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MSCT Potential Benefits and Limits Antoine Sarkis, MD Associate Professor of Cardiology Hôtel Dieu de France Hospital.

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Presentation on theme: "MSCT Potential Benefits and Limits Antoine Sarkis, MD Associate Professor of Cardiology Hôtel Dieu de France Hospital."— Presentation transcript:

1 MSCT Potential Benefits and Limits Antoine Sarkis, MD Associate Professor of Cardiology Hôtel Dieu de France Hospital

2 MSCT is a major innovative technique for non-invasive detection of coronary artery stenoses 129 patients 129 patients Compare the diagnostic accuracy of multislice CT and MRI Compare the diagnostic accuracy of multislice CT and MRI Sensitivity for detection of clinically significant coronary stenoses (> or =50%): 82 % Sensitivity for detection of clinically significant coronary stenoses (> or =50%): 82 % Specificity: 90 Specificity: 90 Negative predictive value: 95 % Negative predictive value: 95 % Ann Intern Med Sep 19;145(6):466-7.

3 Potential Indications MSCT in asymptomatic persons MSCT in asymptomatic persons MSCT in highly suspected Coronary artery disease MSCT in highly suspected Coronary artery disease MSCT in known Coronary artery disease: follow-up of graft patency, stents MSCT in known Coronary artery disease: follow-up of graft patency, stents

4 MSCT in asymptomatic persons: 1st Scenario: Normal CT Normal CT in a person with no or minimal risk factors for CAD Normal CT in a person with no or minimal risk factors for CAD Good news, but was-it a surprise? Was the CT really needed? Good news, but was-it a surprise? Was the CT really needed?

5 MSCT in asymptomatic persons: 2nd Scenario: Plaque or mild to moderate stenosis This patient has risk factors, he is asymptomatic, but CT shows ~ 50% stenosis on LAD and RCA. This patient has risk factors, he is asymptomatic, but CT shows ~ 50% stenosis on LAD and RCA. What is the next step? What is the next step?

6 MSCT in asymptomatic persons: 2nd Scenario: Plaque or mild to moderate stenosis LAD RCA LAD What is the next step? What is the next step?

7 MSCT in asymptomatic persons: 2nd Scenario: Plaque/or mild to moderate stenosis This patient had cardiac cath, then cardiac scintigraphy, exactly the inverse classical way of screening asymptomatic patients This patient had cardiac cath, then cardiac scintigraphy, exactly the inverse classical way of screening asymptomatic patients He received a total of 36 mSv He received a total of 36 mSv Knowing he has multiple risk factors, did CT add information to his status? Knowing he has multiple risk factors, did CT add information to his status? Final treatment: Statins, Aspirin, Anxiolytics Final treatment: Statins, Aspirin, Anxiolytics

8 MSCT in asymptomatic persons: 3rd scenario: severe disease

9 LAD RCA

10 MSCT in asymptomatic persons: 3rd scenario: severe disease Couldnt we identify this patient by non invasive testing: Stress test with or without nuclear imaging or echo? Couldnt we identify this patient by non invasive testing: Stress test with or without nuclear imaging or echo?

11 MSCT in asymptomatic persons: 4th Scenario: massive calcium 56 yrs old man, smoker, dyslipidemia, hypertension

12 MSCT as a screning test? Pro Growing burden of atherosclerotic disease Growing burden of atherosclerotic disease Known and unknown risk factors Known and unknown risk factors Stess test has limited positive predictive value specially for one vessel disease Stess test has limited positive predictive value specially for one vessel disease MSCT is a cross-sectional imaging technique MSCT is a cross-sectional imaging technique It shows the contrast-enhanced vessel lumen (like cath) It shows the contrast-enhanced vessel lumen (like cath) It also has the potential to visualize the vessel wall and non- obstructive soft or calcified coronary atherosclerotic plaque It also has the potential to visualize the vessel wall and non- obstructive soft or calcified coronary atherosclerotic plaque the only clinically available non-invasive study with this capability. the only clinically available non-invasive study with this capability. Do it like mammography for cancer screening? Do it like mammography for cancer screening?

13 MSCT as screning test? Cons Come back to the oculo-stenotic reflex? Come back to the oculo-stenotic reflex? Does CT add to the information obtained by risk scores based on traditional risk factors? Does CT add to the information obtained by risk scores based on traditional risk factors? Could we identify stable plaques, which will stay stable for years, from vulnerable plaques prone to rupture and MI? Could we identify stable plaques, which will stay stable for years, from vulnerable plaques prone to rupture and MI? CT detects disease, but does it make difference in prognosis? CT detects disease, but does it make difference in prognosis? Cost and reimbursment issues Cost and reimbursment issues

14 Best use of MSCT Patients who have equivocal stress-test results, such as a result that is uncertain or suspected to be false positive or false negative; then the CT is a good test to confirm or exclude coronary disease Patients who have equivocal stress-test results, such as a result that is uncertain or suspected to be false positive or false negative; then the CT is a good test to confirm or exclude coronary disease Its high negative predictive value suggests it could select patients who should not be referred to conventional angiography, thus avoiding unnecessary coronary angiograms. Its high negative predictive value suggests it could select patients who should not be referred to conventional angiography, thus avoiding unnecessary coronary angiograms. CT as a first test should be used only in a selected population, perhaps in patients of younger age in whom the likelihood of having a lot of calcium in the coronaries is low.... CT as a first test should be used only in a selected population, perhaps in patients of younger age in whom the likelihood of having a lot of calcium in the coronaries is low....

15 MSCT in highly suspected CAD? Typical chest pain Typical chest pain Positive test for ischemia (Stress test, nuclear imaging) Positive test for ischemia (Stress test, nuclear imaging) Little place for MSCT Little place for MSCT Go directly to coronary angiography, you can do PTCA in the same time Go directly to coronary angiography, you can do PTCA in the same time

16 MSCT in known CAD Follow-up of CABG ? Follow-up of CABG ? Follow-up of stent placement ?

17 Limitations Need to have a relatively slow, regular rythm Need to have a relatively slow, regular rythm Check renal function before injecting Iodine Check renal function before injecting Iodine Problem raised by calcifications Problem raised by calcifications There is still some difficulty identifying stenosis in peripheral segments There is still some difficulty identifying stenosis in peripheral segments Issues raised by high level of radiation Issues raised by high level of radiation

18 Effective radiation dose from various coronary diagnostic studies Cardiac Cath = 5-6 mSv. Cardiac Cath = 5-6 mSv. MSCT = mSv. MSCT = mSv. Calcium scoring scan= 2.6 mSv Calcium scoring scan= 2.6 mSv SPECT Thallium = 18 mSv. SPECT Thallium = 18 mSv. SPECT Sestamibi = 12.2 mSv. SPECT Sestamibi = 12.2 mSv. Normal environment radiation is 3.5 mSv/y. Normal environment radiation is 3.5 mSv/y. Persinakis, health physics 2002.

19 Risk of fatal cancer The International Commission on Radiological Protection (ICRP) has estimated that the additional lifetime risk of fatal cancer is approximately 1 in 20,000 per mSv for the whole population The International Commission on Radiological Protection (ICRP) has estimated that the additional lifetime risk of fatal cancer is approximately 1 in 20,000 per mSv for the whole population Based on available estimates, a coronary CT angiogram with an effective dose of 14.7 mSv has a risk of inducing a fatal cancer of 1 in 1,400. Based on available estimates, a coronary CT angiogram with an effective dose of 14.7 mSv has a risk of inducing a fatal cancer of 1 in 1,400. Conventional coronary angiography (5.6 mSv) has a risk of 1 in 3,600 Conventional coronary angiography (5.6 mSv) has a risk of 1 in 3,600 and a calcium-scoring scan (2.6 mSv) a risk of 1 in 7,700 and a calcium-scoring scan (2.6 mSv) a risk of 1 in 7,700 We never thought about this risk before !! We never thought about this risk before !!

20 ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR Appropriateness Criteria for Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging A Report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology A Report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology Hendel RC, Patel MR, Kramer CM, Poon M. J Am Coll Cardiol. 2006;48:

21 Report Summary Cardiac Computed Tomography (CCT) 1. CCT is not appropriate for initial screening of the general population or as an initial tool in evaluation of symptomatic individuals suspected of having coronary artery disease (CAD). 1. CCT is not appropriate for initial screening of the general population or as an initial tool in evaluation of symptomatic individuals suspected of having coronary artery disease (CAD). 2. CCT is considered appropriate for evaluation of CAD in patients with prior inconclusive stress test results. 2. CCT is considered appropriate for evaluation of CAD in patients with prior inconclusive stress test results. 3. CCT is considered highly appropriate for detection and evaluation of suspected coronary artery anomalies. 3. CCT is considered highly appropriate for detection and evaluation of suspected coronary artery anomalies. 4. CCT is not appropriate for evaluation of bypass grafts and stents in asymptomatic patients 4. CCT is not appropriate for evaluation of bypass grafts and stents in asymptomatic patients 5. CCT is considered highly appropriate for evaluation of complex cardiac anatomy, especially as related to congenital heart disease. 5. CCT is considered highly appropriate for evaluation of complex cardiac anatomy, especially as related to congenital heart disease.

22 Report Summary 6. CCT is considered highly appropriate for evaluation of cardiac masses such as tumor or thrombus, when not ideally evaluated with echocardiographic techniques. 6. CCT is considered highly appropriate for evaluation of cardiac masses such as tumor or thrombus, when not ideally evaluated with echocardiographic techniques. 7. CCT is considered appropriate for evaluation of pericardial disease such as constriction, cyst, or mass when information was not available from echocardiography 7. CCT is considered appropriate for evaluation of pericardial disease such as constriction, cyst, or mass when information was not available from echocardiography 8. CCT with angiography was considered highly appropriate for evaluation of suspected pulmonary embolus. 8. CCT with angiography was considered highly appropriate for evaluation of suspected pulmonary embolus. 9. CCT is considered of uncertain appropriateness for risk stratification prior to non-cardiac surgery. 9. CCT is considered of uncertain appropriateness for risk stratification prior to non-cardiac surgery.

23 In conclusion MSCT will undoubtedly modify our way of thinking MSCT will undoubtedly modify our way of thinking Its place in the screening of asymptomatic persons with multiple risk factors for CAD needs to be defined Its place in the screening of asymptomatic persons with multiple risk factors for CAD needs to be defined Who will resist the temptation of having a look to his coronary arteries by a non invasive technique and without moving one leg ? Who will resist the temptation of having a look to his coronary arteries by a non invasive technique and without moving one leg ?


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