Chapters Transcript Video Coronary CT Anatomy & Plaque Morphology Click here to view presentation deck Back to Symposium I met you a little bit earlier, but I'm Angel but Toska. Uh so today I'm presenting my second talk today would be on the Coronary Ct anatomy and plaque morphology, a full evaluation of coronary disease. So I'll basically start with discussion um about um ac T scanner and then doctor year after he'll pick up and he'll continue what, what would be the right test to choose for the patient in the, in um certain scenarios. So let's begin, I don't have any relevant disclosures to today's talk. So I would like to present the real case. Um So, um a 65 year old uh pulmonary critical care physician comes into a clinic. He has a history of hypertension and hyper epidemic. He complains of chest pressure. That's what he's presented with. Um the chest pressure is worsened with exertion. He said sometimes when he's rounding on critical care patients. Um It's also, he says it's also been present now for a year. Um Sometimes when he works overnight, he noticed that he, when there's a cold and he has to run it. Um And he has to um with high stress level at that, you know, at that time, he gets kind of like emotional ST you know, chest pain and that uh during those cold situations as well, he does not have any pri uh prior coronary artery disease history. He is currently on Vervain 10 mg daily. He is on the 5 mg daily. Um His EKG in the office is completely normal. So uh based on those results, we send our patient for coronary CT. So now why did we choose this specific test for our patients? Well, according to um uh 2021 ac CAA lot of societies based, all of them are cardiology society and imaging societies. But basically, it's a H A AC CASC chest, uh the CT conferences, a lot of them. So and this is actually a very cool document because before that, this was right around when I started my fellowship. Before that, we did not have chest pain guidelines specifically, these are the first uh specifically dedicated chest pain guidelines. Really amazing document. I definitely recommend everyone um read through some portions of it. Um a lot of useful information. But anyway, uh so um based on the, based on the guidelines, we uh can now um calculate our patients risk score. And uh according to the guidelines, if you have a patient with chest uh stable chest pain, like in this patient has been present for the past year, no, no one Coronary disease in the past basically, no diagnosis of coronary disease in the past um we can do their clinical risk assessment of their score. What's our pre test that he has a coronary disease or? Um and if it's intermediate to high risk, which is over 15% then we can send our patient for this two different paths. We can either choose a uh CT scan uh or we can choose a stress test. And in terms of the stress test, there's multiple uh modality, stress CMR stress, pet stress spec stress echo. Um And uh two, a recommendation is stress EKG. So uh in general, my approach, uh CT is preferable in patients less than 65 years of age uh and not an optimal preventative therapy prior in conclusive stress testing or if we want to rule out obstructive C ad. So, back to our patient, our patient, this is the scan. Uh Now um we got a result and he has um this smooth um moderate non calcific plaque, which is 50 to 69% in his mid RC A. So now we have a dilemma. What do we do with our patient? Do we um think that the symptoms are responsible for the patient's chest pain or is this something else just to uh diverge a little bit before we dive in uh into our patient? Um This is just basically how we stage stenosis um uh on based on CT scan. Um And we know that CT scan uh has been around for about 15 years now. And honestly, it has evolution. Um Our ability to evaluate stenosis and characterize plaque. And you see over here, we have various degrees of stenosis on this picture going from left to right. Uh We go from minimal ce D to severe. Minimal is 1 to 24 mild, 25 to 49 moderate would be 48 to 69 and severe could be over 70 we call something obstructive. Uh what do we call obstructive uh disease? It's when you have moderate and above. So basically above 50. So just something to be aware if we put the numbers in our reports. Uh This is what that, what that means. So um so what do we have where we're at right now? So it's class one level evidence, a indication uh for Coronary CTM guidelines in stable and acute chest pain uh in patients with intermediate to high risk to abstain CT scan. But coronary CT scan is not appropriate to every patient. So who are some of our patients who um that may not be benefiting from AC T scan. Um You basically uh multi patient specific factors may result in suboptimal image quality uh including body mass index. Um Over 50 uh I've noticed that um even over 40 may be a little bit challenging on some of the older scanner and patients may receive high radiation doses. So you may want to ask about family history of uh ca cancer just to make sure we don't do not, uh, add more radiation to the patient. Uh Also, if patient has arrhythmia tachycardic, if patient is unable to take, um, beta blockers or nitroglycerin for any reasons that they would not be a candidate for AC T scan because we use those medications. Um, if patient has stents, if the stents are small, uh, if the stent is less than three millimeter, uh, it's unlikely we'll be able to see inside the stent and provide useful informa uh useful information. Also, in terms of the bypass graft, especially in relation to the insertion points, it may be difficult to evaluate those two. And in patients, many of many patients usually have um CT done for any other reasons if you scroll over those CTS. And if you see this type of picture how you are seeing here with heavy calcifications, very heavy all over, do not send them for CT. This would not be very, very, very, very beneficial for the patient because we will not see inside what's behind that plaque. We will not be able to assess the degree of stenosis. We we just will call it probably a dense civic plaque, obscuring the lu and unable to allow stenosis. Unfortunately, I had to use this a lot in my practice and you, we want to be useful and helpful. But if we can't see something inside, we just can't provide useful information. So these are some um of the inappropriate. Um So what are the, what are the advantages of coordinating CTM? So, um coronary CT has a high negative predictive value. Um So, meaning negative CT scan rules out coronary artery disease because we see if it's a well done uh CT scan, if we can see every segment of the coronary artery virtually, if the plaque is not there, we we're not, not gonna see patient does not have a coronary artery disease. Uh It detects non obstructive plaque uh that we would not otherwise pick up with the stress test since patient will not develop ischemia with non obstructive plaque. So, um and that way, if we see this kind of plaque over here, how we have any patient? This is non obstructive plaque, mild. Um We are able to start uh medical therapy for the patients earlier. Um Just to uh give you a little bit of insight how we report patient plug because you will likely see the results of CT scans just to know what all of those results mean. We use um C ad rats to uh reporting system. These are the two most by me use mo by all of us. I'm sure two most use slides. And basically it's a 2022 Coronary Artery disease reporting, uh data and system and expert consensus uh document uh produced by AC CH A uh see multiple societies, Imaging and cardiology Society. But basically what I want you to take a look here that um how we report plaque burden. So we can either uh report plaque burden by, by the amount of calcium C ac calcium score or we can do a visual assessment. Basically how many segments are involved and how many segments have plaque burden. Uh If we identify a patient with a plague burden in severe range, which is B three in terms of calcium score to be 300 up, that's considered severe. Um And, but just want to plug in one point here. Uh When I'm saying I'm talking about plaque burden, I'm not talking about the degree of stenosis patient can have no patient have minimum plaque burden and have a severe stenosis or moderate stenosis. So this, these are a little bit two things. It's different things. For example, CT scan that I I put here shows looks like was severe black burden, but he actually did not have severe disease. It's just a lot of plaque and most of it in him is calcified. So, um well, the, the good outcomes from the CT scan, once we know that the patient has uh coronary artery disease and especially if it's severe range, we can now um talk to our patient and actually show the CT scanner sometimes and show them that we, there's, you know, the, this is the reason why we have to now be very, very um well aggressive to modify your risk factors. So, what are some of the preventative strategies to optimize the patient. Um So we uh cholesterol goals less than 70 even as low as less than 50 in higher risk patients with family history of coronary artery disease, diabetes management, hemoglobin A one C goals less than seven. Also a consideration of SGLD two inhibitors and G LP one um diet modification. Um We suggest Mediterranean diet dash diet exercise, uh about 1 50 minutes per week of moderate intensity exercise. Um and as well as hypertension control. So now our goal for blood pressure is gonna be lower than the general population and not one, not less than 1 40/80 but now less than 1 30/80. And obviously what we do with all our patients smoking, essentially cessation counseling, alcohol cessation counseling as well. So now back to our patients. So um in the meantime, um we, we have our patient, we know that he has moderate stenosis. How do we know uh again, back to the same question, how do we know this is flow limiting disease? And if his chest pain is due to that? In the meantime, um just an update. We started our patient Satin 40. Now we started him on Aspirin 81. We started him on Lisinopril five because his blood pressure was consistently elevated. We started him on Mediterranean diet as well. So the next uh further steps in the guidelines are mentioned. So if you have like our patient obstructive coronary artery disease, and again, moderate stenosis is obstructive coronary artery disease. We can either move into higher risk if patient, if you feel like the patient is higher risk, if let's say his angina is worsening, uh premature coronary artery disease or you know, some other things that you uh some other symptoms that you, you may make the patient higher risk. You can set the patient up with the invasive coronary angiography and they can do invasive FFR. We'll talk about FFR a little bit later or there's, it's also in the guidelines that you can if the patient is um that moderate category but not high risk, still that intermediate risk you can obtain CTFFR. And if your CTFFR is less than 0.8 or moderate severe ischemia, then then you can proceed to further testing. And again, I'll clarify some of it in a, in a little bit. So for our patient just describe a little bit what CTFFR is. Um So CTFFR is functional flow reserve derived from coronary. Uh CT A is a noninvasive physiologic um test to access flow limitations. Basically, that are happening across the coronary stenosis like in this patient over here in the red, it's showing basically uh it has a good correlation with uh CT uh with the invasive FFR as well. So for example, on this patient, when they investigated the patient's middle ad lesion, it basically um was CTFR positive. So um because the number is less than 0.8 in every other segment is more than 0.8. So no flow limiting limiting stenosis. But in that area, it was showing us that the patient has flow limiting stenosis. So that's very useful information in terms of um uh further management for the patient. And where does CT FA R data comes from city of hard data comes from advanced uh you know, some well many sources now. But one of the ones that I like is the advanced registry. And um this is basically the shows one year outcomes um from this registry. And it shows basically that um there's low rates of events in all patients and less re vascularization and trend to towards lower mace and significant lower cardiovascular death or M I in patients with negative CTFFR. So this is basically uh meaning if I send my but that moderate lesion for ctffrctffr comes back as normal, I can rest a little bit easier. That that's that pretty specific stenosis at this point is not causing unlikely to cause a patient, any symptoms and patient will continue to have lower degree of maize. Um unless patient has a high pla burden, that's, that's something that's something else to keep in mind. Um So very good um data, some other things that I uh will look on coordinate CTS and you may see us putting this in the report is high risk plaques. Um Some of the high risk plaques to mention is low at tenation plaques. If um we measure if we put a.in in the plaque on CT and if it's has low hounds fill units, it's like it, it has a higher predisposition of a rapture and having causing a ice later. Uh Some of the other names you may, he may see in the, here in the reports is spotty calcification, positive remodeling or net can ring sign. I'm not gonna go into depth because of that. But in general, if you see, we sometimes may put in our C AD reds reporting system, a modifier uh for high risk block. Um And, but um one more thing to mention, let's say um a patient does not have a high risk block on CT. According to the uh in the Scott Hard study, there's multiple different uh things we can take from the study. But in, in relation to the high risk blood, let's say patient has no high risk pla if the patient has high risk uh plague burden in severe range, that is much more worse for the patient than having one high risk plaque. So just something to keep in mind. So definitely having more plaque overall, even if it's not obstructive, even if it's not because you know, it doesn't have any high risk features. Just having it puts patients at higher risk. A few words before we get back to our patients is a future of CT. Um We uh there's amazing scanners coming out uh photo and counting CT and this is just some of the pictures uh taken from the scanner. You can see how usually on our normal CT scanners, we might not be able to see all those distal segments of the vessels to asses them properly. This is this this scanner now that we can see the details so we can even see through the calcium um you know, to better assess uh that we don't unfortunately, don't have that scanner right now. But this is something um that you will be seeing reports from other places as they are uh entering the market. A I um will be a part of um a different de definitely will be part of our workflow, whether it's scheduling, whether it's sorting the patients, whether it's helping read the scanners, whether it's uh risk stratified. So A I will be uh basically in multiple already coming into multiple areas and radiology in general and plaque analysis and plague uh uh to guide management is a few vendors are coming out with ischemia, uh burdens with um all kinds of new technology to assess ischemia and you know, uh later on new ways to follow it, it is just uh also an emerging market, an emerging market for that. So back to our patient, our patient had a negative. So our patient, we deem to be for him to be a higher risk patients considering that he recently started uh you know, the his chest pain symptoms have worsened recently. Uh He even had a few chest pain episodes at rest. So because of that, we actually chose to, for him to go for invasive uh angiography where they performed invasive of A R and uh it was negative in this case. So um we optimize his GDMT. We did not put a stent. We will basically from now on continue to medically aggressively medically, um medically manage him and his chest pain ultimately resolved and he's feeling and doing great. Um In conclusion, uh CO AC T um AC TFFR has high negative predictive value detects non obstructive plaque helps prevent unnecessary invasive angiography, helps identify the patients with higher risk for medical management optimization, plaque analysis assessment and the respond to treatment. Um Also is the future. Uh we can follow patients longitudinally um and improved imaging protocols, technology and A I will expand cardiac t capabilities with coronary assessment as well as structural procedures. Thank you very much. Published November 5, 2024 Created by Related Presenters Angelina Zhyvotovska, MD Cardiology, Internal Medicine View full profile
BROADCASTMED