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0:46

Today we are honored to welcome Dr. Stephens Zimmerman for

0:49

a lecture on the role of cardiac CT in

0:52

recently updated clinical guidelines.

0:55

Dr. Zimmerman is an assistant professor in Johns Hopkins

0:58

medicine Department of radiology and radiological science. He specializes

1:01

in Diagnostic Radiology with an

1:04

emphasis and cardiac imaging and we are grateful to

1:07

doctors and memorand for his support of MRI online and for

1:10

serving as our cardiac imaging so specialty advisor.

1:13

We've learned so much from you.

1:16

At the end of the lecture join Dr. Zimmerman in a Q&A

1:19

session where he will address any questions you may have on today's topic.

1:23

Please remember to use the Q&A feature to submit your questions to

1:26

get to as many as we can before our time is up.

1:29

With that we are ready to begin today's lecture.

1:32

Doctors Zimmerman, please. Take it from here.

1:35

Okay. Hi everybody. Good afternoon. Thanks for

1:39

joining this talk. And today I'm

1:42

going to talk to you about the role of cardiacct

1:45

in recently updated clinical guidelines. So within the

1:48

past couple of years some of

1:51

the big guidelines that they're really push practices into making

1:55

changes or adjustments to their current the current

1:58

workflow have come out and specifically with

2:01

respect to cardiac CT and

2:04

its use in chest pain. So we're gonna talk about that.

2:07

First the usual disclosure slide. I am

2:10

on The Advisory board that was mentioned for MRI online and I do

2:13

to also do some work with the American College of radiology.

2:16

Okay, so I want to start just just as

2:19

like a warning as a precursor, you know, this is not the

2:22

most exciting talk in the world to talk about guidelines. So

2:25

there's gonna be a lot of charts that have you know workflows and

2:28

things like that. Not not can be

2:31

a bit dry. So I'm trying to

2:34

sprinkle in a few cases just to keep everyone awake

2:37

and interested. So I'm gonna start with a case

2:40

presentation that sort of demonstrates what we're dealing with

2:43

here. This is a patient that

2:46

showed up at the Emergency Department 55 year old man.

2:50

History of high blood pressure and smoking family history of

2:53

early coronary disease and presented with

2:56

non-exertional chest tightness had some sort of, you know,

2:59

nonspecific findings on his EKG

3:02

and then a normal first editor opponents.

3:05

And so the question is, what do you do with this patient right

3:08

in the Ed and our Ed at least

3:11

right. Now the approach is to use a risk calculator.

3:14

So we use this thing called the heart score

3:17

which we'll talk to you a little bit about a little bit more later but this

3:20

risk calculator, they're all available online you put in the patient's information.

3:23

It tells you the patient's risk of major adverse cardiovascular

3:27

events or mace in the next 30 days and

3:30

and his 12 to 17 percent is pretty

3:33

pretty decent number. So he falls into this intermediate range

3:36

category of what to do traditionally like depending on

3:39

where you are some places these this patient will

3:42

be admitted for a rule out, you know cereal enzymes maybe this

3:45

patient will go to a stress test, but this

3:48

is a really great.

3:50

Place for coronary CT to come in and look

3:53

for disease and in a lot

3:56

of these patients we'll find that there's no disease and they can be sent home on

3:59

their merry way other patients though. Like this one

4:02

will find quite a bit of disease. So here's this cardiac CT.

4:05

And this is the LED and you can see there's this non-calcify

4:08

plaque with scattered calcified plaque

4:11

where the Lumen comes down and hits this area of non-cost

4:14

by black and there's basically almost no Lumen

4:17

visual visible at all. Here's a short axis cross-section

4:20

through that area. You can see you know, basically no, no

4:23

Lumen compared to the other

4:27

other areas here, like for instance the distal RCA.

4:30

We see nice enhancement. There. It is an excellent images.

4:33

So this guy has chest pain.

4:36

Intermediate risk factors and a nasty looking

4:39

LED, so he's going to end up going to the cath lab and sure

4:42

enough he did and they found a nice correlation here

4:45

on the cath lab and end up doing putting in a

4:48

stent for this patient.

4:49

So cardiac CT the rescue in this case.

4:52

So let's talk about cardiac CT in chest pain management.

4:55

So basically the what's been

4:58

happening and part of the thing that that sort of Spurs this

5:01

talk.

5:03

Is that the evidence supporting these of cardiacctas have been growing and

5:06

growing and growing over the past decade and now we have really strong recommendations

5:09

for cardiac CT use in clinical care and

5:12

the recent chest pain guidelines and that's what I'm gonna really focus on today and

5:15

because of this we're going to

5:18

see cardiac CT volumes On The Rise and roll due

5:21

to this growing role in the guidelines and we're gonna need

5:24

as a community of Radiologists more and more people who

5:27

have expertise and cardiacct and hopefully programs like

5:30

the ones that are available through MRI online

5:33

can help people pick up the expertise needed

5:36

to read these scans.

5:38

Okay, so some other things there's some

5:41

other things that have kind of come out around the time of

5:44

this newish guidelines that are new guidelines that are

5:47

important to the management of patients with cardiacct that

5:50

I want to mention here. One is Hisense to be

5:53

troponin. You know what your opponent is that biomarker that

5:56

shows us what it has been myocardial damage and would suggest an

5:59

MI traditionally we do that long rule

6:02

out that patients are admitted for with a

6:05

high sensitivity tripone and the advantage

6:08

is it's really really sensitive for picking

6:11

up any damage to the heart. And so if you have a

6:14

negative hyacin troponin, then you actually

6:17

can feel really comfortable sending a patient home which was not the case

6:20

with the old type but your opponent and then the other thing that's great about

6:23

it is that you can if you have sort of borderline numbers your

6:26

rule out sort of window is

6:29

much faster zero one and three hours. So this

6:32

is something that affects us in

6:35

imaging in terms of the fact that maybe some of these patients who

6:38

Have come to cardiac CT now had the highest Institute opponent and

6:41

they could be sent home and that's fine. You know, there are plenty of patients in chest

6:44

pain to go around. So the other

6:47

thing that's new on the scene is that in the past we used to think

6:50

about Imaging for patients

6:53

who are in the low two intermediate risk category, and

6:56

now the current guidelines recommend that if you're

6:59

in the low-risk category just stop there send the

7:02

patient home. Don't do any more imaging. I think that's probably gonna

7:05

be something that's maybe not completely adapted across

7:08

the board because I think there's

7:11

a lot of concern about sending patients home with no testing, but

7:14

at least that's what the guidelines are suggesting.

7:17

Okay.

7:20

So just a couple background slides to talk about the scope

7:23

of the chest pain problem. So in the

7:26

Ed, what's what's the deal with chest pain? How

7:29

big of an issue is it? Well, it's the number two reason for

7:32

all Ed visits in the US and compromises 5% of

7:35

all visits more than six million visits annually and

7:38

then of those millions of visits

7:41

only really 5% are for acute

7:44

coronary syndrome. So the vast majority 95% of those

7:47

visits are for something else and over

7:50

50% of those patients will have non cardiac causes

7:53

for chest pain. So what about the rest? So the

7:56

the one sort of in between the five to 50% Well those patients

7:59

probably have some angina, but they're not actually having a heart attack.

8:02

They're having and general symptoms.

8:05

And then and the outpatient side chronic chest pain

8:08

is also a cause of 4 million

8:11

visits in the US per year. So obviously it's a huge problem and we

8:15

know that coronary disease is the number one cause of death in adults

8:18

so you can't take it lightly and hence the importance

8:21

of these types of care Pathways to help guide management patients.

8:25

So here's an interesting slide that

8:28

is from the guidelines that just came

8:31

out talked about the top 10 causes of Ed.

8:34

Excuse me,

8:37

the top 10 causes of chest pain in patients

8:40

that are shown up to the Ed and interesting. If

8:43

you look the biggest one here way

8:46

way far and above in all age categories

8:49

is non-specific chest pain so not coronary syndrome

8:52

and then the second one less than 10% in

8:55

all categories is coronary artery atherosclerosis. So this is

8:58

where a good rule out test

9:01

comes into play nice to be able to send these patients

9:04

home.

9:05

Who are not having any coronary disease? So that's

9:08

the big strength of coronary CT High negative Predator

9:11

value. It can really rule out disease and that's

9:14

why coronary CT, you know is really

9:17

come to prominence.

9:18

What's the bad at? Well, the biggest problem is it's

9:21

not so accurate at stratifying lesions and patients with extensive cities.

9:24

So it's it's great to rule out disease not so

9:27

good in patients with known severe disease

9:30

to tell like is it a you know moderate stenosis

9:33

or is it severest stenosis? I mean, it does pretty well, but

9:36

it's still not not as good as it

9:39

is at ruling out disease.

9:42

So let's talk about now the guidelines.

9:45

So this is the big one the bulk of this talk

9:48

is going to be based on this particular guideline kind of stepping through

9:51

the foundations of this guideline and the

9:54

various recommendations. It's the 2021, you

9:57

know, multi-society including the

10:00

American Heart American College of Cardiology. This is

10:04

the Society of cardiovascular CT and this is cardiovascular MRI

10:07

guidelines for the evaluation and diagnosis of

10:10

chest pain say it came out in 2021. So it's it's

10:13

more or less fresh off the presses and this

10:16

is it was a big change a lot

10:19

of big changes from previous guidelines, and so let's

10:22

get into it.

10:24

So in this guideline the

10:27

the way they this is a really nice figure of

10:30

figure 5 from the guidelines, which really broke down how to

10:33

really sort of wrap your head around dealing with patients with chest

10:36

pain and it divides patients into

10:39

those with acute chest pain who basically showing

10:42

up in the Ed and those with stable chest pain

10:45

who are showing up for outpatient evaluation and that's

10:48

how I'm going to divide up this talk as well. We're gonna talk about the Ed and

10:51

then the outpatient and basically what you're trying to

10:54

do is trying to stratify patients into risk categories and

10:57

and the two bottom tiers of risk, either the

11:00

asymptomatic patients of the low-risk patients. We should

11:03

be doing adding no testing or maybe screening with a calcium

11:06

score and the outpatient side.

11:08

And then for the really really high risk patients,

11:11

those are the ones that should be going to coronary and geography and

11:14

then what you're left with is this middle group right here the

11:17

intermediate risk category and those are the ones where

11:20

either it's written here anatomic meaning CT

11:23

or functional testing meaning stress. Testing are

11:26

useful for further basically

11:29

to allow us to further differentiate for

11:32

the patient whether they're in this higher risk or lower risk

11:35

categories.

11:36

All right. So let's talk about acute chest pain

11:39

in the Ed. So what are some recommendations for

11:43

management of acute chest pain in the Ed? Well first

11:46

patients should always be assessed initially with an EKG and

11:49

a physical. Basically you're looking for acute

11:52

MI. So once you rule out acute MI,

11:55

then you kind of go down these care pathways.

11:58

So next you want to perform some sort of

12:01

wrist stratification and they're all different options out there that have

12:04

been developed all of them have all different,

12:07

you know acronyms there's

12:10

the heart which is used here at

12:13

Hopkins edax adapt and that, you know cetera Etc.

12:16

They all basically have some combination of

12:19

EKG findings and a****** history

12:22

risk factors and your opponent. They're all kind of like go into

12:25

the the mix there and then these calculators tell

12:28

you you know, what's the risk of this patient having a

12:31

cute mace, you know major adverse cardiovascular

12:34

event.

12:36

in the next 30 days

12:38

So that's where the low low

12:41

risk intermediate risk high risk

12:44

comes in. Okay. So if you

12:47

use one of these calculators and you figure out the patient is low risk,

12:50

what does that really mean? Well, it means that there's less than 1% chance

12:53

of death or major cardiovascular event

12:56

in 30 days. So super low risk, right 99% of

12:59

the chance. This is this patient's gonna be fine.

13:02

Um the like I said these guidelines they've come

13:05

out and said we should just stop there if we find that the patient's low

13:08

risk. We don't need to test anymore send these patients home and

13:11

you're using the

13:14

risk calculator for this and in some cases if if you're

13:17

comfortable if they're comfortable in some institutions, maybe a low

13:20

high sensitive opponent. Maybe the only thing needed to say

13:23

hey this patient is lowest chest pain send him home.

13:28

What about the intermediate risk chest pain now? These are the ones that the sort

13:31

of the the diagnostic dilemma, right? They don't qualify as

13:34

high risk to be, you know shuttled off to the cath lab and they're

13:37

not low risk to say go away. I don't want to

13:40

see you anymore. There's somewhere in the middle and here's

13:43

where you know cardiac CT comes in. We need

13:46

that additional testing to triage these

13:49

patients and figures patients and figure out what to do with them.

13:53

So what are the guidelines say? Well, the guidelines say for intermediate risk

13:56

chest pain patients in the Ed. You've got

14:00

some options one option is anatomic testing and you'll

14:03

notice that the number one thing listed

14:06

here with a strength of

14:09

recommendation of one and a level

14:12

of evidence of a the core

14:16

trying to remember it's like it's basically the

14:20

The strength of the recommendation. I can't remember what it stands for

14:23

basically the highest possible strength of

14:26

recommendation and the highest possible level of evidence. Is that

14:29

for intermediate risk chest

14:32

pain patients and no known

14:35

CAD, they should get a cc coronary

14:38

CTE to I over plaque. So that's the highest possible recommendation,

14:41

which is great for people like me who

14:44

like to do coronary CT where does stress testing fit in

14:47

while stress testing also had a level one

14:51

strength of recommendation? However, you'll notice that

14:54

it has a b and r letter level

14:57

of evidence which means that the evidence supporting its

15:00

use is not as strong as

15:03

cardiacct NRS here stands for

15:06

non-randomized studies. So there's no randomized study that supports the

15:09

the use of stress testing

15:12

in this situation.

15:14

So, how do you decide do I do a cardiac CT

15:17

or do I do a stress test? I mean both of them have a strength and recommendation of

15:20

one and you know, some of it comes down to availability a

15:23

lot of places don't even do cardiacct. So that sort of

15:26

answers your question right there. But if you have both available,

15:29

this figure was provided in the guidelines,

15:32

which is nice for figuring out which patients really

15:35

should get stress and which one should use CT. If

15:38

you look at this box here, what are the things that favor use of

15:41

CT? These are the case patients where

15:45

We really want to rule out disease. We want it. We think they're going to get it.

15:48

We think they're probably going to have a clean test, but

15:51

we need to make sure so these would be your younger

15:54

patients. No known coronary artery

15:57

disease. Maybe they had a prior stress

16:00

test that wasn't particularly useful or other

16:03

indications, like maybe you know, you're worried. They're young. You're

16:06

worried about an almost coronaries or or you might be worried about PE as

16:09

well.

16:10

The stress Imaging you're thinking about people who have maybe have

16:13

some coronary disease in the past.

16:16

They're older.

16:19

They had a bad CT in the past those sorts

16:22

of things which favor stress energy.

16:25

Okay. So what is you know, I mentioned that there

16:28

is all this strong evidence out there

16:31

that supports the use of cardiac CT in the Ed and

16:34

that's why I got this a level recommend level of

16:38

evidence. What what is that evidence and there are

16:41

multiple trials and I'm not going to go into all of them. But I

16:44

want to I want you to be familiar with at least the names

16:47

of two of the biggies in this category and one

16:50

of them.

16:51

Was actually led by my mentor

16:54

my cardiac Fellowship

16:57

director Dr. Harold Litt at University

17:00

of Pennsylvania where I did my fellowship. I actually

17:03

remember when I was there as a fellow we were enrolling patients for

17:06

this trial and so it was really exciting to see the results that came

17:09

out actually after after I left.

17:12

Um has a funny name not super, you know,

17:15

not a great acronym for you know, throwing around in

17:18

conversation, but it's called Akron PA and it

17:21

was sponsored basically by the American College of

17:24

radiology Imaging Network as well as some sponsorship from

17:27

the state of Pennsylvania run out of Penn Medicine,

17:30

but it was multicenter with several different sites.

17:33

And basically the the goal here was to

17:36

look at the use of cardiac CT in low to

17:39

intermediate risk chest pain population for disposition.

17:42

So they had patients who were randomized the usual care

17:45

track or to the cardiac CT track and if the

17:48

car accident was negative, they would send them home and if the usual care you

17:51

take the usual do your usual thing and they

17:54

looked at 30 days to see whether there was any difference in

17:57

mace or death that sort

18:00

of key thing that key parameter that we're looking

18:03

at when we do these risk calculators right that 30 day maze 30

18:06

day death and basically they saw there was no difference

18:09

in death or am I at 30 days whether or not

18:12

he took the CT path or he took the standard care

18:15

path and the CT saved time as well,

18:18

which I don't have written here, but it saved a lot of time for the Ed.

18:22

So then the other big trial out there that happened was called romycat 2

18:25

a little more catchy. This was a cardiac CT

18:28

versus usual care pathway strategy as

18:33

well. In this case. They're actually may now

18:36

come of Interest was the length of stay in the Ed and they saw

18:39

sure enough that you got a shorter length of stay with cardiac CT. And then

18:42

the other secondary I come was obviously mace at 28

18:45

days in this case and they saw no difference. So basically both

18:48

of these studies would show the correct CT

18:51

is safe to use it gets Patients Out The Ed

18:54

faster and there's no risk of the patient, you know, missing that

18:57

we're gonna miss an MRI or something like that that

19:00

you know would be dangerous to the patient.

19:04

So these are just two of the biggest trials. There are several other randomized trials

19:07

that again had more support

19:10

to cardiacct and the Ed and and

19:13

that's explains. This

19:16

level a evidence in the guidelines.

19:20

Okay. Now I didn't talk yet about the high-risk chest patient pain

19:23

patient in the Ed. So you have your lower intermediate and

19:26

this is the high. What do you do with those patients? Well, obviously if they're

19:29

having an MI, then they go to the cath lab the other

19:32

thing that might put somebody in the high-risk category is if you

19:35

find that they have high risk Anatomy on coronary CT 50% or

19:38

greater left main disease three vessel disease

19:41

with greater than 70% stenosis. Those are people who

19:44

are high risk. And then even if you have a cute chest

19:47

pain and you find some severe lesion and generally those patients are also very

19:50

good with cardiac catheterization.

19:53

Um what happens after the CT? So like

19:56

I mentioned if there's mild disease they're

19:59

going to be discharged if there's moderate disease. So 50

20:02

to 69% stenosis. They're still in the question mark category. They may

20:05

get a stress test. If you have ffrct available,

20:08

they might get that or might go

20:11

to Medical therapy kind of depending on how severe their

20:14

symptoms are and how how worried there

20:17

their practitioners are.

20:19

And then severe disease those ones will go to calf.

20:23

Okay, one other question or one of

20:26

the issue to talk about with respect to cardiacct. It

20:29

comes up actually in the Ed a fair bit is what

20:32

if they have an old cardiac CT and what this is one

20:35

of those frequent flyer patients who keeps coming back to the Ed because they

20:38

keep having chest pain and you just did a cardiac

20:41

CT like six months ago. You know, why do I have to repeat it?

20:44

Well, what are the guidelines say about this? They said

20:47

that the coronary CT warranty period is two years and

20:50

and there's a little bit of an asterisk by that because what

20:53

study gives you a warranty. Well, they only only

20:56

said that if you had no plaque whatsoever

20:59

on the prior coronary CT, then you're good for two

21:02

years.

21:03

I think there's there's other data out there that would suggest

21:06

this is probably being quite conservative and it

21:09

that warranty period probably could be extended quite

21:12

a bit and maybe even extended into non-obstructive

21:15

disease, but nonetheless, this is what's in the guidelines.

21:18

Certainly, you can feel confident telling your Ed that if the

21:21

patient had a negative corneasant. It's been two years, you know,

21:24

forget it. Don't even bother this patient should not be scanned again.

21:27

They are low risk send them home or at

21:30

least

21:31

work up some other cause for their chest pain.

21:34

Um now if they had any plaque on the

21:37

prior CT then one should consider repeat testing.

21:40

So this is where kind of clinical judgment comes in comes into

21:43

play, you know, if they had just a tiny bit of disease

21:46

and it's been only a few months then they probably shouldn't repeat

21:49

the CT. But you know, if they compare a

21:52

bit of disease then it certainly is reasonable to think that that the disease

21:55

can progress.

21:56

So this is there's no hard guidelines on this and

21:59

this is really more of a discussion with your reading practitioners as

22:02

far as who should get a repeat CT and who shouldn't

22:06

Okay, so that concludes our our

22:09

trip through the Ed coronary CT

22:12

guidelines next up. We're going to talk about chronic or

22:15

outpatient chest pain, but I'm gonna take a little

22:18

break here to kind of refresh from these boring

22:21

old guidelines and talk about and show a case. So

22:24

this is an interesting case. This is

22:27

actually from from my fellowship long ago a 48

22:30

year old school bus driver with intermittent atypical

22:33

chest pain in retrospect. This is really

22:36

unstable angina.

22:38

Didn't really have any kg findings, you know,

22:41

not much of a history ended up

22:44

getting a coronary CT and sure enough. Her care calcium

22:47

score is zero, but sure enough. You've got this non-calify black

22:50

right here in the middle of the LED causing some

22:53

severe narrowing.

22:55

Um, and this is a really unusual thing and somebody with a calcium score

22:58

of zero to have a severe, you know stenosis and particularly unusual

23:01

to have just one single severe stenosis. And the rest of the

23:04

corner is look perfectly fine, which was the case for her. Nonetheless. It

23:07

can happen and this

23:10

woman who's driving around a School Bus full of kids. You certainly don't

23:13

want her to to have an MI in the next 30

23:16

days. So she went to calf and had a nice

23:19

correlation this tight lesion here

23:22

in the proximal LED that they did end up stenting so

23:25

a nice study.

23:28

good outcome

23:29

Okay. So back to the guidelines. Let's

23:32

talk about stable chest pain. This is the outpatients.

23:37

So actually I do have a little bit of digression

23:40

before we get into the guidelines and that's

23:43

actually to talk about sort of the conceptualization of

23:46

how how stable

23:49

chest pain and actually I should say stable Corner

23:52

energy should be treated in the outpatient realm

23:55

and

23:57

the the old view of engine treatment was

24:00

you know, if we sort of think about it, we think

24:03

let's find us stenosis and let's fix that stenosis. So

24:06

let's do a stress test.

24:08

And if it's positive.

24:10

Then that means that they have some ischemia the

24:13

ischemia explains their angina.

24:16

Angina is bad.

24:17

So let's send them to Cath Lab put in a stent and

24:20

fix the angina and then we'll fix the patient. And this

24:23

is sort of makes a whole lot of sense and that

24:27

sort of view.

24:30

Works great in the acute coronary syndrome realm when

24:33

somebody's coming in with acute symptoms in a

24:36

cute chest pain. However, it turns out and people with chronic angina more

24:39

recent Studies have shown

24:42

have basically upended this Paradigm that this type of

24:45

you know, sort of cease stenosis fixed stenosis. Paradigm

24:48

is is not actually

24:51

Appropriate in a lot of patients. So how

24:54

do we know that? So these are I'm mentioning

24:57

these because these are really important trials that kind of come up

25:00

in conversation a lot. If you ever talking with cardiologists or

25:03

like listening to talks about

25:06

coronary CT or chest pain treatment. So

25:09

I think it's important to have some you know, some familiarity

25:12

with least the names these trials and and the basic

25:15

findings and I'm certainly like people can have spent, you know,

25:18

a paper upon paper upon

25:21

paper getting into the minutiae of these trials and debating the

25:24

results back

25:27

and forth and so I'm just gonna present certainly like just the

25:30

10,000 foot view of what are the big findings that sort of

25:33

generally accepted.

25:34

And with respect to these it really

25:37

really important trials.

25:39

So the first one is called the courage trial. This one

25:42

was from 2007. So a long time

25:45

ago now and basically it addressed the question of do

25:48

patients really benefit from PCI. So they

25:51

took patients who had a stenosis

25:54

of at least 70% in at least one proximal cornea artery

25:57

and evidence of ischemia. So patients you think

26:00

oh this guys really at a lot of risk, we should or guy or

26:04

a girl is that a lot of risk. We should you know

26:07

fix this coronary they basically

26:10

randomize them to either stenting plus medical

26:13

therapy or medical therapy alone and surprise surprise, they

26:16

found that there's really no difference. You can

26:19

see the p-values here all over 0.05 between the

26:22

two patient groups at seven years seven years really really

26:25

far out huge trial right with you

26:28

know over a thousand patients in each group.

26:31

Between PCI and medical therapy in terms of survival and

26:34

in terms of survival free

26:37

of myocardial infarction as well as ACS, which

26:40

is pretty pretty amazing stuff.

26:42

So there was this generated obviously a

26:45

lot of debate in the in the Cardiology community.

26:49

And so it was kind of

26:52

picked apart by certainly people who were proponents of

26:55

PCI.

26:56

And and the thought was well, you didn't quite

26:59

screen the patients correctly and if we do a sub study where we're

27:02

looking just the most high risk patients that they actually may show

27:05

some benefit and and that's what was done. They did a

27:08

nuclear sub study of the courage trial.

27:11

Where they took a small subset of patients from Courage and looked

27:14

at the Patients where they had a lot

27:17

of ischemia and we saw that the

27:20

revascularization reduced the ischemic burden

27:23

and the thought was if you can identify aschemia

27:26

and improve that ischemia, then that is an

27:29

objective indicator that you have helped the patient and

27:32

therefore those patients should do better and sure enough.

27:35

That's what they saw on this study is that

27:38

there was a

27:40

in the patients who had reduction in

27:44

ischemic myocardium. That's the gray one with the the diamonds.

27:47

You saw less events

27:51

greater event for you survival, then those

27:54

who did not have a significant reduction in ischemia, and

27:57

that was both for

28:02

Patients who all comers or especially true

28:05

if you selected only the

28:08

patients who had modern severe ischemia Baseline. So the patients who were

28:11

really high-risk and showed some benefit in

28:14

terms of revascularization those patients actually

28:17

did well in terms of survival out to five years. So so

28:20

the thought here was like, okay great, you know courage trial

28:24

was very discouraging in terms of people wanting to put in stents into

28:27

things but this shows that hey if we can demonstrate a

28:30

lot of ischemia, and we can fix asking me

28:33

we know we're actually going to help patients and and all as well again, but

28:36

then the next thing was done it was

28:39

the ischemia trial and this came out back in 2020 so much more

28:42

kind of hot off the press.

28:45

And in this case, they basically tested this question. They

28:48

randomized a huge number of patients 5000 patients

28:51

with moderate or severe ischemia to PCI. So

28:54

percutaneous coronary intervention and

28:57

medical therapy or medical therapy alone and interestingly

29:00

all these patients also got a coronary

29:03

CT and that was done to exclude severe

29:06

left main disease which

29:09

would be an indication for patient to go right to Cabbage. So we're

29:12

excluding like severe high risk

29:15

disease with coronary CT and then

29:18

we're going to randomize them to either medical therapy or

29:21

medical therapy Plus revascularization.

29:25

And the initial study had three years

29:28

of follow-up and basically they saw no

29:31

difference between the two groups in terms

29:34

of the outcomes. You'll notice that if you

29:37

look at the primary composite outcome, which was a cardiovascular

29:40

death and other cardiovascular

29:43

events, you actually see that there's an

29:46

initial bump where the invasive strategy or strategy has

29:49

more events and

29:52

then it kind of levels off and then the conservative strategy catches

29:55

up. So it seems like in the commentary

29:58

it seems that basically there were more very procedural

30:01

and early in farks in the invasive

30:04

strategy, you know, people have different theories

30:07

about why that might be the case whereas they're sort of like a slow Trickle and

30:10

conservative strategy.

30:13

Also, if you look at death from any cause there's no difference whatsoever and

30:16

these played out at three years. So so

30:19

basically what the promise trial show is showed that there's really

30:22

no difference between excuse me, ischemia trial showed

30:25

that there's no difference between whether you actually do an intervention

30:28

or you don't in these patients that they're all going

30:31

to basically have more or less the same outcomes when

30:34

you're looking at death or or am I

30:37

down the road

30:40

So this is sort of changed our kind

30:43

of thinking of how revascularization should happen in stable

30:46

outpatient chest pain and basically here's here's the current kind

30:49

of thinking if you have high risk anatomy and that's left main

30:52

disease or three vessels with greater than

30:55

70% stenosis. We know from other studies, which I didn't talk about

30:58

here that these patients do benefit from revascularization in

31:01

particular cabbage if they can get it.

31:04

But those other patients so two

31:07

vessels greater than 70 or maybe even just modern disease for

31:10

those patients.

31:11

We know don't get any mortality benefit from revascularization.

31:14

Now one other thing I talked about that's a

31:17

result from the ischemia trial and other trials as they definitely show that

31:20

people can get symptom improvement from the from

31:23

the PCI. So if patients have

31:26

severe symptoms, you may send in a PCI or you

31:29

might try optimal optimal medical therapy see

31:32

if their symptoms improve and then you do Reserve

31:35

PCI for only persistent intolerable symptoms. And that's

31:38

sort of how these new guidelines have been

31:41

set up to deal with how patients

31:44

stable chest pain.

31:47

Okay. So here's the important table from Back

31:50

to the guidelines. Here's the important table from the guidelines. So

31:53

if you have no known

31:56

corner under disease then what do you do with a patient? Well you

31:59

perform again just like in the Ed some sort of risk estimation

32:02

and then you try

32:05

to determine whether the patient's low risk or intermediate risk and

32:08

and they provide in the guideline this

32:11

particular chart, which is

32:14

a very simplified.

32:17

risk estimate for patients just

32:20

based on prevalence age and then

32:22

Whether you have a chest pain symptom or you have

32:25

dyspnea and interestingly the majority

32:28

of women actually who

32:31

were younger than 60 if you have dysmia, or

32:34

if you have chest pain are in the the green

32:37

category, which would be low pretest probability less

32:40

than 15% So in theory, maybe these

32:43

patients don't need to get any testing now.

32:46

Again, this is a very simplified risk estimator.

32:49

They're more more sort of sophisticated ones out there.

32:52

But one thing you can do is let's say you have

32:55

somebody who comes in. It's a woman who's in,

32:58

you know, her early fifties and has chest pain

33:01

symptoms and you think like gosh I really think that she might have

33:04

coronary disease is you can do calcium score and so

33:07

be here is a probability

33:10

range based on calcium score and

33:13

basically once you have a positive calcium score

33:16

anywhere from one all the way up to 1000 you're

33:19

in that intermediate risk group, and if

33:22

your pot you have a positive casting score then that might trigger you going to

33:25

do more further testing.

33:28

Okay, so so let's

33:31

now look at what the guidelines say. As

33:34

far as what type of anatomic testing you should be using for these

33:37

patients like say let's say a woman,

33:40

you know, you're 45 or 55 year old woman.

33:43

I was just talking about now if he has a positive calcium score now, she's

33:46

in this intermediate risk group. What do you do? So you

33:49

can either do they divide it up into two possibilities either

33:52

do anatomic testing or stress

33:55

testing and you'll notice here again cardiac CT

33:58

level 1A recommendation. So

34:01

the highest possible recommendation goes to cardiac CT

34:04

for use of in patients here

34:07

intermediate risk category in the

34:10

intermediate risk categoration say,

34:13

However, if you look over here at stress testing, although it

34:16

does have a level 1 recommendation. It's still a

34:19

B level of evidence. So it does

34:22

not have quite as strong a recommendation as as coronary CT,

34:25

but again both are possibilities.

34:30

And they actually provide this nice little chart which kind of

34:33

helps with thinking wrapping your head around really how these

34:36

this patient workflow should go in these patients with

34:39

chest pain showing up to the clinic.

34:42

And let's focus here on the left side of this chart.

34:45

You do your risk assessment if they fall into the low-risk category

34:48

you do either no testing at all, or maybe you'll

34:51

do a calcium score in select cases, you

34:54

know, if you're really worried or seems like it's a good story that story that sort

34:57

of thing.

34:58

That will then change the patient's risk

35:01

profile. Now that you have

35:04

the calcium score you have more information and you can reassign them into different

35:07

categories. So let's say that calcium score is positive you

35:10

find out there now intermediate risk. Well, then you look in this pathway your choices.

35:13

Are you can do stress testing or you

35:16

can do CT. We're radiologist.

35:19

So let's focus on the CT if you do the CT

35:23

Basically, if it's no coronary disease then

35:26

look for other causes of chest pain non

35:29

obstructive disease same thing look for other causes of

35:32

chest pain in some patients though with nonobstructive CAD

35:35

or obstructive CAD greater than 50% stenosis.

35:38

You could consider stress testing or ffrct

35:41

to look for any ischemia.

35:43

If you have severe ischemia, then you

35:46

might consider coronary angiography. If you

35:49

have high risk lesions. So the three vessel disease the

35:52

left main disease, then you might send

35:55

the patient for invasive angiography for conformation and

35:58

potential cabbage. Now, we just talked about how if you

36:01

have ischemia modern severe ischemia, then we the ischemia trial

36:04

show that that doing revascularization doesn't

36:07

really help and and that that is true. So in

36:10

some cases these patients may need to go to Optical medical

36:14

therapy before you do the invasion corner and geography.

36:17

I think this pathway was put in here for patients,

36:20

you know, if you have severe symptoms, you could consider saying

36:23

the right to corner and jacket for you to help treat their symptoms.

36:27

Okay, so I mentioned or we

36:30

mentioned just like with the Ed pathway in

36:33

the stable chest pain outpatient chip pathway

36:36

that the cardiac CT has an a level of evidence

36:39

from supporting it and so

36:42

I want to talk about you know, what is the evidence that's

36:45

out there so that you are familiar with with these trials that

36:48

they come up all the time and they're two that

36:51

I want to talk about. The first is the Scott Hart trial. So again, these are outpatients with

36:54

stable chest pain.

36:57

And just like with the Ed they randomize them to the usual

37:00

care pathway or the corner CT with

37:03

usual care and then they filed them for a long long time for

37:06

cardiac death or myocardial infarction and really

37:09

really interestingly. They saw that in

37:12

the patients who were treated with her in

37:15

the CTA pathway here. They saw

37:18

less events than patients who went through the usual care

37:21

pathway and that was for both.

37:23

Coronary heart disease death and Mi

37:26

as well as death Mi and stroke you saw.

37:30

Basically better outcomes. So cardiacct is

37:33

Saving Lives when you

37:37

use cardiacct compared to their usual

37:40

care pathway, and so it's kind of hard to wrap your

37:43

head around that like why would cardiac CT save lives the

37:46

real reason that that people think this

37:49

the thing that that seems to be going on here.

37:52

Is that if you do a stress test and

37:55

it's negative?

37:57

You don't know for sure whether that

38:00

patient has coronary disease. You only know

38:03

that they don't have ischemia. So certainly you could have

38:06

quite a bit of plaque in your corner arteries and have

38:09

a negative stress test. However, if you

38:12

do a cardiac CT, you're gonna find plaque, you

38:15

know, if it's there and even just mild and so

38:18

the thought is that those patients who get the cardiac CT.

38:21

They're gonna go into they're gonna

38:24

get more aggressively treated for their plaque more statins

38:27

more cholesterol lowering Etc.

38:30

And that that's gonna help them in the

38:33

long run and reduce events. And that seems to be the

38:36

case and in this trial

38:39

so interestingly, actually, I I misspoke this

38:42

was out at I believe at this

38:46

may have been three years or two years. I can't remember but but actually

38:49

it there was a trend but the p-value is

38:52

just over 0.05.

38:54

And so so I misspoke. So this is the original paper from 2015.

38:58

And it showed that there is no statistical difference

39:01

but a strong Trend to this cardiac

39:04

CT saving lives and then there was a

39:07

follow-up paper with a solid five years

39:10

of follow-up in these patients and

39:13

by five years you're able to see a significant difference

39:16

that was had a significant

39:19

P value. I believe those 0.04 or 0.04

39:22

sure enough 100% It is

39:25

confirmed the cardiac CT in this particular trial saved

39:28

lives and reduced risk of MI.

39:33

Now so that's the one trial really exciting trial in

39:36

terms of results and people who like to do critic CT

39:39

and then the other big trial that came out not

39:42

that long ago. This is back in 2015 was the

39:46

promise trial and so this is outpatients. Actually.

39:49

I apologize. I think that might be an incorrect reference there.

39:52

These are outpatients with chest pain who are

39:55

randomized to anatomic versus functional evaluations. So

39:58

CT or stress, so a

40:01

little bit different from the usual care, right the usual

40:04

care. They may not have tested everybody in this case. Everybody's

40:07

getting tests. You're getting either a CT or you're getting a stress

40:10

test and then you're gonna follow them up for events and

40:13

huge trial 10,000 patients.

40:17

And basically it saw what they saw was that

40:20

there's really no difference between patients who

40:23

got the CT and the stress tests down

40:26

the road. So it didn't show that

40:29

same result of the Scott Hart trial. They thought it's a slightly

40:32

different, you know way of evaluating the

40:36

patients and that's partly explains it but basically the bottom

40:39

line here is you're not gonna you're not gonna harm people by going

40:42

sending them to cardiacct in this

40:45

particular trial. It's basically sort of you know, there's there's

40:48

no difference. So you may have soul choose, you know,

40:51

you use other factors to choose between

40:57

Okay, and actually sorry just

41:00

going back. What are those factors, you know availability patient preference

41:04

costs radiation dose those

41:07

sorts of things, you know should be helping inform which

41:10

test to to use.

41:14

Okay, so that was a lot right? So so we

41:17

talked about stable chest pain and and these trials

41:20

that support these of cardiac 18 stable chest

41:23

pain strong recommendation for CT

41:26

in the guidelines and we didn't talk

41:29

about people who have known coronary disease. So what about the people who

41:32

who already had their CT and we know they've got

41:35

disease. What do we do with those patients? Well,

41:38

The goal here is to optimize medical therapy.

41:41

Right? So let's say you know that this patient has some amount of disease,

41:44

but they don't have the left main disease and they don't have the three vessel disease,

41:47

but they're somewhere in the middle. What do you do with

41:50

these patients if the engine persists generally consider catheterization,

41:53

we know that the catheterization can help and revascularization can

41:56

help reduce anginal symptoms. So so

41:59

that's sort of the general line. If you're

42:02

not completely sure, you know, is this really angina as

42:05

some other type of chest pain, you know, the symptoms are a little funny you could

42:09

do a CT and that could be used to look at the stents

42:12

and people who've had prior stents or in

42:15

the Cabbage graphs and somebody with prior cabbage.

42:18

Here's a nice example of a patent stent and led.

42:23

All right. So that was a lot. We're getting to

42:26

the end of this talk and just one more case here

42:29

to sort of break things up. This

42:32

is actually a case for the past couple years. It's a 45

42:35

year old male very active running a

42:38

race, you know a couple I think

42:41

was about a month before showing up in the Ed. He was running a race

42:44

and had flash pulmonary edema. This is very

42:47

concerning treated the pulmonary edema, you

42:50

know, kind of got some Outpatient Treatment. They're treated

42:53

that acutely then got some outpatient follow up and was fine and

42:56

then and then all of a sudden one day had chest pain

42:59

again.

42:59

Or you chest pain not pulmonary demon.

43:02

The first time was pulmonary demon. Second time was chest pain had chest pain showed

43:05

up to the Ed. We did a coronary CT and and he

43:08

got this this non calcified lesion that led

43:11

actually looks quite a bit like that previously lesion,

43:14

maybe not quite as severe but it's it's getting there. Here's

43:17

the non calcified black sitting on top of the LED there

43:20

and here's the distal LED which looks normal. So we read

43:23

this actually is a 60 deciding percent stenosis. So he

43:26

went to calf and this is one of those lesions where you

43:29

know, sometimes like I said before cardiac CT

43:32

is great for ruling out disease. It's maybe not

43:35

always the best in characterizing disease when it's there

43:38

in terms of is it moderate or is it severe he is

43:41

one of those examples you can see this is the very, you know

43:44

mild sort of Contour regularity

43:47

here. And approximately it looked

43:50

a little bit more severe in different views, but the cath guys

43:53

were convinced is just they would only call it a 50% stenosis

43:56

and that seems reasonable but because the symptoms

43:59

are very convincing, he's a young guy they did a fractional

44:02

flow Reserve in calf.

44:05

And they found that it was 0.86, which is basically

44:08

that's okay. It's a categorizes. This

44:11

is a mile stenosis an ffr less

44:14

than 0.75 is more concerning.

44:17

So nothing was done. There was no stent placed.

44:20

He's you know put on

44:23

Statins Etc and sent on

44:26

his way. So interesting case.

44:29

Okay, so just to wrap up

44:32

this guidelines discussion. I think

44:35

you know, I spent a lot of time talking about the

44:38

guidelines that came out from the American Heart and the

44:41

ACC but obviously, you know

44:44

They're of course. There's a guidelines that also come

44:47

out from the European societies. And so I

44:50

I want to mention those here. They're unlike

44:53

the US guidelines the European

44:57

guidelines. They had two different ones one for basically the

45:00

cute chest pain group and one for the chronic chest pain

45:03

group. So here's the thecube chest pain group that came out in

45:06

2020. So it's acute coronary

45:09

syndrome in patients without St. Elevation. So

45:12

basically meaning people who not having an acute MI. How

45:15

do we manage those patients and very

45:18

much like the chest pain

45:21

guidelines from the US we saw

45:24

that the coronary CT was strongly recommended

45:27

and interestingly. They provide this nice figure where they

45:30

compared changes in the recommendation from their prior in 2015 to

45:33

five years. Later.

45:35

2015 they had a Class 2 recommendations. So

45:38

not quite as strong. Whereas in 2020

45:41

now just like we have for the US guidelines like

45:44

class 1 or the highest strength of recommendation for

45:47

cornea. CT is

45:50

a way to exclude ACS and patients with low to

45:53

intermediate likelihood of CAD.

45:55

And just one more

45:58

thing, which is that.

46:02

Sorry get that out of the way.

46:05

Got a reminder getting my way here guys. Sorry.

46:09

Okay, um, what about the the details and

46:12

the comparison to stress test you can see that here stress testing had

46:15

a level one recommendation. But again just a B

46:18

level of evidence and and just like with the American guidelines level one

46:21

recommendation for

46:23

Cardiac CT with the highest possible level evidence and then same

46:26

goes for The Chronic coronary syndrome.

46:29

So this is your outpatient chest pain group their recommendations

46:33

were oops that for patients

46:36

with this

46:39

chronic chest pain non-invasive Imaging for

46:42

Mount Carlos. Give me a corner CT

46:45

is recommended as the initial diagonal test for diagnosing CD

46:48

and that's a level one recommendation.

46:53

And and they had this nice table here, which

46:56

basically if we focus on the patients who

46:59

are in this kind of basically you

47:02

work up the patient. That's what these things are. We're going

47:05

to assess the symptoms. We're gonna do an EKG we're gonna do

47:08

a assessment of their

47:11

risk.

47:12

And then here's the risk sort of range of

47:15

their low risk over here and high risk over

47:18

here. Basically, we're gonna favor coronary

47:21

CT for the lower risk people because we

47:24

want to rule out disease and we're gonna favor stress testing

47:27

for the higher risk people very similar

47:30

to the US guide lines.

47:34

Okay, so last couple of things I just want to talk about

47:37

really quickly this thing that

47:40

you might hear about. If you're in the sort of

47:43

cardiac CT circles called the nice guidelines and

47:46

then I can't remember what the nice stands for but it's it's the

47:49

UK National Health Service guidelines and

47:52

it doesn't just focus on cardiac stuff. It's just all the different

47:55

health things out there.

47:57

And these guidelines came out in 2016 in the code, you know

48:00

caused a stir in the world of cardiac.

48:02

CT in imaging because basically

48:05

they the folks Behind

48:09

These guidelines did detailed cost-effectiveness analyzes of

48:12

you know, what test is best for

48:15

UK National Health System patients

48:18

and saves the UK money

48:21

while not, you know, not putting patients at

48:24

risk and they found that on this cost Effectiveness

48:27

analysis that the best test out there

48:30

was cardiac CT and believe

48:33

it or not. Their current recommendation is not even

48:36

they're not even going to really use the risk factors. They say just do

48:39

card activity as the first line in any stable chest pain person. It

48:42

should be the first line investigation in all

48:45

patients with atypical or typical angina symptoms or those

48:48

who are asymptomatic with suggested EKG changes,

48:51

so

48:52

You can imagine this is huge. Right like every

48:55

patient who comes in in the UK, you know

48:58

within reason who has chest pain.

49:01

They're gonna in theories send them for cardiac

49:04

CT. They estimated in this paper that there will be a

49:07

700% increase in demand for coronary CT. I have

49:10

to say I don't really have the follow-up on this. I'm not sure how it's

49:13

going. I have heard that the weights for coronary CT are

49:16

big and the Radiologists are

49:19

overwhelmed, but I'm not really sure you know how much the

49:23

practitioners have really adapted these these guidelines

49:26

in practice.

49:28

But certainly it's really interesting and you know, you could

49:31

imagine in your head. If something like this were to happen here where where we

49:34

had big say Insurance payers who decided like

49:37

hey these guys in the UK, they know what they're doing, you know,

49:40

maybe we should follow them in terms of let's make sure

49:43

that our patients who were ensuring get the most cost-effective care

49:46

you could certainly see, you know,

49:49

in the future that maybe we'll be doing even more coronary CT

49:52

especially now that we have these guidelines that are

49:55

giving it such a high level of recommendation.

49:59

Okay, and lastly, this is the last thing I'm going to talk

50:02

about before questions. You know, I think

50:05

in Radiology, I see it in

50:08

my trainees a lot. There's definitely a

50:11

sort of school of thought that Radiologists shouldn't

50:14

even bother with coronary CT because

50:17

Corner CT is going to go to the cardiologists. They've

50:20

done by the car Alex anyways, and we're just gonna get

50:23

sort of

50:24

Pushed out and lose the turf battle and so

50:27

why even bother it's a waste of time.

50:30

So I think you know

50:34

that's certainly something to consider. However, it looks you know

50:37

that this recent study which was put out. It's really interesting data

50:40

that basically says that that sort of

50:43

school thought is wrong and that

50:46

actually Radiologists are playing a bigger role in cardiac CT

50:49

now than they ever have and so what

50:52

these guys did is basically they looked at who was

50:55

doing cardiac CT or who was not who was

50:58

billing her cardiac CT in Medicare over

51:01

time where they are radiologist or were they

51:04

a cardiologist and you can see the whole story of cardiac CT.

51:07

Early on actually surprisingly and I didn't know this

51:10

early on cardiologists build quite a

51:13

bit more and there was a peak and then it kind of

51:16

trended downwards for both cardiologists and Radiologists and

51:19

interestingly. There's this crossover Point here

51:22

in between 2012 and 2013 where Radiologists

51:25

took over and are now

51:28

reading more cardiacct in the cardiologist and you

51:31

can see the cardiologists have you know, sort of flattened out.

51:34

Maybe it's starting to curve upward again out at the end. I'm not sure I'd love

51:37

to see a follow-up follow up

51:40

of this paper just to see what's going on now, but I

51:43

show this side to you know, basically say, you

51:46

know,

51:48

You're in the right place. I think it's great to

51:51

learn about cardiac CT. I think it's it's going to be growing

51:54

and I think we as Radiologists really.

51:57

Are well positioned to play a big role in the

52:00

care of these patients?

52:03

So if you're interested in learning more about cardiac CT, I

52:06

just want

52:09

to plug some of my courses so so like I was mentioned

52:12

earlier. I'm the

52:15

Advisor for the cardiacct for MRI online.

52:18

So we're trying to put together all sorts of content to help people get comfortable

52:21

with cardiacct. And so

52:24

we have already a Mastery series which has

52:27

a lot of different videos to talk about basically how to read a cardiac

52:30

CT in somebody where you're looking at suspected coronary Z.

52:33

So this is just basically the basics.

52:35

This is available now in early 2023 were also

52:38

going to have a cardiac CT fundamentals Mastery series

52:41

and this is not so much the reading but really more the

52:44

technical pieces also super important for starting up

52:47

a cardiac CT practice, you know learning how to scan. What

52:50

are the different parameters you need to use. What are the protocols you use?

52:53

You know, how do you fix artifacts motion Etc. So these

52:56

are two I believe

52:59

really helpful sources for

53:02

learning cardiac CT

53:05

and potentially implementing in your practice just as

53:08

an aside. We also do cardiac MRI if

53:11

you're interested in that so there's a fundamentals of cardiac MRI Mastery

53:14

series as well as Craig and Mariah and

53:17

scheme of cardio mop the and then more recently Dr. Kate

53:20

Hahnemann from Toronto was

53:23

nice enough to actually do an expertise review

53:26

on covid-19 and cardiac MRI.

53:30

So that's all I've got just to sum up recent

53:33

us and European guidelines strongly support

53:36

the use of cardiac CT for the workup of patients with acute and

53:39

chronic stable chest pain and CT guided approaches

53:42

have stronger evidence support than stress test approaches

53:45

and may lead to better patient outcomes. So coronary CT

53:49

for sure is on the rise Radiologists as Radiologists were

53:52

well positioned to be leaders and providing the service to patients

53:55

and thank you for your attention.

53:59

So I think we're gonna open up to Q&A

54:02

now. I'm going to click on the Q&A button

54:05

here and see what we got.

54:09

Okay. So question from Robert

54:12

don't you find that patients

54:15

with moderate or severe coronary calcification have multiple

54:18

non-aviable segments on coronary CT.

54:21

So that's that's a great question and the

54:24

answer is maybe yes, maybe no so

54:27

there in some cases for

54:30

sure. You can have severe coronary calcification

54:33

and that can basically obscure the

54:37

Lumen entirely and it makes it hard to say definitively whether

54:40

somebody has a modern stenosis or severe stenosis.

54:43

That's where that sort of.

54:46

We all mention the shortcomings of cardiacct. That's where

54:49

it comes in. You know, if you have a lot of calcification for in particular

54:52

it can be hard to really definitely characterize the

54:55

severity of stenosis. So that

54:58

is true. However, again remember that

55:01

the big role for Corner CT here is more of a rule

55:04

out test than then anything else. And

55:07

so if you have a if you

55:11

know, you have a lot of calcification you

55:14

may say, you know, try us a stress test

55:17

and said, let's say if you have a really really high calcium score,

55:20

whereas if you have a low calcium score to moderate

55:23

you might want to favor coronary seed team now that's not to say

55:26

that I absolutely 100% had patients who've had high

55:29

calcium score and then the coronaries are

55:32

done and they're 100% completely valuable a

55:35

lot of patients will have

55:37

Calcium that's sort of like in the periphery of

55:40

the vessel not obscuring the vessel. So absolutely,

55:43

you know that that happens sometimes

55:46

so, you know, you just

55:49

don't really know until they get the patient on the table.

55:53

Okay, so what's the rule of triple? What's the

55:56

role of the triple out in the Ed chest pain? So unfortunately, you

55:59

know there really aren't a great.

56:02

Practice guidelines out there with respect to the role

56:05

of triple well in Ed chest pain, so it's it's honestly

56:08

it's a it's a institution by institution

56:11

decision. I'll tell you that here we do perform

56:14

triple rule out scans our Ed

56:17

practitioners think they're very helpful.

56:20

We certainly have had cases where we found, you know,

56:23

either one you find Corner disease or you find peas you can

56:26

find both so we do them.

56:30

You know, I I think if you're interested caring for

56:33

the patient and providing good care, you know,

56:36

a lot of times these chest pain. This chest pain can be hard to differentiate

56:39

and you know, certainly getting the

56:42

Triple A Lot skin can help with that. So I think

56:45

that's a decision for the practice. You know, we only

56:48

provide the coronary CTS During certain hours. So seven to

56:51

seven pm here again very much institution dependent.

56:54

So we certainly aren't providing the triple route

56:57

all hours a day, but

56:59

at least at the corner is available. We'll do it for the

57:02

corner of the cardiac Staffing is available. We'll do it a triple

57:05

Rod of order.

57:07

Okay, next question

57:10

question about radiation burden.

57:13

In a patient with history of four prior chest CTS. When do you

57:16

consider the safety of radiation burden and deciding whether

57:19

to utilize the CC the corner CT so, you

57:22

know radiation is an interesting question. So the

57:25

the question is

57:28

what's the alternative that well two questions really? So so

57:31

one is is the concept of radiation in general,

57:34

right? We know that that radiation damage to

57:37

DNA is a random effect. So the four chest

57:40

CTS that happen before have no bearing on

57:43

whether or not your next cardiac CT is going to cause the mutation

57:46

that gives that patient cancer right so each

57:50

Even though in theory, you know, even though

57:53

the patients had a lot of radiation the individual decision for

57:56

that one particular exam isn't

57:59

necessarily it doesn't necessarily need be influenced by that

58:02

prior those prior exams right that there's there's just a random chance

58:05

of your one cardiac CT examination causing a

58:08

mutation that may lead to cancer. It's not

58:11

an additive effect. So so you really should make the

58:14

decisions based on just the risk benefit of that particular test

58:17

at that, you know snapshot in time,

58:20

you know, the question would be really what are the

58:23

Alternatives is. Are you gonna send them to stress

58:26

test instead? Because if that's the case then stress testing usually involves more

58:31

radiation.

58:33

If they do a nuclear stress test, but perhaps you could do a an echo

58:37

or an EKG stress test and that would be a good option if there's

58:40

a concern about about radiation.

58:43

But I think I don't we don't we certainly don't have any

58:46

overall policies about the about radiation or previous

58:49

tests? It's really just it's an individ. It's an individualized decision

58:52

based on the the risk benefit for that patient at

58:55

that time.

58:57

Okay.

58:58

Um, thank you for this talk. I do not currently read.

59:01

Correct CT would like to how would you recommend? What would you recommend me to

59:04

do for training how to get certified without having done

59:07

a credit card. So that's a great question. Sorry. I

59:10

kind of

59:11

blur that said how do you get certification without

59:14

having done a cardiac Fellowship? So basically they're

59:19

the ACR has a recommendation for

59:22

cardiac certification as

59:25

well as there's a

59:29

service there called the certification. There's a

59:32

service out there called the certification board of cardiovascular

59:35

CT.

59:37

Cbcct they actually offer a test.

59:40

And in order to sit for that test. You need

59:43

to meet some qualifications. What are

59:46

those qualifications? Well, basically it's it depends on

59:49

whether your radiologist or cardiologist and if

59:52

you're ready, I'll just feel probably follow the ACR recommendations and

59:55

those are a certain number of

59:58

Reading a certain number of scans and basically doing

60:01

enough CME to to become familiar

60:04

with the technique so

60:07

though you can basically do all

60:10

that through MRI online if you want there are

60:13

MRI, and I don't know if you saw at the beginning there was

60:16

the the rotating different slides and there

60:19

is a cardiac CT Fellowship available through

60:22

MRI online which basically involves

60:25

using our meeting with

60:28

a fellowship director and that person you'll

60:31

meet remotely over Zoom.

60:35

And you know that person gives lectures

60:38

you have a whole bunch of cases available and then

60:41

access to all the MRI online content which includes

60:44

all the CME hours that you would need to sit

60:47

for that the to basically

60:50

to qualify for that to meet the ACR guidelines

60:53

so that you could

60:56

go sit for that exam if you wanted.

61:00

Okay. I hope that answered the question. So so if

61:03

if there any questions though, basically that the to

61:06

sum up, you know, one of our big objectives in

61:09

in MRI online is to try to meet exactly that

61:12

sort of need that you've just

61:15

expressed that we want people to be able to go through MRI

61:18

online to get all of the training that they

61:21

need and so cardiac CT fellowship and the

61:24

Mastery courses are equated great way to do that.

61:27

Okay, another question, what is the reliability

61:30

or accuracy of cardiac 18

61:33

the presence of stents and this is a tough one. So

61:37

what's the

61:41

Basically, what what is out there in the literature is that

61:44

if you are a stent is three millimeters

61:47

wide or larger than cardiac

61:50

CT does a sufficient job of reliably

61:53

distinguishing whether there's significance stenosis

61:56

or not.

61:57

Um, if it's less than three millimeters then the correct

62:00

CT is you know, it's more of a role of

62:04

the dice and I've absolutely seen that in practice.

62:07

So if it's a

62:11

good quality study with with these inside stents, you can for sure get good

62:14

visualization of the Lumen like I showed on on that

62:17

slide but small sense, you know, it can

62:20

be really really tough. And so the problem is you don't

62:23

often know ahead of time, you know, when the patients booked whether or

62:26

not there's tens of three millimeters or two millimeters. And so

62:29

you end up just having to do the best you can but if stents

62:32

are less than three remember in size and you're reading the

62:35

case you can certainly say, you know, this is just too small for evaluation

62:38

and you know, they may have to go do some

62:41

other type of testing for that patient.

62:45

Okay, next question can duplex top

62:48

or Ultron replace correct? CT in some cases in order to decrease unnecessary

62:51

radiation. No, not unfortunately, not really.

62:54

You just don't get a good

62:57

look at the coronaries with ultrasound. You

63:00

can maybe oftentimes

63:03

see the origins of the Corn

63:06

areas and you can rule out a coronary anomaly, but you can't really

63:09

get a good look at the lumens the Lumina

63:12

coronary to exclude any plaque.

63:15

And then the last question we have what

63:18

sort of patients really need calcium scoring. So that's a good question. I

63:21

think generally what

63:25

People have been thinking as that calcium score

63:28

is useful for somebody Who You're

63:31

you think based on

63:34

their risk factors that they you know

63:37

fit into maybe a low to intermediate risk category. They're

63:40

asymptomatic.

63:43

Um, just let me put that out first. So first of all, calcium scoring

63:46

always or most the

63:49

time is asymptomatications. So so the majority of time it's

63:52

asymptomatic patients.

63:54

You're you know.

63:56

Based on their profile. Maybe they have some high cholesterol

63:59

and their you know hypertensive and

64:02

they have a strong family history. You're worried that they might have

64:05

Corner disease, but maybe

64:08

they don't want to you know, take the Statin or whatever.

64:11

You're not sure how aggressive to be with their cholesterol

64:14

control. So basically people

64:17

who seem like they're high risk, but

64:23

You know, maybe a reluctant to take meds or maybe you're

64:26

you know, hoping that you can't you can sort of

64:29

dial back on the medications. You can

64:32

do a calcium score to see whether they have calcium or

64:35

not. And if somebody has a zero calcium score that's very reassuring that

64:38

they don't need to do they don't need to take you know.

64:42

A lot of the same or they

64:45

don't need to be so aggressive in terms of treating their cholesterol and

64:48

their blood pressure. So that's one category.

64:51

The other category is, you know, people just people

64:54

who are who are worried, you know, it's it's a

64:57

it's a screening test for people who maybe have a strong family history or

65:00

maybe they've had some you know

65:03

their cholesterols up or something and they just want to know it's

65:06

really helpful in those patients

65:09

just to provide them some peace of mind and then

65:12

finally in those chronic chest pain patients

65:15

that we mentioned earlier in the guidelines. So some

65:18

people who have maybe some some potentially coronary Angel

65:21

symptoms who

65:26

maybe when you do the the risk calculator show up is being fairly

65:29

low risk, but you want a little more reassurance.

65:32

You can do a calcium score.

65:36

so that is actually the last question I have I

65:39

hope

65:40

Yeah, I hope everyone, you know

65:43

got something out of this and thank you

65:46

so much for your attention. Thanks for tuning into

65:49

MRI online. And you know, please take a look at all. The

65:52

other offerings we have in the area of

65:55

cardiac. Imaging.

65:56

Doctors ever men. Thank you so much for your lecture today

65:59

and thanks to all for your participation in our new conference.

66:02

A reminder that you can access the recording of today's

66:05

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66:10

Be sure to join us next week on Tuesday, December 13th

66:13

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66:16

Catherine mcgillan on acute gynecologic ultrasound

66:19

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66:22

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66:25

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66:28

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