Multi-Slice CT for Coronary Calcium Scoring and Coronary Angiography

1. Ms. Leonardo Roever Multi-Slice CT for Coronary Calcium Scoring and Coronary Angiography

7. CT Angiogram Interpretation • Calcium Volume Score: ZERO • CT angiography: • Left Main, Circumflex, and Right coronary arteries: normal • LAD: eccentric, soft plaque adjacent to origin of first diagonal (~60% stenosis) • Correlation recommended

8. Cardiovascular Imaging - State of the Art • Multi-slice CT (MSCT) not likely to replace conventional angiography • Post-processing of images for MSCT angiography time & labor intensive • Major strength of CTA is its high negative predictive value • CMR to become the preferred cardiac imaging modality in the future

9. Which Test for Which Patient? • All modalities are improving • No single modality fits all applications and all patients • Choice of initial test depends on the specific clinical question in individual patient

10. Viability AssessmentCMR Delayed Hyper-Enhancement

11. 4 to 64 Slice ScansFive Heart Beats 10 mm detector Pitch ~0.25 3 cm in 5 sec 20 mm detector Pitch ~0.25 6.2 cm in 5 sec 40 mm detector Pitch ~0.25 12.5 cm in 5 sec

12. Maximum Intensity ProjectionSoft Plaque in Proximal LAD

13. Curved Planar Image

18. Calcium Volume Scoring Area = 8 mm2 Peak CT = 290 Score = 8 x 2 = 16 Area = 15 mm2 Peak CT = 450 Score = 15 x 4 = 60 Total Score = S Hn x-factor (Agatston Scoring) 130-199 1 200-299 2 300-399 3 >400 4

19. The Calcium Scale The calcium scale is a linear scale with 4 calcium score categories: 0 none 1–99 mild 100–400 moderate >400 severe *Calcium score correlates directly with risk of events and likelihood of obstructive CAD*

20. Ethnic Differences in Coronary CalcificationThe Multi-Ethnic Study of Atherosclerosis (MESA) 6814 men and women aged 45-84 years Bild DE et al. Circulation. 2005;111:1313-1320.

21. Five-Year Mortality Rates in Framingham Risk Subsets by Coronary Calcium Score * *p<0.001 * * Shaw et al. Radiology 2003; 228:826-833

22. Progression of Coronary Artery Calcium and Risk of First MI495 Asymptomatic Patients Started on Statin Therapy • MI in 41 pts during 3.2 + 0.7 years • LDL levels similar in MI and non-MI pts • Relative risk of MI in presence of CAC progression was 17.2-fold higher (P<0.0001) Raggi P et al. Arterioscler Thromb Vasc Biol. 2004;24:1272-77.

23. Coronary Disease Progression Calcified Plaque Detected by CT >60% stenosis (+) stress/imaging Role for CTA ?

24. Soft Plaque Visualization

25. CTA Limitations • Rapid (>80 bpm) and irregular HR • High calcium scores (>800-1000) • Stents • Contrast requirements (Cr > 2.0 mg/dl) • Small vessels (<1.5 mm) and collaterals • Obese and uncooperative patients • RADIATION EXPOSURE

29. 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 intermediate-risk patient *A negative test (normal CTA) has a 98% chance of revealing normal coronary arteries on invasive angiography*

30. Test Selection According to Pretest Probability of CAD

31. Association for the Eradication of Heart Attacks (AEHA.org)

32. 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

33. CFX LAD RCA Lt Main

34. Mikaelian BJ et al. Circulation. 2005;112:e35-e36.

35. Pulmonary Vein Stenosis Vasamreddy et al. HeartRhythm (2004) 1, 78-81.

37. Aortic Coarctation Visualized by 16-Row Detector MSCT Fröhlich, G et al. Circulation. 2005;112:e81.

38. Pericardial CalcificationMulti-Slice CT Scanning Superior to MRI Hoffmann et al. Circulation 108 (7): 48e Figure IG1

39. Future Indications Nikolaou et al. Cardiology Clinics. 21;(2003):639-655.

40. The Great Promise of MSCTThe “Triple Rule-Out”