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 .

No HTN. LVEF: 50% • Referred for calcium scoring and CTA . or tobacco use • Negative stress echo previously • Atypical chest pain • Stress echo: septal hypokinesis at rest. Case Presentation • 64-year-old female with stage 1 CLL • Dyslipidemia (untreated). diabetes.

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

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Summary 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 .

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 .

Cardiac Magnetic Resonance .

Viability Assessment CMR Delayed Hyper-Enhancement .

Hazards of MRI Magnet-Seeking Projectiles .

First whole-body CT cross-section through a human thorax. generated by Ledley et al in 1974 (Science 1974.186:207) .

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The Examination .

4 mm .conventional coronary angiography 0.Current Generation Scanners • Spatial resolution 0.15-0.25 mm • Temporal resolution (shutter speed) improved to 166 msec with faster gantry rotation (330 msec) – conventional angiography 6 msec • Up to 64 slices in one rotation .

25 Pitch ~0.25 3 cm in 5 sec 6.25 Pitch ~0.5 cm in 5 sec . 4 to 64 Slice Scans Five Heart Beats 10 mm detector 20 mm detector 40 mm detector Pitch ~0.2 cm in 5 sec 12.

can use segments from different heart beats to improve temporal resolution . 64-Slice CT Scanner • More coverage (volume) with each heart beat • Entire heart imaged in 5-15 seconds • Less contrast required • No increase in rotation speed. but with overlapping slices.

3-D Volume Rendered Image .

Maximum Intensity Projection Soft Plaque in Proximal LAD .

Curved Planar Image .

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respectively) • Excellent accuracy with proximal lesions Leber AW et al. 73%.46:147-54 . July 5. J Am Coll Cardiol. Quantification of Obstructive and 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 of stenosis <50%. and >75%: (79%. and 80%. 2005. >50%.

(91%. 935 evaluated (88%) • Quantitative assessment in 773 of 935 segments by MSCT and QCA • Sensitivity. Diagnostic Accuracy of Noninvasive Coronary Angiography Using 64-Slice Spiral Computed Tomography • 70 patients undergoing invasive cath • Of 1.065 segments. 93%. Aug 2.46:552-7. and 97%) – By patient.(95%. and 93%) Raff GL et al. 90%. specificity. 95%. J Am Coll Cardiol. and 98%) – By artery. (+) PV. 66%. 2005. 80%. . (-) PV: – By segment-(86%. 92%.

Coronary Calcium Scoring • Initial ACC/AHA guidelines “may be useful in selected patients”… • Added prognostic power to conventional risk stratification tools (Framingham) • Revised guidelines (and reimbursement for service) likely forthcoming .

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

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* .

Ethnic Differences in Coronary Calcification The Multi-Ethnic Study of Atherosclerosis (MESA) 6814 men and women aged 45-84 years Bild DE et al. . Circulation. 2005.111:1313-1320.

Five-Year Mortality Rates in Framingham Risk Subsets by Coronary Calcium Score * *p<0. Radiology 2003.001 * * Shaw et al. 228:826-833 .

0001) Raggi P et al. Progression of Coronary Artery Calcium and Risk of First MI 495 Asymptomatic Patients Started on Statin Therapy • MI in 41 pts during 3.2 + 0. Arterioscler Thromb Vasc Biol. .2-fold higher (P<0. 2004.7 years • LDL levels similar in MI and non-MI pts • Relative risk of MI in presence of CAC progression was 17.24:1272-77.

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

Soft Plaque Visualization .

0 mg/dl) • Small vessels (<1. CTA Limitations • Rapid (>80 bpm) and irregular HR • High calcium scores (>800-1000) • Stents • Contrast requirements (Cr > 2.5 mm) and collaterals • Obese and uncooperative patients • RADIATION EXPOSURE .

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Effective Dose of Selected
Radiologic Examinations
• PA/Lateral CXR 0.04-0.06 mSv
• Head CT 1-2 mSv
• Chest CT 5-7 mSv
• Abd/Pelvis CT 8-11 mSv
• Diagnostic Cor Angiogram 3-5 mSv
• MSCT angiography 9.3-11.3 mSv
*Average annual background radiation in U.S ~ 3.6 mSv
Morin et al. Circulation 2003;107:917-22.

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 1 in 500
• For a 45 year old adult, the risk of death
from cancer from a single CT exam is
about 1 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 intermediate-
risk 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 .

graft patency) . BiV pacing) • Selected patients pre.and post-bypass surgery (aortic pathology. When to Consider MSCT (continued) • Idiopathic dilated cardiomyopathy • Cardiac transplant evaluation • Patients to undergo electrophysiologic intervention (AF ablation.

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

78-81.Pulmonary Vein Stenosis Vasamreddy et al. Heart Rhythm (2004) 1. .

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

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

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

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 +) .