Cardiac CT

Principles and Practice

Mohd Rahal Yusoff
Consultant Cardiologist and Internal Medicine
Columbia Asia Hospitals, Malaysia
Chair, Society of Cardiac Imaging Malaysia
Cardiac CT

Very progressive and rapidly evolving.

Some applications have matured and some are still at infancy.

Complimentary to other imaging modality.

Many published articles and growing.

Cardiac CT

Its visualization of coronary arteries non invasively.

2 parts: Coronary calcium score (CACS)

CT angiography (CCTA)

Vast improvement in CT scanners – EBCT, MDCT (4, 16, 64), Dual source, 320
slice MSCT.

Faster scanners and lower radiation.

Most importantly, please ensure the indication for the procedure is proper and
appropriate prior to performing the test.

Patient preparation is vital: breath-hold (10-15 seconds), able to raise both hand
over the head, heart rate slow and regular, renal function, contrast allergy.
Coronary Artery Calcium (CAC) Score – “mammogram for the heart”

Introduced more than 25 years ago by Drs Agatston and Janowitz.

Proved time and time again to be an extremely powerful risk stratification tool
regardless of age , gender and ethnicity.

It is a quick, low cost, low risk screening tool to risk stratify, identify patient needing
aggressive preventive treatment, enhance compliance and aid close monitoring of
some patients

CAC scanning is a non-contrasted, limited chest CT, with a 3-5s breath-hold.

Presence of CAC is quantified throughout the entire epicardial coronary system.

Coronary calcium is defined as a lesion above a threshold of 130HU, with an area

> 3 pixel (1mm2)
Hecht H . JACC CVI 2015,5,579-96
Score of 0 – absence of calcified plaque, 1-10 – minimal plaque, 11-100 – mild
plaque, 101-400 – moderate plaque and > 400 severe plaque

MESA study:
6814 Individuals followed up for 3.8years (some sub-group up to 14.5 years).
Compared to CACS of 0, HR for a coronary event were 7.73 for CACS (100-300)
and 9.67 for CACS > 300.

In 2684 female patients, Lakoski et al reported an HR of 6.5 for the 32% with a
CACS of > 0 versus the 68% with a CACS of 0, even though 90% were low risk by
the FRS

In a meta-analysis of 64,873 patients followed for 4.2 years, the coronary event
rate was 1% per year for the 42,283 with a CAC score >0 compared with 0.13%
per year in the 25,903 patients with a CACS of 0.

Detrano R et al, NEJM 2008;358:1336-45, Joshi PH et al, Circ 2014;130:A11701

ZERO Calcium score:
Event rate in patients with a CACS of 0 is very low. Raggi et al, demonstrated an
annual event rate of 0.11% in asymptomatic subjects with a CACS of 0, (10 year
risk of 1.1%).
Absence of calcified plaque conveys a 10 year risk of 1.1-1.7%, irrespective of the
number of risk factors.

Raggi P et al, Circ 2000;101:850-5, Nasir K et al, Circ CVI 2012;5:467-73

Risk assessment and detection in asymptomatic patients with no previous
history of CAD.
Coronary calcium scoring for risk assessment and detection of CAD in
asymptomatic patients

Coronary calcium scoring is recommended in patients with a family history of

premature CAD (AUC A, LOE A).

Coronary calcium scoring is inappropriate in patients at low risk of CAD (AUC I,

LOE A).

Coronary calcium scoring is recommended in patients at intermediate risk of CAD

(AUC A, LOE A).

Coronary calcium scoring can be considered in patients at high risk of CAD (AUC U,
LOE A).
CCTA

Cardiac computed tomographic angiography (CCTA) is most commonly used

to establish the diagnosis of suspected coronary artery disease.

Done via the direct visualization of the coronary arteries.

As with all diagnostic testing, the appropriate and accurate use of CCTA must
take into context the patients symptoms complex and an estimated pretest
probability of IHD.

Wolk MJ et al, JACC 2014;63:380-406

CCTA

For symptomatic patients, the pretest probability may be calculated from an

establish clinical algorithm such as the Diamond and Forrester.

For asymptomatic patients, pretest probability of global CAD risk may be

estimated with various clinical risk scores such as the FRS.

Other factors such as family history, ECG changes and prior diagnostic testing
should be integrated into the decision to proceed to CCTA.
CCTA
The diagnostic utility of CCTA rests on its high sensitivity for angiographically
significant stenosis and thus excellent negative predictive value in patients with a
lower pretest probability of disease.

In the ACCURACY study,

245 patients with CP without CAD who were referred to ICA.

On a per=patient basis, sensitivity of CCTA was 94-95%, specificity was 82%, PPV
of 48% (with a disease prevalence of 14%) and NPV of 99%.

For prognosis, a normal CCTA has an especially good prognosis over 2.5 years
follow up, with rates of adverse events of < 1% per year.

Budoff MJ et al, JACC 2008;52:1724-32, Paech DC et al, BMC Cardiovasc Disord 2011;11:32,
Hulten EA et al, JACC 2011;57:1237-47, Min JK et al, JACC 2011;58:849-60
Representative images of stenosis categories on Coronary CT angiography
Representative images of plaque characteristics on coronary CT angiography
CCTA

CCTA is most useful in symptomatic patients at an intermediate risk of CAD,

especially if they have uninterpretable ECG or are unable to exercise.

ACC guidelines states that it might be reasonable to performed CCTA in

patients with an intermediate pretest probability of CAD who are incapable of
exercise (Class IIa) and might be reasonable in patients with intermediate
pretest probability of CAD who can exercise (Class IIb)

Similarly the European Society of Cardiology has support the use of CCTA for
patients at low to intermediate risk (pre-test probability of 15-50%) of suspected
CAD (Class IIa)
In asymptomatic patients:

More restricted, because the incremental value of CCTA is reduced in this cohort.

CONFIRM registry, there was only a negligible improvement in risk classification by

the use of CCTA compared to CAC scanning alone.

However it may be useful in asymptomatic patients with a CAC score of > 100.

In the same registry, in symptomatic patients, CCTA added incremental

discriminatory power over CAC score for patients at risk of death or myocardial
infarction.

AUC recommends the use of CCTA as may be appropriate only in asymptomatic

patients at high global CAD risk.

Cho I et al, Circ 2012;126:304-313), Cho I et al, EHJ 2015;36:501-5

In patients with diabetes:

CCTA findings conferred incremental risk prediction beyond demographics and

CAC score, for major adverse cardiovascular events (MACE) over a 2.4 years
follow-up.

Screening CCTA for asymptomatic diabetics was not found to be incrementally

benefit in the FACTOR 64 study.

900 diabetics of at least 3-5 years of duration were randomized to CCTA or

optimal diabetes care for 4 years, the primary outcome of mortality, non fatal MI
or unstable angina requiring hospitalization did not significantly differ between
the 2 groups.

Min JK et al, Atherosclerosis 2014;232:298-304, Muhlenstein JB et al, JAMA 2014;312:2234-43

Use of CCTA to follow up prior CAD diagnostic testing:

CCTA is appropriate in patients with new or worsening symptoms and a previous

normal exercise test or an abnormal stress test (exercise or imaging)

CCTA is also appropriate for the follow-up of abnormal or inconclusive stress test.

ESC guidelines for stable CAD give a Class IIa recommendation to the use of CCTA
after a non-conclusive stress test in patient with low to intermediate risk of CAD in
order to avoid otherwise necessary invasive angiography.

Montelescot G et al, EHJ 2013;34:2943-3003

CCTA in the evaluation of acute chest pain syndromes
In patients with acute chest pain but without known CAD presenting to the ED
department.

ACRIN-PA trial – enrolled 1370 low to intermediate risk patients with suspected ACS.
Randomized to CCTA versus usual care. CCTA group had an absolute 27% higher rate
of discharged from the ED, shorter length of stay and a 6% absolute increase in the
detection of CAD. There was no increase in adverse events with the CCTA strategy,
with less than 1% incidence of MI in patients with a negative CCTA.

ROMCAT II trial – randomized patients at intermediate risk with suspected ACS without
ischemic electrocardiography and an initial negative troponin to early CCTA or
standard evaluation. CCTA reduced length of stay by 7.6 hours with more patients
being discharged from the ED, No significance difference in major adverse CV events
at 28 days. Cumulative cost was similar due to increase downstream testing.

Litt HI et al, NEJM 2012;366:1393-403, Hoffman U et al, NEJM 2012;367:299-308

CCTA in the ER: major clinical trials

Randomized prospective trials: low to intermediate risk of CP

CT-STAT (Goldstein et al, JACC 2011)

ROMICAT II (Hoffman et al, NEJM 2012)
ACRIN-PA (Litt et al, NEJM 2012)
CT-COMPARE (Hamilton-Craig et al, Int J Cardiol 2014)

N=3861 patients studied in randomized control trials

REDUCED length of stay, REDUCED cost, safe and reliable

High Risk Plaques
Predictive of cardiac event (cardiac death, MI, unstable angina and revascularization > 90days after
CCTA
Automated Quantification of low
attenuated plaque volume

Dark green – Fibrous plaque

Light green –Fibro-fatty
Grey – Calcified
Red – Low attenuation plaque
Deseive S et al , JCCT
2018
Incremental Prognostic Value of Low-attenuation Plaque Volume
Endpoint = composite of cardiac death and acute coronary syndrome

Deseive S et al , JCCT
2018
 FFR-CT
Fractional Flow Reserve

Advances in computational fluid dynamics

3D models of pressure and flow within the
aortic root and coronary arteries are created
at rest and maximal hyperemia.
Assumptions: coronary flow is proportional
to mass, microvascular resistance is
proportional to vessel size and resistance is
reduced during maximal hyperemia.
Accuracy of FFR-CT

NXT trial – used most up-to-date software and improved CCTA acquisition
protocol. Patients with suspected CAD underwent FFR-CT less than 60 days prior
to scheduled ICA with FFR. Invasive FFR < 0.80 was the reference standard.
FFR-CT was superior to CCTA (AUC 0.9 vs ).81, p=0.0008). Adding FFR-CT to
CCTA increased the per patient specificity from 34% to 79% and PPV from 40% to
65% for diagnosing ischemia producing coronary lesion.

Growing enthusiasm for the evaluation using FFR-CT as a gate-keeper to the

cardiac catheterization laboratory.
Representation of a patient with high
coronary calcification (AS).
Norgaard BL et al, JACCCVI 2015;9:
1045-55.
AUC of coronary CTA and FFRCT for discrimination of ischemia in patients and vessels with low-mid
and high AS level (Norgaard BL et al,JACCCVI 2015;9;1045-55)
Conclusion:
FFR-CT provided high diagnostic performance and discrimination of ischemia in
patients and vessels over a wide range of coronary calcification scores. The
diagnostic accuracy and specificity of FFR-CT was superior to coronary CTA
assessment in patients with low, intermediate or high levels f calcification
Kitabata et al, JCCT 2018
CT in Valvular Heart Disease
Newer Application of Cardiac CT

Dual Energy CT
Spectral CT
Dual Energy CT

Exploiting the differences in energy

dependent attenuation of materials when
exposed to 2 different photon energy levels.

Clinical applications include:

Better tissue characterization

Better atherosclerotic plaque
characterization
Dual Energy CT

Enhanced visualization of myocardial perfusion defects – ischemia assessment potential.

Mapping of iodine distribution in the myocardium as a surrogate marker for perfusion and blood volume.

Myocardial perfusion protocol as a supplement to anatomic evaluation of the coronary arteries with
coronary CTA. (DECT perfusion with CCTA)

Studies have compared DECT with SPECT, CMR or ICA.

Incremental value of DECT perfusion imaging as an adjunct to CCTA, which decreased the number of
false positive results on CCTA, reflected by improvements in both specificity and positive predictive
value.

Infancy, with published studies limited in sample size, referral bias and lack pf proper reference
standard.

Ko Sm et al, Eur Radiol 2011;21:21-23, AJR 2012;198:512-20

Danad et al, JACC CVI 2015
Spectral CT Imaging

Multicolor CT – exploits the energy-dependent

attenuation of X-ray photons and may be coupled
with nanoparticles to potentially offer improved
atherosclerotic evaluation.

Uses multiple energy levels – sophisticated

characterization of tissues.

Looks promising with good potential for improved

cardiac and coronary atherosclerosis.
Conclusion

Field of Cardiac CT is growing tremendously.

Efficacy and patient safety.

Complimentary to other imaging modality.

Thank You Very Much and Good Luck