1. Multi-Slice CT for Coronary Calcium Scoring and Coronary Angiography
Gunjan Gholkar MD
Metro Heart and Vascular

2. Objectives Show lots of pretty pictures
Raise awareness of current indications and clinical scenarios for which to consider CT angiography
Interpretation of reports
Review strengths and limitations of MSCT

3. Pretest Probability
Diamond – Forrester
Duke clinical score

4. Test Selection According to Pretest Probability of CAD

5. Indications of Coronary CTA
Ruling out significant luminal stenoses in stable patients with suspected coronary stenoses, but intermediate pretest likelihood of disease
High negative predictive value and thus allows one to reliably rule out presence of coronary stenosis.
Aim is to avoid unnecessary invasive testing
Most useful in low to intermediate risk
High false positive rate in very low risk patients.
Sensitivity decreases in very high pretest probability patients.

6. Indications of Coronary CTA
Ruling out coronary artery disease in acute chest pain
ER patients with normal enzymes , ekg and low likelihood of CAD.
Patient with new LBBB

7. Special situations- Emergency department chest pain
>60% ED chest pain is noncardiac. Numerous studies Show high NPV % Show poor PPV 47-52% Versus nuclear imaging is faster/cheaper/less repeat presentations.

8. Indications of Coronary CTA
3. Equivocal stress test or persistent symptoms despite negative stress test

9. Indications (Contd.)
Prior to non-coronary cardiac surgery (valve or congenital repair)
Evaluation of coronary artery disease in new onset heart failure.
Suspected coronary anomalies
Cardiac transplant evaluation
Determine patency of bypass grafts

10. Case 1 43 year old man commenced a new exercise program
Left side chest discomfort on exertion
Cholesterol 6.0, LDL 3.6, HDL 1.3
No smoking, diabetes, HT or family history of IHD
BMI 26 kg/m2
Medications – none
Resting ECG – normal
What next ?

11. Functional Test
Objectively negative stress echocardiogram – 13 minutes
However, vague left sided chest pain at peak exercise
“Is my heart OK ?”

12. LAD
CIA Mar 08

13. Indications (Contd.)
Patients to undergo electrophysiologic intervention (AF ablation, BiV pacing)
Aortic diseases
Pericardial disease
Congenital heart diseases

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

15. Pulmonary Vein Stenosis
Vasamreddy et al. Heart Rhythm (2004) 1,

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

17. Left Main Arising from right Cusp

18. The Great Promise of MSCT The “Triple Rule-Out”

19. Normal coronary arteries

20. Tight LAD stenosis

21. Indications (Contd.)
Assessment of complex congenital heart disease especially in regards to both coronary/great vessels and cardiac chambers and valves.

23. Surgical planning
The use of MDCT in surgical planning before cardiothoracic surgery, particularly for reoperations, is increasingly recognized.
Preoperative scans can evaluate the proximity of mediastinal structures to the sternum( i.e. aorta, right ventricle, bypass grafts); the degree of aortic calcification( i.e. to guide cannulation sites); and concomitantly provide information about cardiac morphology( e.g. presence of a ventricular aneurysm).
Ongoing studies are evaluating whether this added information might reduce intraoperative and perioperative complications.

24. Special Situations- Coronary Stents
Core 64 trial showed PPV 57% and NPV 80% if stent < 3.0mm
If left main stent > 4.0mm is 98% accurate
Routine use of CTCA for instent restenosis is NOT recommended.

25. Cardiac morphology/function
Contrast enhanced MDCT can provide high resolution morphologic images of cardiac chambers.
It can also provide accurate assessment of right and left ventricular systolic function.
Other imaging modalities such as echocardiography , MRI which do not require radiation exposure are preferred for cardiac morphology.

26. Inappropriate indications
Asymptomatic patients
High pretest probability including positive stress tests.
Positive cardiac enzymes or ST elevation on ECG.
Instent evaluation especially stents < 3.0 mm.

27. Contraindications

28. Relative contraindications

32. Case 2 48 yr old man Consistent exertional bilateral arm tightness
“like the compression of a blood pressure cuff”
Hyperlipidemia. Father and brother IHD in their 50s. On no medical therapy at time of presentation
Negative Stress Echo after 12 minutes of Bruce protocol. No symptoms with stress test
Worrying symptoms and CV risk factors, but negative functional test

33. Outcome
This patient had a concerning history and risk factor profile. He declined the offer of an invasive angiogram given his negative stress test. He agreed to have a CT coronary angiogram which detected severe proximal LAD disease which required revascularisation.

34. Volume rendered image of Coronary CT
Severe LAD and Diagonal branch stenosis

35. Coronary artery calcium scoring

36. Coronary Calcification
Proven robust technique in identifying at risk population
Coronary Calcium Score >100 or >75th pecentile identifies a CAD equivalent
Coronary Calcium scores are given in all patients undergoing CTA except graft patients and some stent patients.

37. Diagnostic accuracy CTCA vs Invasive coronary angiography
Visualize wall in addition to lumen
ICA may not detect positive remodeling and underestimate plaque burden

38. 2010 ACCF/AHA Guidelines for assessment of cardiovascular risk in asymptomatic adults.

39. Clinical applications

41. The Calcium Scale 1–99 mild 100–400 moderate >400 severe
The calcium scale is a linear scale with 4 calcium score categories:
0 none
1– mild
100– moderate
> severe

43. Interpretation of CTA Calcium score
Severity of stenosis and coronary segments.
Type of plaque
Non-cardiac findings

44. Recommended Quantitative Stenosis Grading
0 Normal: Absence of plaque and no luminal stenosis
1 Minimal: Plaque with <25% stenosis
2 Mild: 25%–49% stenosis
3 Moderate: 50%–69% stenosis
4 Severe: 70%–99% stenosis
5 Occluded

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

46. Thank you