This document discusses CT coronary angiography (CTCA) indications and appropriate use. It provides 12 appropriate indications for CTCA, including evaluation of chest pain with intermediate pretest probability, assessment of coronary anomalies, and mapping of coronary veins prior to pacemaker placement. It also lists 4 inappropriate indications such as for asymptomatic patients. The document reviews diagnostic accuracy, preparation for CTCA, and Medicare rebates. It emphasizes CTCA is cost-effective for evaluating chest pain when pretest risk of coronary artery disease is up to 65%.

1. CT CORONARYCT CORONARY
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INDICATIONSINDICATIONS
Wednesday 19/10/11Wednesday 19/10/11
Dr Alistair BeggDr Alistair Begg
SA Heart Ashford HospitalSA Heart Ashford Hospital

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7. INDICATIONSINDICATIONS
 Noninvasive CoronaryNoninvasive Coronary
Artery Imaging:Artery Imaging:
Current ClinicalCurrent Clinical
ApplicationsApplications
Cardiac Society ofCardiac Society of
Australia and NewAustralia and New
Zealand GuidelinesZealand Guidelines
Heart Lung andHeart Lung and
Circulation July 2011Circulation July 2011

8. Appropriate indicationsAppropriate indications
 1.Chest pain1.Chest pain
evaluation –evaluation –
intermediate pretestintermediate pretest
probability of CADprobability of CAD
where the patient iswhere the patient is
unable to exerciseunable to exercise
or the ecg isor the ecg is
uninterpretable eguninterpretable eg
LBBBLBBB

9. Normal coronary arteriesNormal coronary arteries

10. Appropriate indicationsAppropriate indications
 2.Chest pain evaluation-2.Chest pain evaluation-
uninterpretable or equivocal stress testuninterpretable or equivocal stress test
or stress imagingor stress imaging

11. Appropriate indicationsAppropriate indications
 3.Evaluation of chest pain (ED) if3.Evaluation of chest pain (ED) if
intermediate pretest probability with nointermediate pretest probability with no
ecg changes or cardiac enzymeecg changes or cardiac enzyme
elevationelevation

12. Tight LAD stenosisTight LAD stenosis

13. Appropriate indicationsAppropriate indications
 4.Evaluation of suspected coronary4.Evaluation of suspected coronary
anomaliesanomalies

14. Left main arising fromLeft main arising from
RCARCA

15. Appropriate indicationsAppropriate indications
 5.Evaluation of CAD in new onset5.Evaluation of CAD in new onset
heart failureheart failure

16. Appropriate indicationsAppropriate indications
 6.Assessment of complex congenital6.Assessment of complex congenital
heart disease especially in regards toheart disease especially in regards to
both coronary/great vessels andboth coronary/great vessels and
cardiac chambers and valvescardiac chambers and valves

17. Atrial switch operationAtrial switch operation
(Mustard operation)for(Mustard operation)for
transposition of greattransposition of great
arteriesarteries

18. Appropriate indicationsAppropriate indications
 7.Evaluation of pulmonary vein7.Evaluation of pulmonary vein
anatomy prior to radiofrequencyanatomy prior to radiofrequency
ablation for atrial fibrillationablation for atrial fibrillation

20. Appropriate indicationsAppropriate indications
 8.Coronary vein mapping prior to8.Coronary vein mapping prior to
placement of biventricular pacemakerplacement of biventricular pacemaker

21. Appropriate indicationsAppropriate indications
 9.Repeat CABG – internal mammary9.Repeat CABG – internal mammary
artery and coronary artery mappingartery and coronary artery mapping

22. Appropriate indicationsAppropriate indications
 10.Technically difficult or limited10.Technically difficult or limited
images from echocardiogram or MRIimages from echocardiogram or MRI
in particular relating to cardiac massesin particular relating to cardiac masses
( tumour or thrombus) and evaluation( tumour or thrombus) and evaluation
of pericardial conditionsof pericardial conditions
(mass,pericarditis,post cardiac(mass,pericarditis,post cardiac
surgery)surgery)

23. Appropriate indicationsAppropriate indications
 11.Preoperative coronary assessment11.Preoperative coronary assessment
prior to noncoronary cardiacprior to noncoronary cardiac
surgery.The CTA finding of a stenosissurgery.The CTA finding of a stenosis
> 50% or highly calcified plaque that> 50% or highly calcified plaque that
precludes assessment of stenosisprecludes assessment of stenosis
severity will necessitate invasiveseverity will necessitate invasive
coronary angiographycoronary angiography

24. Appropriate indicationsAppropriate indications
 12.Cardiac transplant follow up12.Cardiac transplant follow up

25. INappropriateINappropriate
indicationsindications
 1.Asymptomatic patients1.Asymptomatic patients

26. INappropriateINappropriate
indicationsindications
2.High pretest probability including positive2.High pretest probability including positive
stress testsstress tests

27. INappropriateINappropriate
indicationsindications
 3.Positive cardiac enzymes or ST3.Positive cardiac enzymes or ST
elevation on ECGelevation on ECG

28. INappropriateINappropriate
indicationsindications
 4.Instent evaluation especially stents4.Instent evaluation especially stents
<3.0mm<3.0mm

29. Special situationsSpecial situations
- Emergency department- Emergency department
chest painchest pain
 >60% ED chest pain is noncardiac>60% ED chest pain is noncardiac
 Numerous studiesNumerous studies
 Show high NPV 97-100%Show high NPV 97-100%
 Show poor PPV 47-52%Show poor PPV 47-52%
 Versus nuclear imageing isVersus nuclear imageing is
faster/cheaper/less repeatfaster/cheaper/less repeat
presentationspresentations

30. Excellent negativeExcellent negative
predictive valuepredictive value

31. Special situationsSpecial situations
Coronary stentsCoronary stents
 CORE 64 trial showed PPV 57% andCORE 64 trial showed PPV 57% and
NPV 80% if stent <3.0mmNPV 80% if stent <3.0mm
 If left main stent > 4.0mm is 98%If left main stent > 4.0mm is 98%
accurateaccurate
 Routine use of CTCA for instentRoutine use of CTCA for instent
restenosis NOT recommendedrestenosis NOT recommended

32. Special situationsSpecial situations
Coronary bypass graftsCoronary bypass grafts
 Excellent accuracy for graftsExcellent accuracy for grafts
 100% NPV100% NPV
 92%PPV92%PPV
 Native coronaries very calcified andNative coronaries very calcified and
diseased,hard to quantitatediseased,hard to quantitate
 Useful if invasive angiography hasUseful if invasive angiography has
failed to assess a graft or patencyfailed to assess a graft or patency
 Can use to plan repeat CABGCan use to plan repeat CABG

33. Coronary bypass graftsCoronary bypass grafts

34. Special situationsSpecial situations
Chronic total occlusionsChronic total occlusions
 Useful to assessUseful to assess
 Chronic total occlusion if consideringChronic total occlusion if considering
PCIPCI
 Assess occlusionAssess occlusion
length,stump,calcificationlength,stump,calcification

35. Diagnostic accuracyDiagnostic accuracy
 Better if segments > 2.0mm diameterBetter if segments > 2.0mm diameter
 Better for left main 91-100% sens andBetter for left main 91-100% sens and
100% specific100% specific
 Worse for mid- RCA 81% sens 95%Worse for mid- RCA 81% sens 95%
specspec
 100% NPV if low-medium risk group100% NPV if low-medium risk group
 89% NPV if high pretest probability89% NPV if high pretest probability

36. Diagnostic accuracyDiagnostic accuracy

37. Diagnostic accuracyDiagnostic accuracy

38. Diagnostic accuracyDiagnostic accuracy

39. Diagnostic accuracyDiagnostic accuracy

40. Diagnostic accuracyDiagnostic accuracy

41. Heart 2010;96:1973-19Heart 2010;96:1973-19

42. Cost effectiveness ofCost effectiveness of
CTCACTCA
 MSAC (medical services advisoryMSAC (medical services advisory
committee) advised that based on costcommittee) advised that based on cost
of $3035 invasive vs $1020of $3035 invasive vs $1020
noninvasive coronary angiographynoninvasive coronary angiography
 Cost effective strategy if symptomaticCost effective strategy if symptomatic
and up to 65% pretest risk of CADand up to 65% pretest risk of CAD

43. Preparation for CTCAPreparation for CTCA
 Recent UEC to avoid nephrotoxicityRecent UEC to avoid nephrotoxicity
 Aim HR 50-55 by giving Metoprolol 50 mgAim HR 50-55 by giving Metoprolol 50 mg
night before and 50 mg morning of scannight before and 50 mg morning of scan
 Fast 4 hours,avoid caffeine on day of testFast 4 hours,avoid caffeine on day of test
 Atrial fibrillation should be treated ?Atrial fibrillation should be treated ?
Cardiovert before , and ideally avoided forCardiovert before , and ideally avoided for
CTCACTCA
 Usually no sedation requiredUsually no sedation required

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46. Medicare rebateMedicare rebate
 57360 57360
COMPUTED TOMOGRAPHY OF THE CORONARY ARTERIESCOMPUTED TOMOGRAPHY OF THE CORONARY ARTERIES
performed on a minimum of a 64 slice (or equivalent) scanner, whereperformed on a minimum of a 64 slice (or equivalent) scanner, where
the request is made by a specialist or consultant physician, and:the request is made by a specialist or consultant physician, and:
a) the patient has stable symptoms consistent with coronarya) the patient has stable symptoms consistent with coronary
ischaemia, is at low to intermediate risk of coronary artery diseaseischaemia, is at low to intermediate risk of coronary artery disease
and would have been considered for coronary angiography; orand would have been considered for coronary angiography; or
b) the patient requires exclusion of coronary artery anomaly or fistula;b) the patient requires exclusion of coronary artery anomaly or fistula;
oror
c) the patient will be undergoing non-coronary cardiac surgeryc) the patient will be undergoing non-coronary cardiac surgery

47. Radiation safetyRadiation safety

48. Radiation safetyRadiation safety

49. Radiation safetyRadiation safety

50. SummarySummary

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 Questions and comments?Questions and comments?