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Angioplasty.Org Interview Series:
Daniel Berman, MD, FACC
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Daniel S. Berman, MD, FACC, is a Professor of Medicine at the UCLA School of Medicine and Director of Cardiac Imaging at Cedars-Sinai Medical Center in Los Angeles, where he has led the invasive group for 29 years. Dr. Berman is also the Vice-President of the Society of Cardiovascular Computed Tomography, which just celebrated its first anniversary.

The rapid development of Multislice Computed Tomography (MSCT) is changing the way patients with suspected coronary artery disease are being diagnosed. Until just a few years ago, standard coronary angiography (cardiac catheterization) was the only way to visualize the coronary arteries. By comparison, MSCT is faster, less expensive and less invasive.

For an illustrated description of MSCT, read our related article, Multislice CT Angiogram.

Daniel S> Berman, MD, FACC
Daniel S. Berman, MD, FACC

Multislice CT Scan
"Multislice CT angiography is...undoubtedly the most accurate non-invasive test for the diagnosis of obstructive coronary disease" **
  Q: How is the availability of 64-slice or Multislice CT for patients changing the diagnostic pathway from what is used to be?
Dr. Berman: What’s happening with Multislice CT is that it is going to change the way we approach the patient with chest pain in terms of establishing the cause.

The main area where the impact will be felt initially is in chest pain that isn’t characteristic of being from heart disease, but could be. We call this the intermediate likelihood state of having coronary artery disease. And it’s been known for years that that’s the time in which you use the most accurate test that’s non-invasive to establish the diagnosis.

That’s what Multislice CT angiography is. It’s undoubtedly the most accurate non-invasive test for the diagnosis of obstructive coronary disease.


Q: Exactly who is the patient with intermediate risk?
Dr. Berman: Every doctor who sees a patient that could be cardiac is thinking in his mind, what’s the likelihood that this patient’s symptoms are related to coronary artery disease?

Clinicians define coronary disease as a greater than 50% stenosis of a coronary vessel. Some people use 50%, some people use 70%. But when they talk about coronary artery disease, clinicians do not mean just the presence of coronary atherosclerosis. It’s not just plaque; it’s obstructive plaque causing chest pain.

 

When patients have typical angina pectoris, it comes on with exertion, is relieved by rest, and is in the middle of the chest. If they’re in the appropriate age group, the chances of them having coronary disease are about 90%. That’s a high likelihood of having coronary disease. Experts in general, do not believe that’s the group that needs Multislice CT scan.

But if you take a patient whose chest discomfort symptoms are less typical, the likelihood that they have obstructive coronary disease falls in the [intermediate] range between 25 to 75% likely that a patient’s symptoms might be explained on the basis of obstructive coronary disease.

These are decisions that a doctor, whether it’s a family practitioner, an internist or a cardiologist make when they are faced with a patient who has chest discomfort or shortness of breath symptoms that might be attributed to the heart. In the intermediate likelihood range, we use the test with the highest sensitivity and specificity for detecting obstructive disease -- and that test is the CT coronary angiogram.


Q: WIll 64-slice CT replace coronary angiography as a diagnostic modality -- or, as some physicians feel, will the impact be more on other diagnostic tests like thallium scans and echo stress tests?
Dr. Berman: The diagnostic coronary angiogram isn’t really a very common test anymore. I’ll bet if we were to survey the number of coronary angiographies done in the United States today that are done just for the purposes of establishing a diagnosis, with no intention of doing angioplasty, it would be a very small number.

The area that will be most affected will be the area in which tests have been used traditionally in patients with an intermediate likelihood of having coronary disease. And that isn’t the diagnostic coronary angiogram; that’s stress imaging, whether it’s a stress nuclear procedure or a stress echo procedure, or even a stress test. I think those tests may actually decline in their use for diagnosis of coronary disease.

 
MIP CT Scan
3D Maximum Intensity Projection (MIP) of CT, showing calcified plaque**

But when you look at the big picture of the use of tests, those other tests may increase in another population. In the people who have already known coronary disease. And, as the baby boomers age, there’ll be more and more in that age group. So it’s complex.

There still will be diagnostic applications. There still will be a lot of use of nuclear testing. But the first test of choice in the patient with intermediate likelihood of coronary artery disease who has symptoms may well become the CT coronary angiogram.

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Q: What is the impact on and the experience of the patient during multislice CT scanning?
Dr. Berman: It’s a very rapid test that involves about 15 minutes of time, and an injection of a contrast agent that does cause a warm sensation. There is a small risk of an allergic reaction to this injected contrast and, in that sense, it differs from other methods such as MRI or nuclear cardiology technologies that also use injections but without that risk of allergy.

The other thing that can happen is that there’s a small risk of kidney impairment on the basis of giving this dye, so patients who have kidney dysfunction or abnormally functioning kidneys are approached very cautiously. There are ways around these risks, however, and they are very small.

There is a radiation exposure associated with the test, but it’s similar to the radiation exposure of other diagnostic tests. Because of the radiation exposure we are not currently recommending that this be used as a screening test for everyone. We would want to use a test with less radiation unless there was a higher suspicion of obstructive disease. But in the future, that radiation burden may be decreasing significantly.

Q: How do you see the future developments in Multislice CT in terms of the ability to use less radiation, and other advances?
Dr. Berman: In the near future, techniques to reduce the radiation exposure will be developed. There will be increased ability to objectively analyze the images so that we don’t rely just on the skill of the operator of the computer workstation And there will be improvement in technology that may reduce the need to rely on beta-blockers to slow the heart rate sufficiently in all cases.

Q: Which professional should be doing Multislice CT scanning for coronary artery disease -- the cardiologist, radiologist, etc.?
Dr. Berman: It’s going to be done by whoever is the best trained in a given circumstance. They will range from people who are doing catheterizations now, to people whose specialty is noninvasive imaging to people whose specialty is radiology with a focus on cardiovascular imaging. I don’t think it’s so much what the person’s area of general specialization is as much as it is what is the person’s skill and expertise in this specific form of testing.

Q: What about Magnetic Resonance Angiography (MRA)?
Dr. Berman: Not going to be a player for the coronary artery because of limitations in multiple different problems that arise for looking at coronary arteries. MRA will be helpful in assessing plaque in other vessels, but coronary artery disease that is such a prominent killer can be active at a time when disease is not active in other vessels in the system, so it’s not as direct an approach as will be provided by plaque imaging using the coronary artery and PET/CT.

Q: In recent years, it's become clear that it's not just the amount of plaque, but the type of plaque that is important to visualize. What is the status of Multislice CT scanning right now with the imaging of different forms of plaque?
Dr. Berman: It’s completely in the research phase and I think it’s premature to say how that’s going to affect patient management. Right now, the amount of soft, of non-calcified, plaque that a patient has -- it shouldn’t be called soft, because often it’s hard, but it’s non-calcified plaque -- can be evaluated in CT in a way that can’t be achieved by any other current technique in the coronary artery. Even the diagnostic coronary angiogram can’t see the non-calcified plaque -- it sees the lumen rather than the wall of the vessel.

We believe that in the more distant future, we will have techniques that will allow us to assess, to identify patients with rupture-prone plaque, which is probably a better term than vulnerable plaque. The rupture-prone plaque is a plaque that is associated with inflammation, a lot of lipid disposition, and has a thin cap on the plaque. The features of inflammation may give us a specific target that could be used in combination with PET scanning and CT scanning in the future.

So looking down the line, I believe that instead of just simply saying that we’ll find patients who have coronary obstruction, we’re going to ultimately have the ability to separate out the people who are at very high risk by identifying patients who have rupture-prone plaque. I also believe that it’s going to be difficult to do that with CT alone and it may require a technique such PET/CT.


Q: You currently are Vice-President of the Society of Cardiovascular Computed Tomography (SCCT). Tell me about the organization, especially with regard to training.
Dr. Berman: Well the Society of Cardiovascular Computed Tomography is really set up to do whatever is necessary to help new technology reach its true potential. And that’s a broad statement, but that’s what all of us as the founders really feel is the mission. The mission statement is on the web site, and it’s really been carefully thought out. I think in simple terms -- it’s to do what is necessary to allow this promising new technique to reach its full potential in patient care.
 
Society of Cardiovascular Computed Tomography
Multislice CT Scan
"Multislice CT angiography is...undoubtedly the most accurate non-invasive test for the diagnosis of obstructive coronary disease" **
  Q: How is the availability of 64-slice or Multislice CT for patients changing the diagnostic pathway from what is used to be?
Dr. Berman: What’s happening with Multislice CT is that it is going to change the way we approach the patient with chest pain in terms of establishing the cause.

The main area where the impact will be felt initially is in chest pain that isn’t characteristic of being from heart disease, but could be. We call this the intermediate likelihood state of having coronary artery disease. And it’s been known for years that that’s the time in which you use the most accurate test that’s non-invasive to establish the diagnosis.

That’s what Multislice CT angiography is. It’s undoubtedly the most accurate non-invasive test for the diagnosis of obstructive coronary disease.


Q: Exactly who is the patient with intermediate risk?
Dr. Berman: Every doctor who sees a patient that could be cardiac is thinking in his mind, what’s the likelihood that this patient’s symptoms are related to coronary artery disease?

Clinicians define coronary disease as a greater than 50% stenosis of a coronary vessel. Some people use 50%, some people use 70%. But when they talk about coronary artery disease, clinicians do not mean just the presence of coronary atherosclerosis. It’s not just plaque; it’s obstructive plaque causing chest pain.

 

When patients have typical angina pectoris, it comes on with exertion, is relieved by rest, and is in the middle of the chest. If they’re in the appropriate age group, the chances of them having coronary disease are about 90%. That’s a high likelihood of having coronary disease. Experts in general, do not believe that’s the group that needs Multislice CT scan.

But if you take a patient whose chest discomfort symptoms are less typical, the likelihood that they have obstructive coronary disease falls in the [intermediate] range between 25 to 75% likely that a patient’s symptoms might be explained on the basis of obstructive coronary disease.

These are decisions that a doctor, whether it’s a family practitioner, an internist or a cardiologist make when they are faced with a patient who has chest discomfort or shortness of breath symptoms that might be attributed to the heart. In the intermediate likelihood range, we use the test with the highest sensitivity and specificity for detecting obstructive disease -- and that test is the CT coronary angiogram.


Q: WIll 64-slice CT replace coronary angiography as a diagnostic modality -- or, as some physicians feel, will the impact be more on other diagnostic tests like thallium scans and echo stress tests?
Dr. Berman: The diagnostic coronary angiogram isn’t really a very common test anymore. I’ll bet if we were to survey the number of coronary angiographies done in the United States today that are done just for the purposes of establishing a diagnosis, with no intention of doing angioplasty, it would be a very small number.

The area that will be most affected will be the area in which tests have been used traditionally in patients with an intermediate likelihood of having coronary disease. And that isn’t the diagnostic coronary angiogram; that’s stress imaging, whether it’s a stress nuclear procedure or a stress echo procedure, or even a stress test. I think those tests may actually decline in their use for diagnosis of coronary disease.

 
MIP CT Scan
3D Maximum Intensity Projection (MIP) of CT, showing calcified plaque**

But when you look at the big picture of the use of tests, those other tests may increase in another population. In the people who have already known coronary disease. And, as the baby boomers age, there’ll be more and more in that age group. So it’s complex.

There still will be diagnostic applications. There still will be a lot of use of nuclear testing. But the first test of choice in the patient with intermediate likelihood of coronary artery disease who has symptoms may well become the CT coronary angiogram.

Q: What is the impact on and the experience of the patient during multislice CT scanning?
Dr. Berman: It’s a very rapid test that involves about 15 minutes of time, and an injection of a contrast agent that does cause a warm sensation. There is a small risk of an allergic reaction to this injected contrast and, in that sense, it differs from other methods such as MRI or nuclear cardiology technologies that also use injections but without that risk of allergy.

The other thing that can happen is that there’s a small risk of kidney impairment on the basis of giving this dye, so patients who have kidney dysfunction or abnormally functioning kidneys are approached very cautiously. There are ways around these risks, however, and they are very small.

There is a radiation exposure associated with the test, but it’s similar to the radiation exposure of other diagnostic tests. Because of the radiation exposure we are not currently recommending that this be used as a screening test for everyone. We would want to use a test with less radiation unless there was a higher suspicion of obstructive disease. But in the future, that radiation burden may be decreasing significantly.

Q: How do you see the future developments in Multislice CT in terms of the ability to use less radiation, and other advances?
Dr. Berman: In the near future, techniques to reduce the radiation exposure will be developed. There will be increased ability to objectively analyze the images so that we don’t rely just on the skill of the operator of the computer workstation And there will be improvement in technology that may reduce the need to rely on beta-blockers to slow the heart rate sufficiently in all cases.

Q: Which professional should be doing Multislice CT scanning for coronary artery disease -- the cardiologist, radiologist, etc.?
Dr. Berman: It’s going to be done by whoever is the best trained in a given circumstance. They will range from people who are doing catheterizations now, to people whose specialty is noninvasive imaging to people whose specialty is radiology with a focus on cardiovascular imaging. I don’t think it’s so much what the person’s area of general specialization is as much as it is what is the person’s skill and expertise in this specific form of testing.

Q: What about Magnetic Resonance Angiography (MRA)?
Dr. Berman: Not going to be a player for the coronary artery because of limitations in multiple different problems that arise for looking at coronary arteries. MRA will be helpful in assessing plaque in other vessels, but coronary artery disease that is such a prominent killer can be active at a time when disease is not active in other vessels in the system, so it’s not as direct an approach as will be provided by plaque imaging using the coronary artery and PET/CT.

Q: In recent years, it's become clear that it's not just the amount of plaque, but the type of plaque that is important to visualize. What is the status of Multislice CT scanning right now with the imaging of different forms of plaque?
Dr. Berman: It’s completely in the research phase and I think it’s premature to say how that’s going to affect patient management. Right now, the amount of soft, of non-calcified, plaque that a patient has -- it shouldn’t be called soft, because often it’s hard, but it’s non-calcified plaque -- can be evaluated in CT in a way that can’t be achieved by any other current technique in the coronary artery. Even the diagnostic coronary angiogram can’t see the non-calcified plaque -- it sees the lumen rather than the wall of the vessel.

We believe that in the more distant future, we will have techniques that will allow us to assess, to identify patients with rupture-prone plaque, which is probably a better term than vulnerable plaque. The rupture-prone plaque is a plaque that is associated with inflammation, a lot of lipid disposition, and has a thin cap on the plaque. The features of inflammation may give us a specific target that could be used in combination with PET scanning and CT scanning in the future.

So looking down the line, I believe that instead of just simply saying that we’ll find patients who have coronary obstruction, we’re going to ultimately have the ability to separate out the people who are at very high risk by identifying patients who have rupture-prone plaque. I also believe that it’s going to be difficult to do that with CT alone and it may require a technique such PET/CT.


Q: You currently are Vice-President of the Society of Cardiovascular Computed Tomography (SCCT). Tell me about the organization, especially with regard to training.
Dr. Berman: Well the Society of Cardiovascular Computed Tomography is really set up to do whatever is necessary to help new technology reach its true potential. And that’s a broad statement, but that’s what all of us as the founders really feel is the mission. The mission statement is on the web site, and it’s really been carefully thought out. I think in simple terms -- it’s to do what is necessary to allow this promising new technique to reach its full potential in patient care.
 
Society of Cardiovascular Computed Tomography

This interview was conducted in June 2006 by Burt Cohen of Angioplasty.Org.