some asymptomatic high-risk individuals , such as those with a higher likelihood of non-calcified plaque. Rarely appropriate in very low-risk symptomatic patients – those under age 40 with non-cardiac symptoms – or those with low- to intermediate-risk asymptomatic patients.

15. Indications.. 2. Known CAD: It is appropriate to perform CTA as a first line test for evaluating patients with known CAD who present with stable typical or atypical chest pain, or other symptoms which are thought to represent a possible anginal equivalent (e.g. dyspnea on exertion, jaw pain). 3. Functional imaging: It may be appropriate to perform CT derived FFR and CT myocardial perfusion Imaging to evaluate the functional significance of intermediate stenoses on CTA (30-70% diameter stenosis). Add FFRCT and stress-CTP to CTA to increase specificity, positive predictive value, and diagnostic accuracy. CTP can be a valuable alternative when CT-FFR is technically difficult.

16. Indications.. 4. Stable Coronary Artery Disease: CCTA Post-Revascularization In intra-coronary stent ≥ 3.0 mm, implementing measures to improve stent imaging accuracy, such as heart-rate control, iterative, sharp kernel, and mono-energetic reconstruction. CCTA is appropriate to evaluate patients with prior CABG , particularly for graft patency, and to visualize grafts and other structures prior to cardiac surgery re-do. Protocols to optimize stent imaging should be developed and followed. It may also be appropriate to perform coronary CTA in symptomatic patients with stents <3.0 mm, especially those known to have thin stent struts (<100 mm) in proximal, non-bifurcation locations.

17. Indications.. 5. Stable Coronary Artery Disease: CCTA in Other Conditions Asymptomatic high risk subjects: may be appropriate in selected asymptomatic high risk individuals, especially in those who have a higher likelihood of having a large amount of non-calcified plaque. Asymptomatic low or intermediate risk : rarely appropriate . Coronary artery bypass grafts : It is appropriate to perform CTA for evaluation of patients with prior CABG, particularly if graft patency is the primary objective.

18. Other Indications: CTA is appropriate for coronary artery evaluation before non-coronary cardiac surgery as an equivalent alternative to invasive angiography in patients with low-to-intermediate probability of CAD and younger patients with primarily non-degenerative valvular conditions. CTA is appropriate to exclude coronary artery disease in patients with suspected non-ischemic cardiomyopathy.

19. CTA is appropriate for the evaluation of coronary anomalies . Limited delay image CTA (60 seconds-to-90 seconds) is appropriate alternative to TEE to exclude LA/LAA thrombus , as well as in patients where TEE-associated risks outweigh the benefits. Late enhancement CT imaging may be appropriate to evaluate myocardial viability in some patients who cannot undergo cardiac MRI if it has the potential to impact diagnosis and treatment.

20. Evaluation Algorithm for Patients With Suspected ACS at Intermediate Risk With No Known CAD. 24 C o l o r s c o rr e s p o n d t o th e C l a s s o f R e c o m m e n d a t i o n i n T a b l e 1.

21. C o l o r s c o rr e s p o n d t o th e C l a s s o f R e c o m m e n d a t i o n i n T a b l e 1. Evaluation Algorithm for Patients With Suspected ACS a t I n t e r m e di a t e R i s k W i t h K n o w n C A D . 25

22. Implementation In Clinical Practice

23. 1. Medical versus Invasive Treatment A central aim of evaluation for CAD is to identify patients who need appropriate revascularization to improve prognosis or symptoms not responding to medical therapy, as well as those that can be managed with medical therapy alone. Stenosis severity still remains the primary arbiter of therapeutic decisions, but more and more data now suggest that anatomy coupled with a physiologic correlate is a better or even possibly, a necessary way for optimal decision-making.

24. 2. Role of CTA for guiding further non-invasive evaluation: CTA facilitates decision making by dividing patients into multiple informative categories . Those with a negative CTA or demonstration of non-obstructive CAD would generally exclude flow limiting CAD with high certainty and avoid downstream testing. CTA seems to allow for more appropriate use of statins and anti-platelet therapies better than when using non CTA methods for CAD diagnosis. CTA and FFRCT may allow for even more uniform down-stream interventions and narrow the differences between revascularization rates between men and women unlike what happens after usual stress testing imaging.

25. Take home message So how to decide for CTA vs ICA Pretest probability of CAD (intermediate vs high likelihood ) Presentation of patient (ACS vs CCS) Coronary CTA should be considered as the test of choice in most symptomatic patients without known CAD. CTA has excellent sensitivity for identifying flow limiting disease and has very high negative predictive value, making it the strongest test to rule out flow limiting CAD, especially in patients with low to intermediate risk. Prior history of revascularization ,PCI(blooming effect of prior stent ) Body habitus (morbid obese patient) Poorly controlled Heart rate Inability to hold breadth due to underlying respiratory distress