1 00:00:05.615 --> 00:00:07.405 Thank you for joining us to talk about 2 00:00:07.965 --> 00:00:10.805 identifying patients who can benefit from coronary 3 00:00:11.005 --> 00:00:12.445 C-T-A-C-T-A 4 00:00:12.505 --> 00:00:15.165 and FFRCT pathway in order 5 00:00:15.165 --> 00:00:17.245 to diagnose coronary artery disease. 6 00:00:17.945 --> 00:00:19.325 My name is Jennifer Robinson 7 00:00:19.345 --> 00:00:21.845 and I work for HeartFlow in Medical Affairs. 8 00:00:22.105 --> 00:00:25.525 As a manager of digital education, I would like 9 00:00:25.525 --> 00:00:28.525 to introduce our esteemed faculty educator. 10 00:00:28.525 --> 00:00:30.645 Joining me today, Dr. 11 00:00:30.645 --> 00:00:32.445 Matthew Budoff is a professor 12 00:00:32.445 --> 00:00:36.285 of medicine at the David Geffen School of Medicine at UCLA, 13 00:00:37.105 --> 00:00:41.585 the director of cardiac ct, an endowed chair 14 00:00:41.685 --> 00:00:43.185 of preventive cardiology, 15 00:00:44.185 --> 00:00:46.245 and the program director in the division 16 00:00:46.265 --> 00:00:49.205 of cardiology at the Lundquist Institute 17 00:00:49.345 --> 00:00:50.525 in Torrance, California. 18 00:00:51.385 --> 00:00:52.575 Thank you, Dr. Budoff 19 00:00:52.575 --> 00:00:54.815 for joining me here today. Please go ahead. 20 00:00:55.605 --> 00:00:56.615 Well, thank you Jennifer, 21 00:00:56.795 --> 00:00:58.695 and thank you all for joining me today. 22 00:00:58.975 --> 00:01:01.295 I think that there's some very, uh, new 23 00:01:01.395 --> 00:01:02.975 and interesting information 24 00:01:02.975 --> 00:01:05.175 that helps us guide our patient course, 25 00:01:05.275 --> 00:01:07.855 and I'll show you some of the benefits of, uh, 26 00:01:07.915 --> 00:01:10.295 of a selected pathway here. 27 00:01:11.225 --> 00:01:12.605 So today we're gonna go through 28 00:01:13.365 --> 00:01:14.885 identifying appropriate patients 29 00:01:14.985 --> 00:01:18.005 for the C-T-A-F-F-R CT pathway. 30 00:01:19.315 --> 00:01:20.465 We'll talk a little bit about 31 00:01:20.525 --> 00:01:22.865 how CTA can assist in preventive care. 32 00:01:24.285 --> 00:01:25.355 We'll talk about, uh, 33 00:01:25.355 --> 00:01:27.475 diagnosing coronary disease in an underserved 34 00:01:27.475 --> 00:01:28.715 patient population. 35 00:01:29.135 --> 00:01:32.635 And, uh, I I work at a county facility, so I I primarily 36 00:01:33.145 --> 00:01:35.555 deal with underserved patient populations 37 00:01:36.135 --> 00:01:39.915 and then helping patients to avoid misdiagnoses, having 38 00:01:40.555 --> 00:01:44.075 repeated and unnecessary tests or invasive procedures. 39 00:01:44.135 --> 00:01:47.115 So, uh, really kind of focusing the care to make sure 40 00:01:47.115 --> 00:01:48.395 that the patients 41 00:01:48.395 --> 00:01:51.115 who have the highest risk are afforded the highest level 42 00:01:51.115 --> 00:01:54.795 of care, matching intensity of care with intensity of risk. 43 00:01:56.665 --> 00:02:00.925 So let's start with first the appropriate use of CTA 44 00:02:00.925 --> 00:02:03.085 and FFR to diagnose coronary disease. 45 00:02:03.625 --> 00:02:06.405 And it's not my opinion of where appropriate use is. 46 00:02:06.405 --> 00:02:09.845 These are from the 2021 American College of Cardiology, 47 00:02:10.285 --> 00:02:12.965 American Heart Association Chest Pain guidelines. 48 00:02:13.505 --> 00:02:16.925 You should know that CT angio is the only class one 49 00:02:16.925 --> 00:02:19.325 non-invasive test with a level A evidence. 50 00:02:19.465 --> 00:02:23.045 So the only OR recommendations there were two Class one A 51 00:02:23.045 --> 00:02:24.605 recommendations given out for, 52 00:02:24.705 --> 00:02:27.285 for a non-invasive testing in the chest pain guidelines. 53 00:02:27.345 --> 00:02:30.405 One was for CTA in the acute setting 54 00:02:30.745 --> 00:02:33.885 and one was for CTA in the, uh, stable 55 00:02:34.685 --> 00:02:36.045 coronary population. 56 00:02:36.545 --> 00:02:39.285 So all the other tests got, got lower levels 57 00:02:39.285 --> 00:02:44.045 of recommendations, uh, nuclear MR treadmill, et cetera. 58 00:02:44.785 --> 00:02:49.485 On top of that FFR CT was designated a class two A level B 59 00:02:49.825 --> 00:02:50.845 uh, recommendation, 60 00:02:51.195 --> 00:02:54.685 providing additional actionable information across a 61 00:02:54.685 --> 00:02:55.805 broad range of patients. 62 00:02:56.465 --> 00:03:00.605 So specific to the, uh, F-F-R-C-T, you can see for both 63 00:03:01.265 --> 00:03:03.085 stable or acute chest pain. 64 00:03:03.465 --> 00:03:06.165 For intermediate risk patients with acute chest pain 65 00:03:06.165 --> 00:03:09.405 and no known CAD with a coronary stenosis of 40 66 00:03:09.465 --> 00:03:13.885 to 90% F-F-R-C-T can be useful for the diagnosis of vessel 67 00:03:14.405 --> 00:03:16.685 specific ischemia and to guide decision making 68 00:03:16.755 --> 00:03:19.445 regarding the use of coronary revascularization. 69 00:03:20.025 --> 00:03:23.005 And that's actually a very robust recommendation 70 00:03:23.025 --> 00:03:25.045 to talk about guiding decision making. 71 00:03:25.425 --> 00:03:26.965 Uh, we don't often see that. 72 00:03:26.965 --> 00:03:30.445 We saw that for CTA and we see that now for FFR ct. 73 00:03:31.525 --> 00:03:33.225 So why did they get that recommendation? 74 00:03:33.225 --> 00:03:35.505 And I'll go through one of the studies that supported that. 75 00:03:36.525 --> 00:03:41.185 But the general process, the typical CTA workflow 76 00:03:41.765 --> 00:03:43.865 is we start with a CT, a angiogram. 77 00:03:44.165 --> 00:03:48.665 The reader decides whether there's a 40 to 90% stenosis, 78 00:03:48.775 --> 00:03:51.505 whether there'd be a benefit of FFR ct, 79 00:03:51.505 --> 00:03:54.265 and that's usually about a third of cts. 80 00:03:54.605 --> 00:03:55.785 Uh, have a study in that 81 00:03:56.395 --> 00:03:58.505 about two thirds either have completely normal 82 00:03:58.645 --> 00:03:59.745 or very mild disease 83 00:03:59.765 --> 00:04:01.065 or very severe disease 84 00:04:01.065 --> 00:04:05.305 where you don't need the additional action item of an FFR CT 85 00:04:06.005 --> 00:04:08.905 in the third of the cts that require FFR ct, 86 00:04:09.365 --> 00:04:12.945 you can see then you can then go back to another informed 87 00:04:13.865 --> 00:04:17.705 decision based on the CT results and the FFR CT results. 88 00:04:17.925 --> 00:04:20.265 You can decide whether you wanna go down a conservative 89 00:04:20.265 --> 00:04:23.065 management arm or an invasive management arm, 90 00:04:23.485 --> 00:04:25.625 and again, using optimal imaging 91 00:04:25.645 --> 00:04:28.905 and physiological information, combining both anatomy 92 00:04:29.045 --> 00:04:32.345 and physiology to make your informed decision when there are 93 00:04:32.345 --> 00:04:34.305 these moderate range stenosis. 94 00:04:36.495 --> 00:04:39.895 Y-F-F-R-C-T. Well, this is a really nice study. 95 00:04:39.895 --> 00:04:41.535 This is the Pacific study. 96 00:04:41.995 --> 00:04:44.375 The Pacific Study did head-to-head comparison 97 00:04:44.595 --> 00:04:47.575 of different modalities including SPECT and orange. 98 00:04:47.715 --> 00:04:50.015 You can see SPECT performs as it usually does. 99 00:04:50.015 --> 00:04:54.695 It's about 70% accurate with a lower, uh, specificity, 100 00:04:55.035 --> 00:04:57.575 uh, than sensitivity, but suboptimal 101 00:04:57.575 --> 00:04:59.535 because it misses about a third of cases. 102 00:04:59.795 --> 00:05:01.015 That's the orange bar. 103 00:05:01.395 --> 00:05:03.415 You can see CT angio in red 104 00:05:03.475 --> 00:05:06.575 and PET in green were similar, uh, 105 00:05:06.575 --> 00:05:08.615 with better diagnostic accuracies. 106 00:05:09.115 --> 00:05:11.935 And then FFR CT in blue, adding that 107 00:05:11.935 --> 00:05:15.095 to the CT angio had the highest diagnostic accuracy 108 00:05:15.245 --> 00:05:19.655 significantly better than PET CTA or spect. 109 00:05:20.035 --> 00:05:22.055 So in this head-to-head comparative study, 110 00:05:22.255 --> 00:05:25.255 FFR CT showed the highest diagnostic performance 111 00:05:25.255 --> 00:05:26.815 for vessel specific ischemia. 112 00:05:27.065 --> 00:05:29.095 Again, the gold standard here was 113 00:05:30.055 --> 00:05:32.255 invasive FFR ischemia. 114 00:05:32.355 --> 00:05:35.295 So very high level of of validation. 115 00:05:35.435 --> 00:05:38.535 So F-F-R-C-T clearly is the most accurate. 116 00:05:39.275 --> 00:05:42.455 But does it help us with patient determination? 117 00:05:42.475 --> 00:05:45.455 And I think this is a very interesting registry. 118 00:05:45.455 --> 00:05:49.215 The advanced registry is a multi cohort observational 119 00:05:49.795 --> 00:05:54.135 cohort looking at patients who underwent CT and FFR CT 120 00:05:54.155 --> 00:05:58.045 and really just showing us above the line their fff RCT was 121 00:05:58.675 --> 00:06:00.245 okay, was normal. 122 00:06:00.385 --> 00:06:02.925 And below the line, the F-F-R-C-T was below 123 00:06:02.925 --> 00:06:06.085 that 0.80 threshold. 124 00:06:06.505 --> 00:06:08.565 And you can see where the areas are, 125 00:06:08.565 --> 00:06:12.965 where it's more 50 50 is really in that 30 to 70 range. 126 00:06:13.385 --> 00:06:16.765 The, uh, guidelines defined it as 40 to 90%. 127 00:06:16.945 --> 00:06:18.925 But to be honest, I use it more in this 30 128 00:06:18.985 --> 00:06:21.565 to 70% range when I read out these studies. 129 00:06:21.865 --> 00:06:24.485 Uh, but there you can see it's nearly 50 50, 130 00:06:24.535 --> 00:06:29.045 about half the patients who have a 30 to 70% stenosis end up 131 00:06:29.045 --> 00:06:31.125 with an abnormal FFR CT 132 00:06:31.145 --> 00:06:34.085 and about a half have a normal FFR ct. 133 00:06:34.145 --> 00:06:36.605 So it really does change the management in these 134 00:06:36.605 --> 00:06:38.685 intermediate risk patients. 135 00:06:39.535 --> 00:06:42.985 What about the use of CT and ffr CT and preventive care? 136 00:06:43.185 --> 00:06:46.265 I think this is potentially even a more robust use 137 00:06:46.265 --> 00:06:50.025 of this tool is to identify patients who need more therapies 138 00:06:50.025 --> 00:06:51.505 and we'll, we'll go through this trial 139 00:06:51.705 --> 00:06:54.705 'cause I think this was a incredible study by Pam Douglas, 140 00:06:54.925 --> 00:06:56.025 the precise trial. 141 00:06:56.095 --> 00:06:59.105 This was, uh, presented at American Heart in 2022. 142 00:06:59.645 --> 00:07:01.865 Uh, and you can see the patients were randomized 143 00:07:01.885 --> 00:07:04.865 to either traditional testing over a thousand patients. 144 00:07:05.415 --> 00:07:07.385 They got a, a functional stress test 145 00:07:07.645 --> 00:07:11.425 or direct to cath depending on the site clinician. 146 00:07:11.425 --> 00:07:13.785 So this is kind of a traditional algorithm 147 00:07:13.785 --> 00:07:15.225 where the Dr. May say, you know what, 148 00:07:15.285 --> 00:07:17.585 I'm gonna do a stress treadmill or a nuke or, 149 00:07:17.845 --> 00:07:20.585 or a, a stress echo, or I'm gonna just cath you 150 00:07:20.785 --> 00:07:22.305 'cause you're high pretest probability. 151 00:07:22.685 --> 00:07:24.225 And then all subsequent testing 152 00:07:24.325 --> 00:07:26.225 and care was made by the site clinician 153 00:07:27.175 --> 00:07:28.835 or the precision pathway, 154 00:07:29.015 --> 00:07:30.595 and that's taking the same number 155 00:07:30.595 --> 00:07:33.155 of participants over a thousand, assigning them 156 00:07:33.175 --> 00:07:35.235 to the promise risk stratification. 157 00:07:35.295 --> 00:07:36.675 So if patients got randomized, 158 00:07:36.675 --> 00:07:39.155 they then underwent this risk stratification tool 159 00:07:39.775 --> 00:07:42.195 and just saying that if they had very low risk, 160 00:07:42.375 --> 00:07:43.915 so they were deemed very low risk 161 00:07:43.915 --> 00:07:45.395 that they got no testing at all. 162 00:07:46.095 --> 00:07:49.195 Uh, in the A-C-C-H-A algorithm for very low, 163 00:07:49.255 --> 00:07:52.355 for low risk patients, in this stage, 21%, 164 00:07:52.415 --> 00:07:54.955 the algorithm says you can do, uh, no testing, 165 00:07:55.095 --> 00:07:56.915 you can do coronary calcium testing, 166 00:07:57.255 --> 00:07:59.715 but you do not need to go on to CTA. 167 00:08:00.225 --> 00:08:03.475 Then they went for the, about the 79% who went 168 00:08:03.475 --> 00:08:07.115 for elevated risk above low risk, got a CTA with 169 00:08:07.115 --> 00:08:08.635 or without an F-F-R-C-T, 170 00:08:08.635 --> 00:08:11.035 depending on the results of the CTA. 171 00:08:11.415 --> 00:08:13.435 And then all subsequent care was made again 172 00:08:13.455 --> 00:08:15.115 by the clinician. 173 00:08:16.605 --> 00:08:20.505 The endpoint of this trial was a one year composite endpoint 174 00:08:20.505 --> 00:08:22.945 of MACE and cath finding no obstructive disease 175 00:08:23.525 --> 00:08:28.305 and follow up was about a year completed in 96% of patients. 176 00:08:29.505 --> 00:08:32.635 Here you can see the composite endpoint, 177 00:08:32.725 --> 00:08:36.715 there was a 70% reduction in the composite primary endpoint, 178 00:08:36.895 --> 00:08:39.315 all cause death, non-fatal MI 179 00:08:39.375 --> 00:08:42.395 or catheterization without obstructive disease in the 180 00:08:42.395 --> 00:08:44.195 precision pathway compared 181 00:08:44.195 --> 00:08:46.075 to traditional testing at one year. 182 00:08:46.775 --> 00:08:49.355 So a highly different, a highly significant difference 183 00:08:49.355 --> 00:08:51.795 with a p value of less than 0.001. 184 00:08:53.025 --> 00:08:56.995 And talking about the preventive medication use, the use 185 00:08:56.995 --> 00:09:01.315 of the precision strategy led to significantly higher use 186 00:09:01.315 --> 00:09:04.595 of lipid lowering medications, anti-platelets 187 00:09:04.975 --> 00:09:08.275 and anti-hypertensives in that cohort. 188 00:09:08.855 --> 00:09:10.515 So you can see a, a nice 189 00:09:11.025 --> 00:09:14.395 improvement in preventive therapies when CTA 190 00:09:14.495 --> 00:09:17.955 and F-F-R-C-T are used, identifying not only whether 191 00:09:17.955 --> 00:09:20.315 or not they have significant stenosis 192 00:09:20.315 --> 00:09:22.635 that are physiologically significant or not, 193 00:09:23.095 --> 00:09:26.235 but also whether they have subclinical atherosclerosis 194 00:09:26.465 --> 00:09:29.075 that may also benefit from things like lipid lowering 195 00:09:29.375 --> 00:09:30.835 and antiplatelet therapies. 196 00:09:32.445 --> 00:09:36.225 So the precise trial reiterated a CTA strategy was 197 00:09:36.225 --> 00:09:37.825 associated with a higher proportion 198 00:09:37.825 --> 00:09:39.865 of patients on optimal medical therapy. 199 00:09:40.485 --> 00:09:42.545 And you can see the same thing was shown in 200 00:09:42.545 --> 00:09:43.625 the Scott Hart trial. 201 00:09:43.925 --> 00:09:46.065 And the same thing was shown in the promise study. 202 00:09:46.125 --> 00:09:47.945 So this is not a a one-off, 203 00:09:47.945 --> 00:09:52.025 this is now a consistent finding in every randomized trial. 204 00:09:52.055 --> 00:09:55.985 This is now precise as the third large randomized trial 205 00:09:56.325 --> 00:09:59.825 of patients undergoing CTA versus functional testing. 206 00:10:00.205 --> 00:10:02.305 And in all three Scott Hart promise 207 00:10:02.605 --> 00:10:05.265 and precise optimal medical therapy, 208 00:10:05.405 --> 00:10:08.945 things like lipid lowering therapy, hypertensive therapies, 209 00:10:09.255 --> 00:10:14.095 diet, lifestyle, are improved with the, in the CTA arm 210 00:10:14.155 --> 00:10:16.215 as compared to the, uh, traditional arm. 211 00:10:16.275 --> 00:10:20.175 And that's why the guidelines favor CTA over functional 212 00:10:20.175 --> 00:10:22.775 testing now in those 2021 guidelines. 213 00:10:25.015 --> 00:10:27.155 So then the question is, are there patients 214 00:10:27.155 --> 00:10:29.595 that we are missing with a CAD diagnosis 215 00:10:29.815 --> 00:10:32.315 and are there underserved patient populations 216 00:10:32.335 --> 00:10:35.795 who could benefit from the CT A F FFR CT pathway? 217 00:10:35.935 --> 00:10:38.755 And I think that this is, these are important questions 218 00:10:39.075 --> 00:10:41.875 'cause a negative functional test does not always 219 00:10:41.875 --> 00:10:42.955 mean they don't have disease. 220 00:10:43.015 --> 00:10:47.115 It it means that, you know, nuclear has a 70% sensitivity, 221 00:10:47.415 --> 00:10:49.635 so it misses a third of people or, 222 00:10:49.815 --> 00:10:52.875 and you know, obviously underserved patients are 223 00:10:52.875 --> 00:10:54.195 unfortunately less tested. 224 00:10:54.615 --> 00:10:57.035 So in the guidelines, this is from, again, 225 00:10:57.035 --> 00:10:58.515 the 2021 guidelines. 226 00:10:58.575 --> 00:11:01.035 You can see a class one B recommendation. 227 00:11:01.405 --> 00:11:03.755 Women who are PR who present with chest pain are at risk 228 00:11:03.755 --> 00:11:04.955 for underdiagnosis 229 00:11:05.015 --> 00:11:08.315 and potential cardiac causes should always be considered. 230 00:11:08.495 --> 00:11:09.995 And then, uh, similarly, 231 00:11:10.115 --> 00:11:13.035 a one B recommendation in women presenting with chest pain. 232 00:11:13.035 --> 00:11:14.555 It's recommended to obtain a history that, 233 00:11:14.905 --> 00:11:16.715 that emphasizes accompanying symptoms 234 00:11:16.715 --> 00:11:17.875 that are more common in women. 235 00:11:18.575 --> 00:11:20.035 But it's important to remember 236 00:11:20.035 --> 00:11:22.995 that women are make up more than half of the patients 237 00:11:22.995 --> 00:11:25.635 who present to the emergency department with chest pain, 238 00:11:25.745 --> 00:11:28.995 they're less likely to have a timely and appropriate care. 239 00:11:29.465 --> 00:11:32.155 They're more likely to experience prodromal symptoms 240 00:11:32.155 --> 00:11:34.795 that may be considered atypical or, 241 00:11:34.855 --> 00:11:38.235 or not classic, such as unusual fatigues, 242 00:11:38.325 --> 00:11:39.995 sleep disturbances or anxiety. 243 00:11:40.855 --> 00:11:44.635 And the traditional schools often underestimate risk. 244 00:11:45.315 --> 00:11:47.315 I do want to point out as we're talking about women, 245 00:11:47.665 --> 00:11:50.515 that CT angiography is the only test 246 00:11:50.575 --> 00:11:53.445 and F FFR CT as well are the only tests 247 00:11:53.955 --> 00:11:57.405 that are similar in accuracy in men and women. 248 00:11:58.025 --> 00:12:00.485 We know about the false positive treadmills. 249 00:12:00.545 --> 00:12:03.205 We recognize breast attenuation artifacts 250 00:12:03.205 --> 00:12:06.245 and limited windows with stress imaging cause women 251 00:12:06.265 --> 00:12:09.645 to have less accurate testing with functional testing. 252 00:12:10.585 --> 00:12:13.405 CT angiography has similar accuracy in men and women 253 00:12:13.505 --> 00:12:16.725 and often in some studies even women have superior accuracy 254 00:12:16.725 --> 00:12:18.205 because they have less coronary calcium. 255 00:12:18.425 --> 00:12:20.125 Higher calcium scores, as you know, 256 00:12:20.145 --> 00:12:23.645 may preclude accurate assessment in cardiac ct. 257 00:12:23.705 --> 00:12:25.405 So, so women have either similar 258 00:12:25.465 --> 00:12:29.205 or better diagnostic accuracy if you choose a CT angiogram 259 00:12:29.465 --> 00:12:32.485 as compared to a functional test for this population. 260 00:12:32.505 --> 00:12:34.245 And I preferentially do that. 261 00:12:34.445 --> 00:12:37.885 I always try to shunt, uh, my female patients 262 00:12:37.885 --> 00:12:40.645 who have chest pain down a CTA arm if possible. 263 00:12:42.715 --> 00:12:44.875 A good example of that, this is one of my patients, 264 00:12:44.955 --> 00:12:48.395 a 64-year-old Hispanic female, uh, with atypical 265 00:12:48.615 --> 00:12:50.475 or non-classical chest pain, 266 00:12:50.505 --> 00:12:52.955 potentially non cardiac chest pain. 267 00:12:53.415 --> 00:12:56.715 Not the, the exact classic symptoms that we expect she had, 268 00:12:56.895 --> 00:12:59.315 uh, hypertension and high cholesterol, but, 269 00:12:59.375 --> 00:13:00.595 but no other risk factors. 270 00:13:00.775 --> 00:13:04.195 You can see here she has some coronary, uh, calcifications 271 00:13:04.215 --> 00:13:08.855 and some mild stenosis, but nothing that looks high grade. 272 00:13:09.815 --> 00:13:12.235 But because she had sequential, um, 273 00:13:12.425 --> 00:13:14.995 less than 50% stenosis in the LAD 274 00:13:14.995 --> 00:13:17.715 and we were concerned about the length and 275 00:13:17.775 --> 00:13:20.115 and number of of LAD lesions, 276 00:13:20.415 --> 00:13:22.755 we did an FFR CT and this is her result. 277 00:13:22.855 --> 00:13:24.515 And a little surprising to me. 278 00:13:24.675 --> 00:13:27.795 I was expecting potentially a negative study, 279 00:13:28.405 --> 00:13:32.475 maybe my own biases about, about, uh, women who present with 280 00:13:33.105 --> 00:13:35.635 non-cardiac or presumed non-cardiac chest pain. 281 00:13:35.695 --> 00:13:38.555 But I was wrong and this woman had significant 282 00:13:39.225 --> 00:13:41.795 that LAD lesion that did not look very significant. 283 00:13:41.905 --> 00:13:45.235 I'll go back to it. You can see in this bottom left panel, 284 00:13:45.295 --> 00:13:47.955 you can see the, the lesion looked more on the mild 285 00:13:48.015 --> 00:13:50.715 to moderate side, definitely less than 50% 286 00:13:50.775 --> 00:13:51.955 by our interpretation. 287 00:13:52.135 --> 00:13:55.155 But you can see here a very significant stenosis. 288 00:13:55.215 --> 00:13:56.635 And she underwent stenting 289 00:13:56.635 --> 00:13:59.155 and revascularization successfully. 290 00:13:59.615 --> 00:14:02.315 So really helped with my, uh, management 291 00:14:02.315 --> 00:14:04.795 because it changed, changed our algorithm 292 00:14:04.815 --> 00:14:05.875 of care significantly. 293 00:14:06.095 --> 00:14:09.315 And her chest pain went from non-cardiac to cardiac 294 00:14:09.895 --> 00:14:11.675 and now she's, uh, angina free. 295 00:14:13.175 --> 00:14:16.195 We also have to think about, uh, diverse populations. 296 00:14:16.195 --> 00:14:18.675 This is again from the 2021 guidelines. 297 00:14:19.735 --> 00:14:21.815 Cultural competency training is recommended 298 00:14:21.995 --> 00:14:24.375 to help achieve the best outcomes in patients 299 00:14:24.375 --> 00:14:26.255 of diverse racial and ethnic backgrounds 300 00:14:26.315 --> 00:14:27.455 who present with chest pain. 301 00:14:27.835 --> 00:14:28.935 And of these patients 302 00:14:28.945 --> 00:14:31.175 where English is not their primary language. 303 00:14:31.515 --> 00:14:34.295 Making sure we use formal translation services is 304 00:14:34.295 --> 00:14:36.455 recommended, but just a couple of these 305 00:14:36.455 --> 00:14:37.575 that we have to keep in mind. 306 00:14:37.715 --> 00:14:40.015 Uh, black patients presenting 307 00:14:40.015 --> 00:14:42.615 with chest pain are less likely to be treated urgently. 308 00:14:43.235 --> 00:14:46.845 So you have to make sure that we, we start undoing some 309 00:14:46.845 --> 00:14:48.605 of the social issues, uh, that 310 00:14:48.605 --> 00:14:51.045 that have occurred over over decades past 311 00:14:51.915 --> 00:14:53.865 South Asians are now elevated, 312 00:14:53.865 --> 00:14:56.705 they're now considered a cardiac risk factor just being 313 00:14:56.705 --> 00:14:57.825 of South Asian descent. 314 00:14:58.125 --> 00:15:00.385 And South Asians have a 40% higher chance 315 00:15:00.385 --> 00:15:03.185 of mortality from heart attacks than the average population. 316 00:15:03.245 --> 00:15:05.345 So we need to, just being a a patient 317 00:15:05.345 --> 00:15:08.065 of South Asian descent makes them an additional risk 318 00:15:08.405 --> 00:15:10.305 of both having coronary disease 319 00:15:10.485 --> 00:15:12.705 and having an event from coronary disease 320 00:15:13.515 --> 00:15:15.335 of all patients presenting with chest pain. 321 00:15:15.335 --> 00:15:17.855 African Americans and Hispanics are less likely 322 00:15:17.855 --> 00:15:21.815 to be categorized in the emergent triage category and women 323 00:15:21.875 --> 00:15:24.415 and people of color with chest pain waited longer to be seen 324 00:15:24.415 --> 00:15:27.295 by physicians independent of clinical features. 325 00:15:27.475 --> 00:15:31.135 So again, we just need to keep in mind, uh, you know, 326 00:15:31.135 --> 00:15:35.015 coronary disease is not a a white male only disease 327 00:15:35.155 --> 00:15:37.975 and there's no specific predilection there. 328 00:15:39.665 --> 00:15:42.785 I think this is probably one of the most impactful studies. 329 00:15:42.895 --> 00:15:46.065 This was, uh, just published in the Journal 330 00:15:46.065 --> 00:15:47.705 of American College of Cardiology. 331 00:15:47.935 --> 00:15:49.185 This is, uh, from, uh, 332 00:15:49.285 --> 00:15:52.625 our UK colleagues in the United Kingdom. 333 00:15:53.185 --> 00:15:57.305 Remember 2016 the algorithm of care change 334 00:15:57.365 --> 00:16:01.385 to A CTA as a first line test for all chest pain, atypical 335 00:16:01.895 --> 00:16:03.425 non-cardiac possible 336 00:16:03.525 --> 00:16:08.105 or probable coronary disease, even typical angina got, uh, 337 00:16:08.105 --> 00:16:11.905 gets shunted to CTA first and they do in their algorithms 338 00:16:11.905 --> 00:16:16.465 and the NICE guidelines also advocate for FFR ct. 339 00:16:16.925 --> 00:16:19.545 But you can see here this is looking at changes 340 00:16:20.165 --> 00:16:21.705 of in mortality. 341 00:16:22.485 --> 00:16:24.705 So just are more people alive 342 00:16:25.445 --> 00:16:28.425 if they have CTA more CTA use. 343 00:16:29.005 --> 00:16:31.705 And you can see that as the curves go down, 344 00:16:31.705 --> 00:16:35.465 meaning mortality went down in those populations, both 345 00:16:35.485 --> 00:16:38.665 for all cause mortality on the left, cardiovascular 346 00:16:39.265 --> 00:16:41.425 mortality in the middle, and just coronary 347 00:16:41.745 --> 00:16:42.865 mortality on the right. 348 00:16:43.605 --> 00:16:48.105 All of them follow a very strong linear trend that says 349 00:16:48.725 --> 00:16:51.545 if they have more use of CTA in their region, 350 00:16:52.435 --> 00:16:54.285 they have lower death rates. 351 00:16:54.825 --> 00:16:58.845 So those regions that they assessed that incorporated ct, 352 00:16:59.825 --> 00:17:02.645 CT was uh, greater regional increases in the use 353 00:17:02.645 --> 00:17:05.845 of CT were associated with fewer hospitalizations for MI 354 00:17:06.105 --> 00:17:09.045 and a more rapid decline in coronary artery 355 00:17:09.045 --> 00:17:10.125 disease mortality. 356 00:17:10.745 --> 00:17:12.045 So very, very important. 357 00:17:12.385 --> 00:17:15.765 And cardiovascular mortality was reduced significantly. 358 00:17:18.335 --> 00:17:19.635 So let's go back to 359 00:17:19.635 --> 00:17:22.115 that precise trial when we talk about 360 00:17:22.325 --> 00:17:23.835 efficiency in the cath lab. 361 00:17:23.835 --> 00:17:27.435 Another important aspect, uh, that we need to consider 362 00:17:27.435 --> 00:17:31.555 because if we're utilizing our cath lab resources for normal 363 00:17:32.275 --> 00:17:35.235 patients, then we might be potentially missing patients 364 00:17:35.495 --> 00:17:37.475 who have significant disease. 365 00:17:37.575 --> 00:17:40.795 So if we go back to that precise trial where we randomized, 366 00:17:40.815 --> 00:17:42.235 uh, over a thousand patients 367 00:17:42.235 --> 00:17:44.035 to traditional testing algorithms 368 00:17:44.035 --> 00:17:46.835 where the physician guided the treatment based on their 369 00:17:46.835 --> 00:17:48.995 traditional guideline directed medical care 370 00:17:49.585 --> 00:17:52.045 or the precision pathway where they were kind 371 00:17:52.045 --> 00:17:55.685 of forced into a ct, a first algorithm, you can see 372 00:17:55.685 --> 00:17:59.485 that in the traditional testing, uh, per 100 patients, 18 373 00:18:00.195 --> 00:18:01.805 went for cardiac cath. 374 00:18:02.265 --> 00:18:05.685 So more than went for cardiac cath in the precision pathway, 375 00:18:05.835 --> 00:18:08.365 only 14 went to the cath lab per hundred. 376 00:18:08.585 --> 00:18:11.285 So 14% ended up in the cath lab 377 00:18:11.305 --> 00:18:12.925 of these chest pain participants. 378 00:18:13.625 --> 00:18:18.005 But how many PE patients got appropriate revascularization 379 00:18:18.425 --> 00:18:22.125 and the total in the traditional testing algorithm was six. 380 00:18:22.585 --> 00:18:26.605 So only six patients per hundred ended up getting 381 00:18:26.885 --> 00:18:28.285 revascularized with chest pain 382 00:18:28.385 --> 00:18:30.445 or you can look at six per 18. 383 00:18:31.105 --> 00:18:34.645 So, uh, only one third of all the patients who went 384 00:18:34.645 --> 00:18:37.325 to the cath lab ended up getting a PCI or cabbage. 385 00:18:37.585 --> 00:18:38.765 Two thirds did not. 386 00:18:39.265 --> 00:18:42.165 And then you can see at the bottom 10 out of 14 patients, 387 00:18:42.165 --> 00:18:44.205 over 70% of patients who went 388 00:18:44.445 --> 00:18:46.725 to the cath lab based on CT angio 389 00:18:46.745 --> 00:18:50.045 and FFR CT got revascularized. 390 00:18:50.505 --> 00:18:55.045 So if we look at the net, we have 10% of patients ended up 391 00:18:55.045 --> 00:18:57.365 with revascularization from the precision pathway, 392 00:18:57.955 --> 00:19:00.125 only 6% from the traditional pathway. 393 00:19:00.265 --> 00:19:04.045 So we missed about 40% of patients who presumably 394 00:19:04.585 --> 00:19:07.325 the groups were balanced, had obstructive disease 395 00:19:07.325 --> 00:19:08.885 with ischemia and were missed 396 00:19:09.225 --> 00:19:11.645 by a lower sensitivity of functional testing. 397 00:19:12.345 --> 00:19:17.005 And the false positive rates drove 12 people, 12% 398 00:19:17.005 --> 00:19:19.085 of patients, two thirds of those who went 399 00:19:19.085 --> 00:19:21.325 to the cath lab had no obstructive disease 400 00:19:22.025 --> 00:19:25.605 or no, where that only happened in 4% 401 00:19:25.605 --> 00:19:27.165 of patients in the precision pathway. 402 00:19:27.745 --> 00:19:30.125 So a much different algorithm of care, 403 00:19:30.235 --> 00:19:32.445 much more efficient use of the cath lab 404 00:19:32.705 --> 00:19:35.805 and a higher yield for PCI and cabbage. 405 00:19:36.545 --> 00:19:38.445 So from an interventional standpoint, 406 00:19:38.445 --> 00:19:41.045 we got more appropriate patients to the cath lab 407 00:19:41.545 --> 00:19:43.685 and we decreased our normalcy rate. 408 00:19:43.865 --> 00:19:47.965 Two very important aspects for delivering efficient care. 409 00:19:50.255 --> 00:19:53.675 So let me uh, just show you a, a case study now, uh, we went 410 00:19:53.675 --> 00:19:55.555 through one already, but we'll go through one other. 411 00:19:55.825 --> 00:19:58.315 This is a patient with severe calcification. 412 00:19:58.495 --> 00:20:01.395 Uh, this was another one of my recent patients, 413 00:20:01.475 --> 00:20:05.395 a 72-year-old African American male, high blood pressure, 414 00:20:05.425 --> 00:20:08.115 high cholesterol, really minimum symptoms 415 00:20:08.135 --> 00:20:09.835 and had a normal nuclear study 416 00:20:09.895 --> 00:20:12.275 but persisted to have these symptoms. 417 00:20:12.295 --> 00:20:13.515 And given his risk factors 418 00:20:13.575 --> 00:20:17.755 and his age, I decided to pursue CT angiography. 419 00:20:18.175 --> 00:20:20.235 So remember he had a normal nuclear study, 420 00:20:20.655 --> 00:20:23.115 had a calcium score well over a thousand 421 00:20:23.505 --> 00:20:25.675 with you can see just extensive, 422 00:20:25.825 --> 00:20:28.835 extensive calcifications throughout the coronary disease. 423 00:20:28.855 --> 00:20:30.915 We read this as probable moderate 424 00:20:31.015 --> 00:20:32.555 to severe disease in the LAD 425 00:20:32.575 --> 00:20:36.195 but severe calcification precludes accurate assessment. 426 00:20:36.575 --> 00:20:39.515 So we submitted this for FFR ct. 427 00:20:40.035 --> 00:20:43.915 FFR CT you should know does better with coronary calcium 428 00:20:44.825 --> 00:20:46.475 than our visual reads. 429 00:20:46.635 --> 00:20:49.085 'cause when I read, I have to look at each segment in each 430 00:20:49.085 --> 00:20:51.285 lesion and if there's a lot of calcium there 431 00:20:51.285 --> 00:20:54.605 that may cause an artifact that causes a false positive 432 00:20:54.605 --> 00:20:55.725 or a false negative. 433 00:20:56.135 --> 00:20:59.505 Whereas FFR CT looks at the cumulative flow down the vessel 434 00:20:59.685 --> 00:21:02.785 and the morphology and the plaque and the myocardium 435 00:21:03.045 --> 00:21:06.385 and looks at the vessel in its entirety, uh, 436 00:21:06.385 --> 00:21:07.905 rather than any one segment. 437 00:21:08.405 --> 00:21:12.185 And FFR CT said there was a very significant reduction in 438 00:21:12.185 --> 00:21:14.905 flow starting in the mid LAD 439 00:21:14.905 --> 00:21:18.265 and you can see a 0.61 FFR ct. 440 00:21:18.325 --> 00:21:22.505 So this patient was also referred for revascularization. 441 00:21:22.845 --> 00:21:25.665 And you can see here again, while you can argue, 442 00:21:25.775 --> 00:21:28.385 well maybe there is something in that mid LIDI think 443 00:21:28.915 --> 00:21:31.545 being dogmatic 'cause that lesion was right 444 00:21:31.545 --> 00:21:33.425 after that, that septal perforator 445 00:21:33.425 --> 00:21:35.745 and that's where the, the calcium was the highest, 446 00:21:35.795 --> 00:21:38.385 where it really was not very interpretable. 447 00:21:38.485 --> 00:21:41.105 So I think this is just another excellent example 448 00:21:41.245 --> 00:21:42.905 of proper use or, 449 00:21:42.965 --> 00:21:47.465 or a good use of of FFR ct, uh, as an adjunct to us 450 00:21:47.485 --> 00:21:49.745 who read cardiac CT angiography. 451 00:21:50.835 --> 00:21:52.255 So as we, we conclude 452 00:21:52.255 --> 00:21:55.495 and we think about the big picture here, we have 453 00:21:56.205 --> 00:21:57.655 more accuracy leading 454 00:21:57.655 --> 00:22:01.695 to more confidence in diagnosing coronary disease leading 455 00:22:01.835 --> 00:22:04.855 to more appropriate treatments and better outcomes. 456 00:22:05.195 --> 00:22:07.535 So again, from a preventive standpoint as well 457 00:22:07.535 --> 00:22:10.055 as from a revascularization standpoint, 458 00:22:10.555 --> 00:22:12.935 and it can definitely optimize efficiency 459 00:22:12.935 --> 00:22:14.935 and value of your cath lab. 460 00:22:15.035 --> 00:22:16.575 So a great opportunity to partner 461 00:22:16.575 --> 00:22:20.375 with your interventionalists to get them more procedures, 462 00:22:20.445 --> 00:22:23.855 more PCIs, but less normal coronaries, which I think all 463 00:22:23.855 --> 00:22:25.855 of them will, will welcome widely. 464 00:22:26.695 --> 00:22:28.555 So, uh, things that are now available 465 00:22:28.815 --> 00:22:32.995 or, uh, coming very shortly is, uh, anatomical roadmap. 466 00:22:32.995 --> 00:22:36.315 It's called the roadmap analysis. It's FDA cleared already. 467 00:22:36.325 --> 00:22:37.595 It'll help diagnose 468 00:22:37.695 --> 00:22:41.475 and rule out just coronary disease from a plaque 469 00:22:41.495 --> 00:22:42.915 and stenosis standpoint. 470 00:22:43.455 --> 00:22:46.235 Of course we have FFR CT as we discussed today, 471 00:22:46.595 --> 00:22:48.475 determining the significance of coronary disease 472 00:22:48.475 --> 00:22:49.955 and informing treatment plans 473 00:22:50.655 --> 00:22:53.795 and then plaque analysis, giving quantitative plaque 474 00:22:54.555 --> 00:22:59.035 analysis, also FDA cleared informing risk and prognosis. 475 00:22:59.055 --> 00:23:01.635 And you can then track atherosclerosis over time 476 00:23:01.655 --> 00:23:03.875 by getting plaque quantification metrics. 477 00:23:04.695 --> 00:23:07.635 So with that, I will stop and open it up. 478 00:23:07.655 --> 00:23:09.875 Uh, thank everybody for joining me today 479 00:23:09.895 --> 00:23:11.635 and open it up for any questions 480 00:23:11.735 --> 00:23:13.675 or comments that you may have 481 00:23:14.255 --> 00:23:16.035 and I'll turn it back over to Jennifer. 482 00:23:17.335 --> 00:23:20.325 Thank you Dr. Budoff, that was great information. 483 00:23:20.645 --> 00:23:23.325 I really appreciate you taking us through all of that. 484 00:23:23.725 --> 00:23:25.085 I would like to remind the audience 485 00:23:25.085 --> 00:23:27.605 that if you have questions, please put them in the chat 486 00:23:27.705 --> 00:23:31.165 or the q and a and we can get those questions answered. 487 00:23:31.705 --> 00:23:35.645 Dr. Budoff, I did receive a question privately was texted 488 00:23:35.825 --> 00:23:38.045 to me from, uh, a customer account. 489 00:23:38.185 --> 00:23:40.965 And the question was, do you show the CT 490 00:23:41.185 --> 00:23:45.005 and maybe even the F-F-R-C-T to the patients 491 00:23:45.085 --> 00:23:47.765 that you mentioned and during follow up? 492 00:23:47.785 --> 00:23:49.205 And then how does that, how has 493 00:23:49.205 --> 00:23:51.405 that been impacting their treatment plans? 494 00:23:52.135 --> 00:23:54.785 Yeah, you know, I I do, when I meet with patients, uh, 495 00:23:54.785 --> 00:23:56.865 they're not all, not all the CTAs I do are, 496 00:23:56.865 --> 00:23:59.145 are my own patients, but for my own patients that I meet 497 00:23:59.145 --> 00:24:00.945 with after their test, I do go through both. 498 00:24:01.405 --> 00:24:02.985 We, we generate two reports. 499 00:24:03.165 --> 00:24:06.065 The heart flow report is a separate report from 500 00:24:06.065 --> 00:24:07.185 the CT angio report. 501 00:24:07.205 --> 00:24:10.305 We incorporate them together with the CT angio report, 502 00:24:10.365 --> 00:24:13.865 but I show them the FFR CT report, the heart flow report 503 00:24:13.865 --> 00:24:16.825 because it has some beautiful pictures as you saw. 504 00:24:17.085 --> 00:24:19.465 You know, and it's very, it's very intuitive, right? 505 00:24:19.465 --> 00:24:22.185 It is bad, right? You know, red is stop, you know, 506 00:24:22.205 --> 00:24:24.265 red is red is not, is not good. 507 00:24:24.285 --> 00:24:25.545 And that's where the problem is. 508 00:24:25.545 --> 00:24:29.305 So I can show them the areas that turned yellow or red 509 00:24:30.085 --> 00:24:32.905 and I can show them, you know, kind of talk to them about 510 00:24:32.905 --> 00:24:34.665 where the problem is and I can go back 511 00:24:34.665 --> 00:24:37.105 and forth between the anatomical images of the CT 512 00:24:38.255 --> 00:24:41.795 and the functional images of the heart flow to, 513 00:24:41.855 --> 00:24:44.715 to show them exactly where the stenosis is 514 00:24:44.715 --> 00:24:45.795 and what we're gonna do next. 515 00:24:48.015 --> 00:24:50.045 Great, thank you for that answer. 516 00:24:50.345 --> 00:24:52.365 Um, I just received another question. 517 00:24:53.145 --> 00:24:55.525 You mentioned, uh, during the talk that 518 00:24:56.185 --> 00:25:00.285 the FFR CT can actually really help in reading 519 00:25:00.865 --> 00:25:04.085 the ct, especially when it comes to calcification, 520 00:25:04.155 --> 00:25:05.925 when there's extensive calcification. 521 00:25:06.625 --> 00:25:11.245 Do you have, you know, a limit on a calcium score 522 00:25:11.575 --> 00:25:13.525 where you don't send a patient 523 00:25:14.225 --> 00:25:16.765 or that you find more problematic? 524 00:25:16.905 --> 00:25:19.485 Or how have you adjusted for 525 00:25:19.685 --> 00:25:21.885 that when you do have high calcium scores? 526 00:25:22.475 --> 00:25:24.045 Yeah, so you know, the traditional 527 00:25:24.585 --> 00:25:26.125 cut point has been a thousand, 528 00:25:26.245 --> 00:25:27.765 a calcium score above a thousand. 529 00:25:27.765 --> 00:25:29.565 If you knew that in advance, let's say they just had a 530 00:25:29.565 --> 00:25:32.245 coronary calcium score and it was, you know, 1500 531 00:25:32.345 --> 00:25:35.645 or 2000, I would not say your next best test is 532 00:25:35.725 --> 00:25:36.965 a CT angiogram. 533 00:25:37.625 --> 00:25:38.885 But most of our patients 534 00:25:38.885 --> 00:25:41.325 who are getting CT angiography today don't have a 535 00:25:41.325 --> 00:25:42.525 calcium score in advance. 536 00:25:42.705 --> 00:25:44.565 So we proceed with the CTA 537 00:25:44.865 --> 00:25:45.885 and then we have to deal 538 00:25:45.885 --> 00:25:48.565 with these severely calcified vessels. 539 00:25:48.625 --> 00:25:51.165 Now sometimes it's obvious they have total occlusion 540 00:25:51.165 --> 00:25:52.565 somewhere it's easy to see. 541 00:25:52.795 --> 00:25:55.445 Sometimes they have huge coronaries and I'm, 542 00:25:55.465 --> 00:25:56.645 and I'm comfortable saying 543 00:25:56.645 --> 00:25:58.165 that there's no obstructive disease, 544 00:25:58.545 --> 00:26:01.925 but these are ones that end up probably more likely than not 545 00:26:01.945 --> 00:26:04.325 at HeartFlow for further analysis 546 00:26:04.835 --> 00:26:07.005 because these are the ones that, again, 547 00:26:07.025 --> 00:26:08.925 and there's some nice studies that document 548 00:26:08.925 --> 00:26:11.365 that HeartFlow has better diagnostic accuracy. 549 00:26:11.385 --> 00:26:13.685 We even published it from the original, I was the core lab 550 00:26:13.685 --> 00:26:15.245 for defacto one 551 00:26:15.245 --> 00:26:18.245 of the first multicenter studies for heart flow. 552 00:26:18.265 --> 00:26:20.405 And even from that study, we demonstrated 553 00:26:20.405 --> 00:26:22.085 that heart flow did a better job 554 00:26:22.355 --> 00:26:26.165 with the higher calcium scores than, than the CTA reader, 555 00:26:26.175 --> 00:26:27.805 which, which was me in that case. 556 00:26:28.265 --> 00:26:30.725 So I, I think it does add value. 557 00:26:31.165 --> 00:26:34.605 I think it's good selective use of FFR CT 558 00:26:34.605 --> 00:26:38.645 and those severely calcified segments or, or patients. 559 00:26:39.465 --> 00:26:41.525 But again, if it's over a thousand, you know 560 00:26:41.525 --> 00:26:43.365 that in advance, it, it might, you know, 561 00:26:43.585 --> 00:26:47.085 CT A is not my first choice anymore for diagnostic accuracy. 562 00:26:47.085 --> 00:26:48.605 And remember if they have symptoms 563 00:26:49.185 --> 00:26:52.085 and a very high calcium score, they are likely 564 00:26:52.085 --> 00:26:53.325 to have obstructive disease. 565 00:26:53.425 --> 00:26:54.925 So I think, you know, those are patients 566 00:26:54.925 --> 00:26:57.885 that if you have a patient who has, you know, significant, 567 00:26:58.025 --> 00:26:59.405 you know, symptoms that are believable 568 00:26:59.405 --> 00:27:01.525 and they happen to just get a calcium score 569 00:27:01.545 --> 00:27:04.725 for whatever reason and it's high, that might be a, a case 570 00:27:04.725 --> 00:27:07.405 where you can argue to maybe go straight to the cath lab. 571 00:27:07.525 --> 00:27:09.885 I, I don't usually go calcium score to the cath lab, 572 00:27:09.945 --> 00:27:12.805 but in symptomatic patients there's actually a pretty good 573 00:27:12.805 --> 00:27:13.965 algorithm of care there. 574 00:27:15.305 --> 00:27:17.005 Gotcha. Great. Um, 575 00:27:17.105 --> 00:27:19.685 not sure if you saw the question in the chat, 576 00:27:19.945 --> 00:27:22.925 but there was a, a question from Dr. 577 00:27:22.975 --> 00:27:27.885 Hyatt that says, is FFR always contraindicated in patients 578 00:27:28.235 --> 00:27:32.405 with prior PCI or are there substitutions to this rule? 579 00:27:33.185 --> 00:27:34.605 Yep, so that's a great question. 580 00:27:34.745 --> 00:27:37.485 So unfortunately right now, uh, 581 00:27:37.485 --> 00:27:40.565 heart flow does not read stented vessels. 582 00:27:41.025 --> 00:27:42.165 But, uh, let's say, 583 00:27:42.185 --> 00:27:44.045 and I send patients still with them 584 00:27:44.105 --> 00:27:46.405 who have a single artery stenting. 585 00:27:47.055 --> 00:27:48.805 Let's say the right coronary is stented 586 00:27:48.805 --> 00:27:52.485 and I have now a moderate lesion in the LAD, they will do 587 00:27:52.485 --> 00:27:54.965 that left-sided analysis for us. 588 00:27:55.585 --> 00:27:58.805 So, uh, there are exceptions to the rule of stenting. 589 00:27:58.835 --> 00:28:01.205 Obviously bypass is a different thing, but, 590 00:28:01.265 --> 00:28:03.045 but stenting I think is very clear. 591 00:28:03.105 --> 00:28:05.845 If it's a single vessel stent only, 592 00:28:05.995 --> 00:28:07.565 it's not multi-vessel stenting, 593 00:28:07.755 --> 00:28:10.565 then you can still get an FFR CT analysis. 594 00:28:10.585 --> 00:28:13.245 If you have a question about the non stented segment, again, 595 00:28:13.245 --> 00:28:16.725 they're not gonna inform you about stent re stenosis. 596 00:28:16.825 --> 00:28:20.605 So if the question is in the vessel that's stented, then 597 00:28:20.605 --> 00:28:21.765 that's not gonna be something 598 00:28:21.765 --> 00:28:23.125 that's gonna be helpful for you. 599 00:28:23.775 --> 00:28:25.365 Great, thank you very much. 600 00:28:26.625 --> 00:28:30.155 Looks like the question was answered, so thank you Dr. 601 00:28:30.255 --> 00:28:32.955 Budoff. I believe that is all the questions we have for now. 602 00:28:33.175 --> 00:28:34.995 Oh, I just received one more. 603 00:28:36.225 --> 00:28:39.035 Everybody wants to, seeing an increased number 604 00:28:39.055 --> 00:28:43.475 of CCTA is ordered in asymptomatic patients recognize 605 00:28:43.475 --> 00:28:47.075 that CCTA plaque characterizations, uh, 606 00:28:47.255 --> 00:28:48.715 and quantification is useful. 607 00:28:48.775 --> 00:28:53.475 But curious how CCTA changes the management in asymptomatic 608 00:28:53.875 --> 00:28:58.315 patients beyond what we already see in their calcium scores? 609 00:28:59.075 --> 00:29:00.685 Yeah, that's a great question and, 610 00:29:00.705 --> 00:29:01.885 and a tough one to answer. 611 00:29:02.025 --> 00:29:04.085 We really don't have great data yet. 612 00:29:04.325 --> 00:29:07.085 I can tell you that there are some prospective studies 613 00:29:07.195 --> 00:29:09.205 ongoing, including Scott Hart two, 614 00:29:10.025 --> 00:29:12.125 but there's other, other trials ongoing 615 00:29:12.355 --> 00:29:16.365 that are looking at asymptomatic patients randomized 616 00:29:16.425 --> 00:29:18.925 to CTA versus, you know, 617 00:29:18.925 --> 00:29:21.045 traditional guideline directed therapy. 618 00:29:21.545 --> 00:29:23.725 Uh, I don't think they're gonna answer the question 619 00:29:23.725 --> 00:29:26.165 of coronary calcium and the incremental value 620 00:29:26.405 --> 00:29:27.645 'cause I think that would be tough. 621 00:29:28.485 --> 00:29:30.845 I think that there's probably some incremental value, 622 00:29:30.845 --> 00:29:32.005 especially in patients 623 00:29:32.005 --> 00:29:34.845 where the calcium score may be missing the predominance 624 00:29:34.845 --> 00:29:36.645 of plaque like in a younger patient. 625 00:29:37.425 --> 00:29:40.325 But, uh, I'm not, I'm not con totally convinced yet 626 00:29:40.755 --> 00:29:44.085 that asymptomatic CT angiography adds a ton 627 00:29:44.085 --> 00:29:45.165 to coronary calcium. 628 00:29:46.105 --> 00:29:49.285 But you can imagine if they have that high, high volume 629 00:29:49.345 --> 00:29:52.925 of low attenuation plaque, if they have a cult stenosis 630 00:29:53.635 --> 00:29:54.845 that we won't see obviously 631 00:29:54.845 --> 00:29:56.325 or can't see on a calcium score, 632 00:29:56.395 --> 00:29:58.165 that those might be too examples 633 00:29:58.175 --> 00:30:00.085 where you might change your management 634 00:30:00.085 --> 00:30:01.485 and you might become more aggressive. 635 00:30:02.105 --> 00:30:04.325 And again, remember, calcium scoring is clearly 636 00:30:04.465 --> 00:30:05.805 not a perfect test. 637 00:30:05.865 --> 00:30:08.605 It doesn't perform very well in the younger populations. 638 00:30:08.945 --> 00:30:13.205 You can argue men under 45 or uh, women under 45 639 00:30:13.205 --> 00:30:16.765 or 50 not the best test, and it may miss plaque. 640 00:30:17.725 --> 00:30:20.865 And of course CAC doesn't inform us on OC cult stenosis. 641 00:30:21.365 --> 00:30:24.305 So you, you might be potentially missing something. 642 00:30:24.405 --> 00:30:27.625 So I think that there'll be populations, maybe diabetes, 643 00:30:27.715 --> 00:30:31.705 maybe terrible family history, maybe familial hyperlipidemia 644 00:30:32.075 --> 00:30:34.305 where we might be more nervous about the, 645 00:30:34.405 --> 00:30:38.305 the noncalcified plaque out of proportion to CAC and, 646 00:30:38.365 --> 00:30:40.705 and preferentially order a CTA. 647 00:30:41.285 --> 00:30:44.305 But I, for now, most of my asymptomatic patients, 648 00:30:44.385 --> 00:30:47.865 I do see calcium score first as my opening test. 649 00:30:48.435 --> 00:30:51.865 Thank you. That answered the question. All right. 650 00:30:52.795 --> 00:30:55.315 I believe that is now all the questions 651 00:30:55.475 --> 00:30:56.835 that we have for you Dr. 652 00:30:56.975 --> 00:30:59.555 Budoff. I really appreciate you taking the time 653 00:30:59.655 --> 00:31:00.795 to educate all of us 654 00:31:01.535 --> 00:31:05.035 and um, I hope everyone has a wonderful rest of your day. 655 00:31:05.125 --> 00:31:06.125 Thank you. 656 00:31:06.925 --> 00:31:08.135 Take care everyone. Be well.