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How is AI changing CAD diagnostics?

Artificial intelligence (AI) has the potential to transform healthcare, and while there are several concerns about its safety and accuracy in clinical use, its presence is inevitable and improving patients’ outcomes.1

“It is not the strongest of the species that survives, nor the most intelligent. It is the one that is most adaptable to change.”
– Charles Darwin

At the annual SCCT meeting in Boston this past July, several companies presented their newest AI based technologies for evaluation of cardiac plaque, stenosis severity, flow limitation and inflammation.

All these technologies are CT based, meaning they obtain information gathered by coronary CTA (CCTA). Some of them are in clinical use already, while others are emerging with novel imaging features that are changing the way we diagnose and treat coronary artery disease (CAD).

HeartFlow, was the first FDA approved company providing Fractional Flow Reserve derived from CCTA (FFRCT), a 3D functional analysis that supplements anatomical information from CCTA. This is equivalent to a stress test that can avoid layered testing, unnecessary radiation, and invasive procedures.2

For example, at a 1-year follow-up the PRECISE trial demonstrated that in comparison to a usual care pathway of stress testing or invasive angiography, a pathway centered on CCTA+FFRCT informed clinical decision-making such that clinical events were reduced by approximately 70%, non-invasive and invasive cardiac testing were reduced, preventive medication usage was increased, and the PCI:ICA ratio was improved.3

Multiple trials including the recent FISH&CHIPS found that adding FFRCT availability yielded clear improvement in endpoints within just 24 months. Among patients receiving a CCTA, those scanned during the period of FFRCT availability had 8% lower all-cause mortality, 14% lower cardiovascular mortality, 14% fewer additional non-invasive cardiac tests, 5% fewer additional invasive cardiac angiograms (ICA), Improved cath lab efficiency (higher ratio of PCI:ICA) and no increase in myocardial infarction rates.4

Results from RevealPlaque showed that HeartFlow’s Plaque Analysis demonstrated a 95% agreement compared to IVUS in quantification and characterization of total plaque volume.5

Cleerly provides qualitative and quantitative plaque analysis, including calcified, non-calcified and low attenuation plaque. Cleerly demonstrates high agreement with intravascular ultrasound (IVUS) for absolute measures of coronary lumen size to determine accurate stenoses measurements.6

Plaque stages can navigate physicians to initiate, intensify or de-intensify lifestyle interventions and medical management of patients with CAD.

Follow up scans demonstrate the effectiveness of statins for phenotypic plaque transformation through preferentially accelerating the calcification of plaque and reducing high-risk plaque development.7

Elucid Vivo offers the only AI based plaque analysis technology that was validated with histopathology. PlaqueIQ shows plaque characteristics and its vulnerability including lipid-rich necrotic core, calcifications, intraplaque hemorrhage and fibrous cap/perivascular adipose tissue. The company is also pursuing an indication for FFRCT derived from its PlaqueIQ technology to non-invasively measure extent of ischemia.8

Caristo diagnostics is an AI-enabled imaging solution that quantifies coronary inflammation and characterizes plaque, to help clinicians make more informed patient management decisions. Cari Analysis uses a novel imaging biomarker, the Fat Attenuation Index (FAI) to quantify coronary Inflammation. It provides an 8-year risk of a fatal cardiac event if left untreated, based on the FAI-Score values, the coronary atherosclerotic plaque burden, and the clinical risk factors.9

Other AI based algorithms (Bunkerhill) can obtain calcium score from lung cancer screening non-contrast chest CTs decreasing amount of radiation and cost for patients.

With the inevitable advancement of the AI technologies for diagnosis and treatment of heart disease, how adaptable is your cardiac program?

References
  1. http://doi.org/10.1056/NEJMoa1805971
  2. https://www.heartflow.com 
  3. https://jamanetwork.com/journals/jamacardiology/fullarticle/2808765
  4. Fairbairn, et al. FFRCT In Stable Heart disease and CCTA Helps Improve Patient care and Societal costs. Presented at ESC 2023
  5. REVEALPLAQUE Study, presented at SCCT 2023
  6. Coronary CTA Plaque Volume Severity Stages According to Invasive Coronary Angiography and FFR. Journal of Cardiovascular Computed Tomography. Published March 2022.
  7. Progression of Atherosclerotic Plaque DetermIned by Computed TomoGraphic Angiography Imaging [PARADIGM]. Journal of the American College of Cardiovascular Imaging. Last Updated 2018.
  8. http://elucid.com
  9. https://caristo.com
  10. https://www.bunkerhillhealth.com
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We asked Dr. Nelson to share a few heart health statistics with us to recognize American Heart Month. She told us, “Cardiovascular disease is the leading cause of death in the U.S. for both men and women. There are 400,000 deaths a year among women and 386,000 deaths among men a year in the U.S. Coronary Artery Disease (CAD) alone is the cause of 175,000 deaths a year. This makes CAD the most common cause of mortality among adults in the United States.

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A coronary calcium scan is a specialized imaging test using computed tomography (CT) technology to create detailed images of the coronary arteries. The primary purpose of this scan is to identify and quantify the amount of calcium deposits in the coronary arteries, which are indicative of atherosclerosis or plaque buildup.

Calcium deposits in the coronary arteries are a key marker of atherosclerosis, a condition characterized by the hardening and narrowing of the arteries. As plaque accumulates over time, it can restrict blood flow to the heart, leading to cardiovascular issues, including heart attacks. “The calcium score, also known as the Agatson score or coronary calcium CT scan, is a special computerized tomography (CT) scan of the heart,” Dr. Nelson said. “It looks for calcium deposits in the heart arteries.

“Coronary calcium scan results can help determine the risk of heart attacks or strokes, and the results from the scan can guide therapies for coronary artery disease.”

How Can It Save Your Life?

The information obtained from a coronary calcium scan is invaluable in assessing an individual’s risk of developing heart disease. By identifying the presence and extent of calcified plaque, healthcare professionals can gauge the severity of atherosclerosis and tailor a preventive strategy accordingly.

Early detection through a coronary calcium scan allows for timely intervention, enabling individuals to make lifestyle changes, initiate medications, or undergo medical procedures to prevent the progression of heart disease. This proactive approach significantly reduces the risk of heart attacks and other cardiovascular events.

How Can You Get a Coronary Calcium Scan?

Getting a coronary calcium scan involves consulting with a health care provider, who will assess your risk factors for heart disease. Common risk factors include age, family history, smoking, high blood pressure, and high cholesterol levels. Your provider may recommend a coronary calcium scan to evaluate your cardiovascular health based on the evaluation.

The procedure itself is quick, usually taking 15 minutes or less, and painless. During the scan, you lie on a table that slides into the CT scanner. The scanner captures detailed images of your heart, and the results are analyzed to determine the presence and extent of calcium deposits.

Popularity of Coronary Calcium Scans

Coronary Calcium Scan

The popularity of coronary calcium scans has steadily increased as awareness of preventive cardiology grows. Many recognize the importance of early detection and intervention to safeguard their heart health. Health care providers also incorporate these scans into routine screenings for individuals at risk of heart disease.

The availability and recommendation of coronary calcium scans may vary based on geographical location, health care infrastructure, and individual risk profiles. However, the rising prominence of preventive health care is contributing to the widespread adoption of these scans in many regions.

Who Benefits Most?

“The calcium score is best for asymptomatic patients with no known coronary artery disease, who are over 45 years old with a strong family history of early coronary artery disease, borderline or elevated lipids to guide treatment decisions for cholesterol management and potential further testing.”

Dr. Nelson

It is not, she warned, the best course for those at high risk of heart attacks or who have previous heart conditions.

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Next Steps

The decision to undergo a coronary calcium scan should be in consultation with a health care provider. Before recommending the scan, they will assess your overall health, medical history, and risk factors. Additionally, guidelines may vary, and health care professionals will consider individual circumstances when making recommendations.

In the quest for optimal heart health, coronary calcium scans emerge as a powerful tool for early detection and prevention of heart disease. By providing crucial insights into the presence of calcified plaque in the coronary arteries, these scans empower individuals and health care professionals to take proactive measures to mitigate cardiovascular risks. As awareness grows, the coronary calcium scan will play a pivotal role in preventive cardiology, ultimately saving lives through early intervention and personalized care.

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