Multi-Slice CT for Coronary Calcium Scoring and Coronary Angiography John D Symanski, M.D., F.A.C.C The Sanger Clinic, PA and Carolinas Medical Center No Disclosures Objectives • Show lots of pretty pictures • Overview fundamental principles of MSCT technology • Review strengths and limitations of MSCT • Raise awareness of current indications and clinical scenarios for which to consider CT angiography Case Presentation • 64-year-old female with stage CLL • Dyslipidemia (untreated); No HTN, diabetes, or tobacco use • Negative stress echo previously • Atypical chest pain • Stress echo: septal hypokinesis at rest, LVEF: 50% • Referred for calcium scoring and CTA Radiation Risks • Exact quantification of harmful effects of radiation difficult to ascertain • For a child under age 15, the risk of cancer death from a single CT scan is approximately in 500 • For a 45 year old adult, the risk of death from cancer from a single CT exam is about in 1,250 Brenner et al Radiology, 231(2):440-445 Clinical Indications for MSCT • Calcium Scoring (CS) - risk stratification in the intermediate risk patient • Non-invasive coronary angiography (CTA) in the symptomatic low-risk patient or asymptomatic intermediaterisk patient *A negative test (normal CTA) has a 98% chance of revealing normal coronary arteries on invasive angiography* Test Selection According to Pretest Probability of CAD Association for the Eradication of Heart Attacks (AEHA.org) When to Consider MSCT • Equivocal stress test or persistent symptoms despite negative stress test • Prior to non-coronary cardiac surgery (valve or congenital repair) • Patients with difficult access or on therapeutic warfarin • Suspected coronary anomalies CFX LAD RCA Lt Main When to Consider MSCT (continued) • Idiopathic dilated cardiomyopathy • Cardiac transplant evaluation • Patients to undergo electrophysiologic intervention (AF ablation, BiV pacing) • Selected patients pre- and post-bypass surgery (aortic pathology, graft patency) Mikaelian BJ et al Circulation 2005;112:e35-e36 Pulmonary Vein Stenosis Vasamreddy et al Heart Rhythm (2004) 1, 78-81 Aortic Coarctation Visualized by 16-Row Detector MSCT Fröhlich, G et al Circulation 2005;112:e81 Pericardial Calcification Multi-Slice CT Scanning Superior to MRI Hoffmann et al Circulation 108 (7): 48e Figure IG1 Future Indications Nikolaou et al Cardiology Clinics 21;(2003):639-655 The Great Promise of MSCT The “Triple Rule-Out” Appropriateness Criteria “an appropriate imaging study is one in which the expected incremental information together with clinical judgment exceed the expected negative consequences* by a sufficiently wide margin that the procedure is generally considered acceptable care and a reasonable approach for the indication.” *include risks of the procedure and the downstream impact of poor test performance such as delay in diagnosis (false -) or inappropriate diagnosis (false +) ... forthcoming Calcium Volume Scoring Area = mm2 Peak CT = 290 Score = x = 16 Area = 15 mm2 Peak CT = 450 Score = 15 x = 60 Total Score = S Hn x-factor (Agatston Scoring) 130- 199 200- 299 300- 399 >400... Sensitivity, specificity, (+) PV, (-) PV: – By segment-(86%, 95 %, 66%, and 98 %) – By artery- (91 %, 92 %, 80%, and 97 %) – By patient- (95 %, 90 %, 93 %, and 93 %) Raff GL et al J Am Coll Cardiol Aug 2, 2005;46:552-7... Nonobstructive Coronary Lesions by 64 -Slice Computed Tomography • 59 patients with stable angina subjected to CTA before catheter-based angio • Diagnostic image quality in 55 of 59 • Sensitivity for detection