contemporary therapeutic issues in cardiovascular disease · 2018-05-04 · issues in...
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Noninvasive Evaluation of Coronary Artery Disease:
Anatomical, Functional, Clinical
May 5, 2018
Mark Hansen MD FRCPC Cardiologist, Schulich Heart Centre Assistant Professor, Department of Medicine University of Toronto
21st Annual Contemporary Therapeutic Issues in Cardiovascular Disease
No Conflict or Disclosure
LEARNING OBJECTIVES
To develop a greater understanding of the application of cardiac imaging modalities in the detection and management of coronary artery disease:
stress echocardiography myocardial perfusion imaging coronary CT angiography
Coronary Artery Disease
Libby P NEJM 2013;368:2004-2013
Hansson G NEJM 2005;352:1685-1695
Libby P, Theroux P, Circulation 2005;111:23481-3488
When seeking an answer, begin with the right question
Detection vs. Management?
Anatomy vs. Function?
Diagnosis vs. Prognosis?
Case
49 year old male Phys. Ed. teacher Diminished exercise capacity ?aging Positive family history of premature CAD BP 148/88 Glucose 5.4 Cholesterol 6.88, TG 4.92, HDL 1.28 GXT: 12min Bruce, 12.8METs, mild dyspnea, peak BP 210/73, 2mm horizontal ST depressions
Case
49 year old male Phys. Ed. teacher Diminished exercise capacity ?aging Positive family history of premature CAD BP 148/88 Glucose 5.4 Cholesterol 6.88, TG 4.92, HDL 1.28 GXT: 12min Bruce, 12.8METs, mild dyspnea, peak BP 210/73, 2mm horizontal ST depressions
What Now?
What Now?
Reassurance? Medical therapy? Stress echocardiography? Myocardial perfusion imaging? CT coronary angiography? Invasive coronary angiography?
The Ischemic Cascade
The Ischemic Cascade
The Ischemic Cascade
The Ischemic Cascade
Will this information:
change health behaviour? change management?
Is this investigation:
cost effective? worth the risk?
Case - cont.
Referred for stress echocardiography
STRESS IMAGING
StressRest
Exercise
Pharmacological
STRESS ECHO
StressRest
Exercise
Dobutamine
STRESS ECHO
DisadvantagesAdvantagesCheap No radiation Specific
Operator-dependent Not very sensitive e.g. circumflex ischemia
Special ConsiderationsExtensive literature on pre-op evaluation (dobutamine) Poor images = poor accuracy Inadequate stress = nondiagnostic test Challenging when baseline wall motion abnormality
STRESS ECHO
Ideal LabIdeal PatientRule-in scenario Interpretable ECG Good image quality Capable of reaching max HR Normal baseline LV function (Serial follow-up)
Direct MD supervision Excellent equipment Excellent sonographer
Case - cont.
Stress echocardiography: 12min Bruce, 12.8METs, mild dyspnea, 2mm horizontal ST depressions, normal left ventricular systolic function at rest and stress
What Now?
Case - cont.
Referred for myocardial perfusion imaging
MYOCARDIAL PERFUSION IMAGING
StressRest
ExercisePersantineAdenosine
MYOCARDIAL PERFUSION IMAGING
DisadvantagesAdvantagesSensitive Quantitative Less operator dependent
Expensive Radiation Less specific (Breast, diaphragm attenuation)
Special ConsiderationsVery extensive literature on prognosis Applicable to known CAD LBBB (pharmacological) Inadequate stress = nondiagnostic test
Ideal LabIdeal PatientRule-out scenario Intermediate body habitus (Not serial follow-up)
Excellent equipment Excellent analysis Case correlation
MYOCARDIAL PERFUSION IMAGING
Einstein A et al. Circulation 2007;116:1290-1305
Case - cont.
Exercise myocardial perfusion scan: 12min Bruce, 12.8METs, mild dyspnea, 2mm horizontal ST depressions, normal myocardial scintigraphy, left ventricular volumes, and scintigraphy at rest and stress
What Now?
Boiten H et al. J Nuc Card 2016
Case - cont.
Referred for CT coronary angiography
CT CORONARY ANGIOGRAPHY
CT CORONARY ANGIOGRAPHY
DisadvantagesAdvantagesExcellent anatomical information Sensitive & specific Quantitative Less operator dependent
Relatively expensive Radiation Contrast Does not provide functional information
Heart rate-dependent Beta-blocker, NTG pre-treatment
Special Considerations
Ideal LabIdeal PatientBradycardia Rule-out scenario Not previous PCI Not extensive Ca++ (Not serial follow-up)
Excellent equipment Excellent analysis Case correlation
CT CORONARY ANGIOGRAPHY
RANDOMIZED TRIALS IN CARDIOVASCULAR IMAGING
CHALLENGES: ?Study population Core lab vs. community / real life? Indirect association between imaging strategy and outcomes. ?What endpoint
Accuracy? Clinical outcomes? Patient-centred outcomes? Cost-effectiveness?
NEJM 2015;372(14)
NEJM 2015;372(14)
PROMISE STUDY
Lancet 2015;385:9985:2383-2391
J Am Coll Cardiol Img 2011;4:740 –51
J A C C : C A R D I O V A S C U L A R I M A G I N G V O L . 4 , N O . 7 , 2 0 1 1
J A C C : C A R D I O V A S C U L A R I M A G I N G V O L . 4 , N O . 7 , 2 0 1 1
Case - cont.
Agatston (Coronary Artery Calcium) score: 0 “No significant coronary arterial calcification in all three vessels. Minimal noncalcified plaque at the proximal D1 causing less than 30% narrowing of the lumen”
Case - cont.
Agatston (Coronary Artery Calcium) score: 0 “No significant coronary arterial calcification in all three vessels. Minimal noncalcified plaque at the proximal D1 causing less than 30% narrowing of the lumen”
What Now?
What Now?
Reassurance? Medical therapy? Repeat stress testing? Invasive coronary angiography?
What Now?
Reassurance? Medical therapy? Repeat stress testing? Invasive coronary angiography?
Advised to take ASA, statin, ACE-inhibitor… patient declined
6 weeks later…
Conclusions
GXT, Stress Echo, Myocardial Perfusion Imaging and CT coronary angiography are all reasonable initial diagnostic strategies in patients with suspected coronary artery disease. Choice should be informed by patient factors and local resources. Coronary risk can be estimated, but events are difficult to predict. Integration of all clinical data is necessary in formulating a treatment plan.
SUMMARY
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