Using Medical Imaging for Early Plaque Detection with Dr. Jagat Narula

On this Inside the Texas Heart Studio episode, Dr. Joseph G. Rogers sits down with Dr. Jagat Narula to discuss the cutting-edge advancements in cardiac imaging, specifically focusing on CT-based methodologies for atherosclerosis characterization.

They will discuss:

• Dr. Narula's personal journey and emotional connection to cardiac health.
• Importance of CT-based methodologies in early plaque detection.
• Role of AI in refining diagnostic accuracy and patient triage.
• Discussions on the cost-effectiveness of coronary CT and plaque morphology analysis.

For more information about heart attacks, visit texasheart.org/heart-health/heart-information-center/topics/heart-attack/

For more information about stroke, visit texasheart.org/heart-health/heart-information-center/topics/stroke/

Watch the sit-down interview here

Watch Dr. Narula's Grand Rounds

Watch On Demand Videos on Texas Heart TV

Visit Our Website: texasheart.org

Chapters

• 2:23 Screening for Early Plaque
• 5:46 The Future of Cardiac Imaging
• 8:49 The Future of Serum Biomarkers
• 9:40 Is a Coronary CT Cost Effective Method?

Transcript

0
00:00:00.065 --> 00:00:01.725
Hi, I'm Dr. Joe Rogers, president,

1
00:00:01.725 --> 00:00:03.845
and CEO of, uh, the Texas Heart Institute,

2
00:00:03.845 --> 00:00:06.005
and I'm joined here in the studio today by Dr.

3
00:00:06.025 --> 00:00:08.245
Jagged Naula, who just gave grand rounds at

4
00:00:08.245 --> 00:00:09.285
the Texas Heart Institute.

5
00:00:09.835 --> 00:00:14.045
It's a wonderful grand rounds today, uh, discussing, uh,

6
00:00:14.675 --> 00:00:17.005
what I thought was some of the most interesting

7
00:00:17.005 --> 00:00:20.645
and important data about atherosclerosis

8
00:00:20.645 --> 00:00:22.285
and the progression of atherosclerosis and,

9
00:00:22.345 --> 00:00:24.805
and how we should be thinking about characterizing plaques.

10
00:00:24.865 --> 00:00:26.245
I'd encourage people

11
00:00:26.305 --> 00:00:28.485
who didn't watch grand rounds to watch it.

12
00:00:28.585 --> 00:00:31.445
And, uh, if you've, uh, if you did watch it,

13
00:00:31.525 --> 00:00:33.565
I would encourage you to watch it again, uh,

14
00:00:33.565 --> 00:00:35.885
because I think there were so many important pearls,

15
00:00:36.545 --> 00:00:37.685
uh, in your talk today.

16
00:00:37.945 --> 00:00:40.165
So thank you for joining us just here in the studio

17
00:00:40.425 --> 00:00:43.165
to spend, you know, five or 10 minutes just talking a little

18
00:00:43.165 --> 00:00:45.365
bit more, taking a deeper dive into some of the topics.

19
00:00:46.515 --> 00:00:50.005
It's, it's, it's, uh, truly an honor, uh, to be here, Joe.

20
00:00:50.185 --> 00:00:52.125
And, uh, I'm grateful for the invitation

21
00:00:52.665 --> 00:00:56.405
and I, as I said, uh, when I started my, uh,

22
00:00:56.405 --> 00:00:58.525
grand rounds today, that, uh,

23
00:00:58.625 --> 00:01:00.605
it was more emotional than anything else

24
00:01:01.115 --> 00:01:05.085
because, uh, 1988, I brought my father here

25
00:01:05.545 --> 00:01:08.525
for a seven vessel bypass by Dr. Cooley and Dr.

26
00:01:08.595 --> 00:01:13.485
Rule. And, uh, he returned home, uh, completely recovered,

27
00:01:14.075 --> 00:01:16.765
came with 23% ejection fraction, returned home

28
00:01:16.765 --> 00:01:18.725
with 65% ejection fraction,

29
00:01:19.465 --> 00:01:21.525
not needing any nitroglycerine pills,

30
00:01:21.545 --> 00:01:25.005
and living 16 years thereafter to die of cancer.

31
00:01:25.865 --> 00:01:28.685
And, uh, so I, I have an emotional connect here,

32
00:01:28.685 --> 00:01:32.605
and it was truly gratifying, uh, to come back here

33
00:01:32.735 --> 00:01:34.405
after 30 plus years.

34
00:01:34.755 --> 00:01:35.885
Well, it was our great fortune

35
00:01:36.075 --> 00:01:38.485
that you took some time to, to come today.

36
00:01:38.515 --> 00:01:41.405
Just for those of you who, um, don't know Dr.

37
00:01:41.755 --> 00:01:43.485
Nula and his recent move

38
00:01:43.545 --> 00:01:45.725
to Houston about a little more than a year ago.

39
00:01:46.225 --> 00:01:49.045
Uh, you were the executive Vice President of the University

40
00:01:49.045 --> 00:01:51.845
of Texas, uh, health Science Center here in Houston,

41
00:01:52.265 --> 00:01:55.125
but equally importantly, you're the Chief Academic Officer

42
00:01:55.265 --> 00:01:57.485
and really guiding, I think, all

43
00:01:57.485 --> 00:01:59.165
of the academics in that organization.

44
00:01:59.185 --> 00:02:01.805
And we're very fortunate to have you in the area.

45
00:02:01.925 --> 00:02:05.005
I know that, um, you've been, um, you've enriched so many,

46
00:02:05.065 --> 00:02:08.045
so much of our cardiovascular, uh,

47
00:02:08.285 --> 00:02:10.645
programs across the Texas Medical Center just

48
00:02:10.805 --> 00:02:11.845
by, by your presence.

49
00:02:11.845 --> 00:02:13.885
And so we're so happy that you, we could,

50
00:02:13.985 --> 00:02:16.245
we could attract you from New York to, to Houston.

51
00:02:16.695 --> 00:02:18.965
Honor has been entirely mine. Thank you.

52
00:02:19.625 --> 00:02:22.565
So, I, I thought that I, I wanted to explore a couple

53
00:02:22.585 --> 00:02:24.165
of topics with you today and,

54
00:02:24.165 --> 00:02:26.365
and one of them started with the question that I asked you

55
00:02:26.365 --> 00:02:28.405
after, uh, after your lecture,

56
00:02:29.065 --> 00:02:32.885
and it was really around how you recommend

57
00:02:33.035 --> 00:02:37.045
that we begin approach approaching screening, uh,

58
00:02:37.385 --> 00:02:40.565
for people using CT based methodologies

59
00:02:40.865 --> 00:02:44.645
to really characterize not only calcium scores,

60
00:02:44.905 --> 00:02:46.165
but you know,

61
00:02:46.385 --> 00:02:49.285
how you would begin thinking about characterizing early

62
00:02:49.345 --> 00:02:53.125
plaque and how that should drive our decision making.

63
00:02:53.145 --> 00:02:55.205
You know, many of the people who will watch this segment,

64
00:02:55.785 --> 00:02:58.525
uh, that we're taping today, are gonna go back

65
00:02:58.525 --> 00:02:59.880
to the office this afternoon,

66
00:02:59.945 --> 00:03:01.765
or they'll be in the office on Monday morning.

67
00:03:02.585 --> 00:03:04.565
How should they use the information

68
00:03:04.565 --> 00:03:08.405
that you presented about plaque characterization using ct,

69
00:03:08.985 --> 00:03:10.605
uh, in their patient population,

70
00:03:11.305 --> 00:03:13.925
Uh, coronary artery calcium, as you said,

71
00:03:13.985 --> 00:03:15.085
it, it does very well.

72
00:03:15.425 --> 00:03:17.405
Uh, the reason being that, uh, most

73
00:03:17.525 --> 00:03:19.605
of the time when there is an atherosclerosis,

74
00:03:19.605 --> 00:03:22.805
there is calcium there, uh, whether it is

75
00:03:22.805 --> 00:03:25.405
because of the macrophage death or whatever else it is.

76
00:03:26.025 --> 00:03:29.885
And, uh, the, the calcification normally can be seen

77
00:03:30.065 --> 00:03:33.685
as almost a universal surrogate for the presence

78
00:03:33.685 --> 00:03:38.005
of atherosclerosis when, uh, it is very early,

79
00:03:38.545 --> 00:03:42.485
uh, uh, for example, uh, in early thirties or mid thirties,

80
00:03:42.625 --> 00:03:44.525
or even to forties in men

81
00:03:45.065 --> 00:03:47.485
or, uh, even later in, in women,

82
00:03:47.755 --> 00:03:49.325
calcium may still not be there.

83
00:03:49.385 --> 00:03:51.405
And we might miss out on the plaques.

84
00:03:51.585 --> 00:03:53.245
And that is where the importance

85
00:03:53.245 --> 00:03:57.045
of these early CT angiography comes in normally.

86
00:03:57.385 --> 00:03:59.645
Uh, the most important thing that we really need

87
00:03:59.645 --> 00:04:02.085
to do is we really need to look at the risk factors.

88
00:04:02.425 --> 00:04:06.125
We have to be cognizant of that important part for that is

89
00:04:06.125 --> 00:04:09.525
that the way we treat with the, the treat risk factors

90
00:04:10.225 --> 00:04:11.925
is not the way we should be doing that.

91
00:04:12.705 --> 00:04:14.605
Uh, we are normally looking

92
00:04:14.665 --> 00:04:16.685
for the extreme elevation of the risk factors.

93
00:04:16.755 --> 00:04:17.925
Your patients come to you

94
00:04:17.945 --> 00:04:20.245
and you tell them that your sugar is borderline,

95
00:04:20.825 --> 00:04:22.765
or, uh, your cholesterol is borderline,

96
00:04:22.765 --> 00:04:24.125
your blood pressure is borderline.

97
00:04:24.125 --> 00:04:25.165
This is the borderlines,

98
00:04:25.455 --> 00:04:27.605
which really create a problem for us.

99
00:04:27.975 --> 00:04:31.525
We've got to be very, very careful, uh, about that,

100
00:04:31.915 --> 00:04:34.205
that we don't have to really go, uh,

101
00:04:34.295 --> 00:04:36.325
after the extreme elevations.

102
00:04:36.785 --> 00:04:40.205
And secondly, the normal values that we call,

103
00:04:40.635 --> 00:04:44.645
they are the usual values of a risk factor, uh, uh,

104
00:04:44.745 --> 00:04:47.685
of the population, which is at high risk of dying

105
00:04:47.685 --> 00:04:50.805
of a premature atherosclerotic or vascular disease.

106
00:04:51.145 --> 00:04:53.885
So basically, the normal values are usual values.

107
00:04:54.025 --> 00:04:57.205
We really need to know what the normal values are

108
00:04:57.205 --> 00:04:58.845
or what the ideal values are.

109
00:04:59.305 --> 00:05:02.325
So, uh, uh, risk factors

110
00:05:02.935 --> 00:05:04.885
would still be the most important way to go.

111
00:05:05.425 --> 00:05:08.125
The second important thing would be looking at the CT

112
00:05:08.135 --> 00:05:11.965
angiograms, and when would I recommend early CT angiogram is

113
00:05:12.435 --> 00:05:17.125
when a subject comes to me and, uh, it is 10 years

114
00:05:17.145 --> 00:05:19.405
before his father died of a heart attack

115
00:05:19.425 --> 00:05:20.565
or had a heart attack.

116
00:05:20.915 --> 00:05:22.525
That would be the time that I would like

117
00:05:22.525 --> 00:05:27.205
to start looking at them, uh, with the CT angiograms, uh, so

118
00:05:27.205 --> 00:05:30.485
as to have a deeper dive into their, uh, disease process.

119
00:05:31.265 --> 00:05:33.725
And then using the lipid-lowering therapy.

120
00:05:34.165 --> 00:05:37.085
I think it has, uh, um, uh, proven

121
00:05:37.225 --> 00:05:42.085
to be the most important, um, anchor for,

122
00:05:42.225 --> 00:05:45.125
uh, uh, the, uh, disease prevention.

123
00:05:45.355 --> 00:05:46.355
Yeah.

124
00:05:47.305 --> 00:05:49.765
You obviously have spent a lot of your time, uh,

125
00:05:49.765 --> 00:05:53.205
professionally thinking about cardiac imaging,

126
00:05:54.105 --> 00:05:57.645
and we focus today primarily on using CT

127
00:05:57.945 --> 00:06:01.605
as an imaging modality to understand the pathobiology

128
00:06:01.625 --> 00:06:03.325
of atherosclerotic disease.

129
00:06:04.075 --> 00:06:07.285
What do you think are the next imaging tools

130
00:06:07.795 --> 00:06:10.125
that will emerge over the next decade

131
00:06:10.195 --> 00:06:13.165
that might help us characterize vulnerability

132
00:06:13.165 --> 00:06:14.885
of plaques, progression?

133
00:06:15.265 --> 00:06:16.925
And the, I thought the comments

134
00:06:16.925 --> 00:06:18.525
that you made today about sort

135
00:06:18.525 --> 00:06:21.325
of serially looking at progression of plaques

136
00:06:21.325 --> 00:06:25.085
and the, the remodeling of the vessels was so important,

137
00:06:25.585 --> 00:06:28.325
but what, what's coming jagged, do you think, in the future

138
00:06:28.395 --> 00:06:31.605
that will refine our knowledge, uh, from ct?

139
00:06:32.745 --> 00:06:35.325
Uh, I think that we have found the right, uh,

140
00:06:35.435 --> 00:06:36.645
imaging test already.

141
00:06:37.465 --> 00:06:41.445
CT angio angiogram is probably the most important thing

142
00:06:41.445 --> 00:06:42.805
that we could have developed

143
00:06:42.825 --> 00:06:46.165
or we would develop in terms of, uh, assessment

144
00:06:46.225 --> 00:06:47.405
of the coronary plaques.

145
00:06:47.825 --> 00:06:51.685
The only important thing which is remaining is its

146
00:06:51.775 --> 00:06:52.965
right application.

147
00:06:53.665 --> 00:06:56.885
And, uh, our willingness to use it more commonly.

148
00:06:57.705 --> 00:07:01.645
Uh, the, as far as the interpretation is concerned, uh,

149
00:07:01.925 --> 00:07:05.805
I think the AI tools which are now becoming available should

150
00:07:05.805 --> 00:07:07.485
be able to predict the likelihood

151
00:07:07.485 --> 00:07:10.325
of having an event in a much better manner

152
00:07:10.325 --> 00:07:11.525
than what we do today.

153
00:07:12.155 --> 00:07:14.925
Automatic assessment is also extremely important,

154
00:07:14.955 --> 00:07:16.765
looking not only at the plaque,

155
00:07:17.025 --> 00:07:19.405
but looking at the total vasculature as a part

156
00:07:19.405 --> 00:07:20.645
of the whole patient.

157
00:07:21.305 --> 00:07:23.885
And, uh, then going with the recommendation,

158
00:07:24.335 --> 00:07:26.005
it'll be the one which will be able

159
00:07:26.005 --> 00:07:29.965
to also triage the patients in terms of, uh,

160
00:07:30.115 --> 00:07:33.525
whether they would require the, uh, primary prevention

161
00:07:33.525 --> 00:07:36.245
with the optimal medical therapy, which are the patients

162
00:07:36.245 --> 00:07:38.645
who should be sent for revascularization,

163
00:07:38.875 --> 00:07:43.045
because it can give you the anatomic, uh, characterization

164
00:07:43.145 --> 00:07:44.805
as well as functional characterization.

165
00:07:45.145 --> 00:07:46.605
And then also look at the plaque.

166
00:07:46.905 --> 00:07:51.685
And as you have recently seen, uh, our, uh, uh,

167
00:07:51.875 --> 00:07:55.285
fast track cabbage study, uh, which was presented by Dr.

168
00:07:55.505 --> 00:07:59.965
Uh, pat Roys recently in the TCT, where, uh, uh,

169
00:08:00.185 --> 00:08:02.045
we could even send the patients straight

170
00:08:02.335 --> 00:08:04.085
after doing the CT angiography

171
00:08:04.105 --> 00:08:06.205
for the coronary bypass surgeries.

172
00:08:06.505 --> 00:08:10.365
And, uh, except one case, there was no need

173
00:08:10.665 --> 00:08:13.125
for looking at the invasive coronary angiograms in

174
00:08:13.125 --> 00:08:14.445
those, uh, subjects.

175
00:08:14.625 --> 00:08:17.445
So I think we have, we have got almost everything

176
00:08:17.445 --> 00:08:19.045
covered with this test.

177
00:08:19.825 --> 00:08:21.965
And, uh, uh, with the AI

178
00:08:22.065 --> 00:08:25.405
and better interpretation, we should be able to

179
00:08:26.965 --> 00:08:30.485
automate, uh, uh, the, uh, the characterization.

180
00:08:30.985 --> 00:08:34.205
And more important than that, would we be able

181
00:08:34.205 --> 00:08:37.125
to identify those plaques which are likely

182
00:08:37.305 --> 00:08:40.605
to progress over a period of time based on their

183
00:08:41.805 --> 00:08:43.325
baseline, uh, findings.

184
00:08:43.325 --> 00:08:46.325
Mm-hmm. That would be the most important goal

185
00:08:46.585 --> 00:08:49.165
for the coming years and investigation.

186
00:08:50.505 --> 00:08:52.645
Do you perceive that there will be a,

187
00:08:53.085 --> 00:08:58.045
a new serum biomarker that either adds to

188
00:08:58.045 --> 00:09:01.645
what we're understanding from coronary CT

189
00:09:01.825 --> 00:09:05.205
or could supplant, uh, coronary ct?

190
00:09:05.205 --> 00:09:07.765
What, what are your thoughts about, about biomarkers?

191
00:09:07.985 --> 00:09:10.325
So the future, obviously is in

192
00:09:11.565 --> 00:09:13.325
omics plus the imaging.

193
00:09:13.785 --> 00:09:16.325
So we have to genomically

194
00:09:16.745 --> 00:09:20.165
or proteomic characterize the disease.

195
00:09:20.545 --> 00:09:23.605
And on the other hand, we have to do it with the phenomic,

196
00:09:23.745 --> 00:09:28.205
uh, biomarkers, quite like, uh, imaging, uh, future for

197
00:09:28.205 --> 00:09:32.165
that matter, for any, any medical condition is going

198
00:09:32.245 --> 00:09:34.965
to be dependent upon the omics on one hand.

199
00:09:35.105 --> 00:09:36.765
And imaging on the other hand,

200
00:09:37.485 --> 00:09:39.045
regardless whether we are treating coronary

201
00:09:39.045 --> 00:09:40.365
artery disease or anything else.

202
00:09:41.305 --> 00:09:43.325
And the last thing I wanted to explore with you, Jack,

203
00:09:43.435 --> 00:09:46.845
just, um, as we wrap up, you know,

204
00:09:47.185 --> 00:09:51.085
we all have the challenges in the office of, um,

205
00:09:51.315 --> 00:09:54.125
getting authorization for tests, et cetera.

206
00:09:54.675 --> 00:09:58.085
What do we know about the cost effectiveness of

207
00:09:59.085 --> 00:10:02.405
coronary CT and looking at plaque morphology

208
00:10:02.505 --> 00:10:05.925
and looking at, um, at, at coronary FFR in terms

209
00:10:05.925 --> 00:10:08.725
of being a cost effective approach, especially

210
00:10:08.725 --> 00:10:11.485
for this lower risk patient population?

211
00:10:12.145 --> 00:10:16.885
Uh, it'll be extremely important again, that,

212
00:10:16.985 --> 00:10:19.605
uh, we have our investigations completed.

213
00:10:20.305 --> 00:10:23.365
Uh, we do not have the, uh, um,

214
00:10:23.875 --> 00:10:28.405
substantial data in terms of the prospective analysis, uh,

215
00:10:28.545 --> 00:10:29.805
for the cost effectiveness.

216
00:10:30.025 --> 00:10:34.205
And I think that data are the most important, um,

217
00:10:34.865 --> 00:10:38.245
uh, deficiency in our, our proposals at this time.

218
00:10:38.865 --> 00:10:40.645
Uh, if you look at the CT

219
00:10:40.645 --> 00:10:43.365
and geography, it is one of the most recent, uh, uh,

220
00:10:43.395 --> 00:10:46.965
imaging, uh, modality as compared

221
00:10:46.965 --> 00:10:48.725
to when we look at the echocardiography

222
00:10:48.785 --> 00:10:49.925
or the nuclear imaging

223
00:10:49.945 --> 00:10:53.405
and all where the, uh, the results are available

224
00:10:53.585 --> 00:10:55.005
for 40 years now.

225
00:10:55.745 --> 00:10:59.725
And, uh, so I think we are getting into that, uh, arena

226
00:10:59.735 --> 00:11:02.445
where it should be soon characterized,

227
00:11:02.445 --> 00:11:07.005
and we should be able to, uh, define the importance of CT

228
00:11:07.005 --> 00:11:11.365
and geography, uh, uh, better, uh, ischemia trial

229
00:11:11.705 --> 00:11:14.965
and, uh, other trials have, uh, uh, all

230
00:11:14.965 --> 00:11:16.525
that data, uh, available.

231
00:11:16.995 --> 00:11:19.645
They have CT characterization of all their patients,

232
00:11:19.915 --> 00:11:24.085
they have, uh, uh, echocardiograms and, uh, nuclear tests.

233
00:11:24.465 --> 00:11:27.725
And I think that data should be able

234
00:11:27.725 --> 00:11:30.405
to inform us better than what we know today.

235
00:11:31.705 --> 00:11:33.645
It has been such a pleasure to have you here.

236
00:11:33.985 --> 00:11:38.125
Uh, we'll be sure to invite you back next year to, uh, to,

237
00:11:38.125 --> 00:11:39.325
you know, to give us another update

238
00:11:39.385 --> 00:11:41.765
and to expand our knowledge in, in this space.

239
00:11:41.825 --> 00:11:43.005
But Jack, thank you so much

240
00:11:43.025 --> 00:11:44.925
for taking the time today to visit THI.

241
00:11:45.225 --> 00:11:47.725
It was truly a pleasure, and I'm always available.

242
00:11:47.865 --> 00:11:51.165
I'm around the corner less than a mile away, so any day.

243
00:11:51.335 --> 00:11:52.165
Thank you. Thank you.