CT Coronary Angiogram VS Cardiac Stress Test

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CT coronary angiogram vs
Cardiac stress tests
Dr Chan Wan Xian
Consultant Cardiologist
Heart Failure Specialist
Echocardio...

CT Coronary Angiogram Cardiac Stress Tests

CT coronary angiogram

Advances in Cardiac CT
• High quality images of the heart
• Improved tissue and material characterization
• Advances in ra...

National Institute of Health and Care Excellence (NICE)
guideline

2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS
guideline

European Society of Cardiology 2013 non-invasive
testing in
patients with suspected stable coronary artery disease
Class I...

Pro: NICE guidelines represent a NICE evolution
• Computed tomography angiography offers improved
accuracy
• Computed tomo...

Meta-analyses of the diagnostic performance of functional imaging and
CCTA with ICA >50% Diameter Stenosis as reference st...

• With invasive FFR ≤0.80 as the reference, CCTA, and stress MRI and PET prove to be the most
sensitive, and the latter tw...

Pooled results of the shorter-term trials revealed significantly fewer myocardial infarctions with CTA (3.8% vs.
5.6%, P= ...

Calcium imaging and selective computed tomography angiography in comparison to functional
testing for suspected coronary a...

Functional Testing or Coronary Computed Tomography Angiography in
Patients With Stable Coronary Artery Disease
• The Danis...

Coronary CT Angiography and 5-Year Risk
of Myocardial Infarction
The SCOT-HEART Investigators
N Engl J Med 2018;379:924-33...

• In three studies, there was significantly more non-obstructive ICA following UC than CTA
• Downstream testing was signif...

CT coros likely to improve compliance with
appropriate use criteria (AUC)?
• In the United States, the number of stress te...

Anatomic approaches for stable chest pain
miss the mark?
• Approach of using non-invasive stress test to assess for presen...

Initial diagnostic management of patients with suspected
stable coronary artery disease
Stepwise approach
• Clinical asses...

Determine pretest probability
Analysis of probability as an aid in the clinical
diagnosis of
coronary-artery disease. N En...

• Groups in white boxes have a PTP <15% and hence can be managed without further testing.
• Groups in blue boxes have a PT...

Interpretation of non-invasive cardiac tests
requires a Bayesian approach to diagnosis
• Uses clinicians’ pre-test estimat...

Approach in selection of diagnostic tests
• Functional or stress testing to detect inducible ischemia has been the
“gold s...

Principles within the ischemic cascade

Cardiac Stress Tests to provoke Ischemia
Patient CAN exercise Patient canNOT exercise
Exercise stress tests Pharmacologica...

Treadmill Exercise Stress Test
1918 - Bousfield noted ST depressions during angina
1929 - Masters and Oppenheimer develope...

Baseline ECG

Peak Exercise ECG

Treadmill+ Echo
End-Point: HR, BP, Exercise Capacity, ECG, Symptoms, ECHO images, Wall motion abnormalities and POST peak ...

Dobutamine Stress Echo
End-Point: HR, ECG, Symptoms and ECHO images, Wall motion abnormalities (demand state), PEAK stress...

3RPL 75-80% stented with Orsiro 3.0 x 22mm. pLAD 75% stented with Orsiro 4.0 x 18mm. D1 ostium 75% treated wlth Magic Touc...

Treadmill Exercise + SPECT Nuclear Myocardial Perfusion Scan
End-Point: HR, BP, Exercise Capacity, ECG, Symptoms and coron...

Pharmacological Nuclear Myocardial Perfusion Scan
Indications:
• Abnormal baseline ECG : Atrial
fibrillation, LBBB, paced,...

Large, severe, reversible defect involving the anterior wall, septum, apex and inferior wall
-> Cath confirmed 85% mid LAD...

Large-sized area of severely decreased uptake in the inferior wall.
This defect is almost fully reversible on rest images,...

Cardiac MRI perfusion scan
First-pass perfusion study with a
saturation-recovery-prepared
gradient echo sequence covering
...

A, Stress and, B, rest first-pass
perfusion images show ischemia in
anterolateral wall and a fixed defect in
the inferolat...

E, F, Subsequent coronary angiograms ordered at the discretion of the referring
physician show, E, critical luminal narrow...

Illustration of the sequence of protocol components in a cardiac MR examination, which includes assessment of myocardial p...

CT Myocardial Perfusion Imaging
A, Curved multiplanar reformatted view of left anterior descending artery shows noncalcifi...

A, Curved multiplanar reformatted view of left circumflex artery shows mixed plaque (arrow) with
intermediate-to-severe st...

A, Three-dimensional volume-rendered reconstruction of coronary CTA shows stent (arrow) in first obtuse
marginal branch of...

Combined dynamic rest and stress CT perfusion studies can require radiation exposure of
approximately 18 mSv

Con: anatomic approaches for stable chest
pain miss the mark
• Computed tomography angiography is a relatively new procedu...

Optimal Medical Therapy with or without PCI
for Stable Coronary Disease
- COURAGE TRIAL
• Randomized trial involving 2287 ...

There were no significant differences
between the PCI group and the
medical-therapy group in
• 4.6-year cumulative primary...

A Randomized Trial of Therapies for Type 2 Diabetes and
Coronary Artery Disease
The BARI 2D Study Group
• There was no sig...

Advances in Cardiac CT
• CT-FFR is an advanced post-processing technique. FFR is obtained
non-invasively from a routine co...

Coronary angiogram FFR

Accuracy of Fractional Flow Reserve Derived From Coronary Angiography, Volume: 139, Issue: 4, Pages: 477-484, DOI: (10.116...

CT coronary angiogram FFR
Determination of FFRCT by using computational fluid dynamics principles
Acquisition of standard
...

The balanced view…

What is the clinical question???
1. The presence of CAD (of any degree)
2. High-risk plaque that portends hard events
3. S...

• To answer different clinical questions,
different diagnostic strategies are needed
• Not realistic to think that one tes...

What should be the future approach to
evaluation of stable CAD?
• Establish goal of testing in patient with suspected CAD ...

Thank you
6 Napier Road # 04-13
Gleneagles Annex Block
Singapore 258499
38 Irrawaddy Road #08-58
Mount Elizabeth Novena
Sp...

MRI and PET perfusion scans

Talk outline
• Chest pain approach guidelines
• Management of stable IHD/ angina guidelines
• Ischemic cascade/ controvers...

• 10 000 symptomatic patients were randomized to CTA or functional testing (SPECT 67.5%, SE
22.4%, ETT 10.2%) and followed...

Objectives- Coronary artery diesase
• Improved diagnosis
• Improve prognosis assessment

CT coronary angiogram
• Can identify both nonobstructive and obstructive coronary artery
disease (CAD)

• Not so much which test but Importance of an approach- not studied
or trialed- difficult- logistics and expenses

Cardiac Stress Tests to provoke Ischemia
• Treadmill exercise stress test
• Echocardiography stress test
• Myocardial Perf...

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