0:01

Patients who are at high risk for lung cancer are also at

0:03

high risk for cardiovascular disease.

0:06

In the National Lung Cancer Screening trial,

0:08

we saw a 20% reduction in lung cancer specific mortality,

0:12

but we saw a nearly 7% reduction, all cause mortality.

0:16

Much of that is attributed to cardiovascular disease.

0:20

We'll talk about the most common cardiovascular

0:24

incidental findings that you can see on a CT examination.

0:27

Some people would say the term incidental is maybe not the

0:30

most correct term to use

0:31

because we expect patients with a heavy history

0:34

of cigarette smoking to have atheros disease,

0:37

to have lung disease in the form of emphysema.

0:40

The question in front

0:42

of us is when we identify them is are they

0:44

significant for the patient?

0:46

Do they need to be managed

0:47

and can they impact their future morbidity and mortality?

0:51

So we'll talk about the frequency

0:52

of these most common cardiovascular sent findings,

0:55

and the three that we're gonna talk about

0:57

specifically our corona arterial calcification.

0:59

Something that most people are quite familiar

1:01

with from the days of beginning.

1:03

The Atkinson scoring for dedicated coronary calcium cts

1:08

to a dilated aorta aortic aneurysms

1:11

for which there are guidelines on which to make decisions,

1:14

and then something that doesn't get as much recognition,

1:16

which is beginning to be known as important

1:19

for patient's health, which is increased epicardial fat.

1:23

If we look at the first 1.7 million screens in the

1:28

ACRs lung cancer screening registry, we can look at how

1:31

commonly cardiovascular findings occur.

1:34

Remember, an S finding or the S modifier is a significant

1:38

or potentially significant finding found on a lung

1:41

cancer screening ct.

1:43

The first time you identify in the abnormality,

1:45

it's now a new significant

1:46

or potentially significant finding.

1:48

But if the finding is unchanged on subsequent cts,

1:52

it's no longer an S modifier.

1:55

However, it still may be important for you

1:57

to put it in the impression of your report.

1:59

Coronary arterial calcification occurred on the first

2:04

1.7 million screens about 11.6% of the time

2:08

and represented 62% of all the patients

2:12

who have an S finding.

2:14

We report the S modifier

2:16

for coronary art trial calcification generally in patients

2:19

who have moderate

2:20

or severe coronary art trail calcification.

2:23

Another important cardiovascular finding

2:26

that's incidental on lung screening.

2:28

cts are aortic aneurysms

2:30

and generally thoracic aortic aneurysms are silent

2:34

until a patient either has it found incidentally,

2:36

usually getting a chest CT for some other reason, or

2:40

because they come in with an acute aortic emergency due

2:44

to the RUP of aortic aneurysm.

2:46

Abdominal aortic aneurysms in contrast, have other signs

2:50

of disease such as potentially a palpable mass

2:53

or other ways of screening, such

2:55

as ultrasound screening is recommended

2:57

in high risk patients.

3:00

So these are two really important categories

3:02

that we should look at on our lung cancer screening.

3:04

cts coronary trial calcification

3:07

for which lipid modification is gonna be important in

3:09

cardiovascular risk assessment, an aortic aneurysms

3:12

for which their guidelines on which to base the frequency

3:15

of followup imaging and the inclusion of echocardiography.

3:20

If we look at the American College

3:21

of Radiology's lung cancer screening, incidental findings,

3:25

quick reference guide,

3:26

we have a specific section on these cardiovascular findings

3:30

for the thoracic aorta.

3:32

If it's a little bit dilated,

3:33

but still considered within normal, for example,

3:36

an ascending aorta under 40

3:38

to 42 millimeters is considered normal.

3:41

You might call that fusiform dilatation

3:43

or mild ectasia

3:44

of the thoracic aorta in the ascending component

3:47

and no follow-up recommendation may be made when the ascend

3:51

aorta hits 42 millimeters in diameter.

3:53

This is where recommended surveillance occurs

3:56

and potentially a cardiology

3:57

or cardiac surgery consultation.

4:00

Commonly, an echocardiogram is recommended

4:02

to evaluate the aortic valve for evidence of stenosis

4:05

or insufficiency, which can be the cause

4:08

or be related to an ascent aorta that is dilated

4:12

as ascent aortic increase in size.

4:14

The risk of rupture increases reaching surgical thresholds

4:18

of approximately 5.5 centimeters in the a c aorta

4:22

for most patients, but five centimeters for patients

4:26

who have underlying connective tissue diseases

4:29

that can cause rapid increase in size

4:32

and increase the risk of acute aortic emergencies, such

4:35

as patients with Aler Danlos syndrome or LODE syndrome.

4:39

We can certainly look at the heart

4:41

and pericardium for abnormal chamber size

4:43

for pericardial thickening calcification

4:45

or pericardial effusion and manage

4:47

accordingly as you would in a standard chest

4:50

CT interpretation.

4:51

Coronary arterial calcification,

4:53

we're gonna talk about a little bit more detail,

4:55

and in the main pulmonary arteries,

4:57

we can measure them for dilatation.

4:59

Generally, under 31 millimeters is considered a normal

5:03

diameter main pulmonary artery and 31 millimeters

5:06

or larger as considered enlarged.

5:08

However, people have called into question the

5:11

31 millimeter criterion.

5:13

The ACRs white paper

5:15

for incidental fines in the chest uses this size threshold.

5:19

However, many cardiologists considered the appropriate size

5:22

threshold closer to 33

5:23

or 34 millimeters, believing there were over calling

5:27

possible pulmonary hypertension by using such

5:29

as a low threshold

5:31

and subjecting these patients to unnecessary referral

5:34

and unnecessary testing.

5:36

So in our practice, we're using a threshold

5:38

of about 33 millimeters

5:40

to call mild pulmonary tear enlargement.