The New Era of Coronary CT | Podcast

She's the current President of the Society of Cardiovascular Computer Tomography.Welcome to our program.To start our discussion, this year has been called an inflection point for coronary CT.What shifted in the evidence or clinical landscape to make that true now?Dr. Kavitha Chinnaiyan-Thank you so much for having us on this podcast.So this year is called an inflection point because several studies and opinion statements as well as scientific statements are coming out regarding the use of advanced plaque imaging with AI tools and how this can be helpful in the diagnosis, treatment and prognosis of patients with coronary artery disease.And this is a big step in cardiology in general because it moves from the old paradigm of detecting disease at more advanced stages to further upstream.Dr. Jonathan Leipsic-Dr.Chu, first of all, thank you for the opportunity.I couldn't agree more with Dr. Chinnaiyan's comments, but I also think that with any inflection point, it obviously reflects really many, many years.I think as Dr. Chinnaiyan highlights, these sort of advanced analytics creating opportunities for quantitation of atherosclerosis and beyond is incredibly exciting.But of course, the bedrock is the 20 years of evidence, some of which came from Dr. Chinnaiyan and her group around the safety of cardiac CT or the opportunities of doing a cardiac CT safely at low radiation, doing it in the acute care setting, again, a lot of that work from Beaumont.And then all of the prognostic data that really supported its integration followed by large-scale registries, national registries, randomized trials that show that CT-informed medical management really creates an opportunity for more personalized care and also an opportunity for improved downstream clinical outcomes.So, you know, when we talk about this inflection point, Dr. Chu, I wouldn't want listeners to think, you know, this was, and they wouldn't, but that this is this magical moment which just happened by chance, but really it's been a tremendous amount of work on the part of so many over the last 20 years.Dr. Linda Chu-In thinking about a lot of the advances, in the past, when we think about coronary CT, we're mostly focused on the degree of stenosis, but now it seems like we're moving beyond that and moving more towards the plaque quantification and disease characterization.So how is all of that changing the coronary artery disease management in practice?Dr. Jonathan Leipsic-This is a really important question.I think what you've highlighted is that we sort of moved beyond historical limitations of coronary CT and certainly a lot of interest in quantitative atherosclerosis, but I would suggest to you that perhaps larger historical gap with regards to information from CT has been the ability to answer that final clinical question.You identify a stenosis.Do we think the patient will derive a meaningful benefit from revascularization? Are they likely to derive an angina benefit over and above medicine alone, or even an MI reduction benefit over above medicine alone?And we couldn't answer that with CT alone because we know that the totality of randomized evidence doesn't support revascularization by anatomy in isolation.And so over a decade ago, the opportunity to integrate FFR-CT, you know, calculated pressure-specific values that allow the phenotyping, not only in a binary sense, is the physiology normal or not, but how abnormal is it?Is it focally abnormal?What is the translesional pressure loss?With a high degree of concordance, albeit imperfectly, obviously, but with a high degree of concordance with invasive physiology actually creates an opportunity to not just complement CT but provide unique information, unlike historical functional data, which answers a lot of important questions, but doesn't tell you specifically if that lesion is the driver of the flow disturbance.So I think the ability to really avoid those, that uncertainty that we were left with when we identified an anatomical stenosis is a very pragmatic opportunity and is embedded in the guidelines as a class IIa indication.And so I think that really helped us move forward in also managing perhaps patients with complex anatomical disease, where we were often left with uncertainty as what to do next, often requiring, you know, historically, either a perfusion study or a trip to the cath lab.And that, I think, pivots nicely to perhaps Dr. Chinnaiyan to shed some light on some of the new opportunities with quantitative athero.