Evaluation of Suspected CAD in 2011 Nader M. (Nader) Banki, MD - - PowerPoint PPT Presentation

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Evaluation of Suspected CAD in 2011 Nader M. (Nader) Banki, MD - - PowerPoint PPT Presentation

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RWC Physicians Conference Evaluation of Suspected CAD in 2011 Nader M. (Nader) Banki, MD Xiushui (Mike) Ren, MD March 4, 2011 Disclosure of Relevant Financial Relationships Under the ACCME Standards for Commercial Support, everyone who

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SLIDE 1

RWC Physicians’ Conference

Evaluation of Suspected CAD in 2011 Nader M. (Nader) Banki, MD Xiushui (Mike) Ren, MD

March 4, 2011

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SLIDE 2

Disclosure of Relevant Financial Relationships

  • Under the ACCME Standards for Commercial Support, everyone who is in

a position to control the content of an education activity must disclose all relevant financial relationships with any commercial interest. A “commercial interest” includes any proprietary entity producing health care goods or services, with the exemption of non-profit or government

  • rganizations and non-health care related companies. A financial

relationship is relevant if it pertains to the activity’s content matter including any related health care products or services to be discussed or presented.

  • Drs. Banki and Ren have disclosed that they have no relevant

relationships with commercial or industry organizations. The CME Department has reviewed their disclosure information for the planner(s) and/or committee/faculty for this program and they do not have relationships that present a relevant conflict of interest.

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Outline

  • Indications for

“stress testing”

  • Contraindications
  • Testing modalities
  • Including CTA
  • Test selection
  • Cases
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SLIDE 4

Indications

  • Suspected CAD
  • Pre-operative
  • Pulmonary hypertension
  • DOE
  • Valvular heart disease
  • Viability
  • Risk stratification
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SLIDE 5

Indications: Suspected CA

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SLIDE 6

Bayes’ Theorem

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SLIDE 7

Indications: Suspected CA

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SLIDE 8

Indications: Suspected CA

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SLIDE 9

Contraindications

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SLIDE 10

Evaluation of Suspected CAD (symptomatic)

  • Treadmill ECG
  • Stress Echo
  • Exercise
  • Dobutamine
  • Myocardial perfusion (nuclear)
  • Exercise
  • Persantine
  • CTA
  • Coronary angiography (invasive)
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SLIDE 11

Evaluation of Suspected CAD

  • Functional:
  • Treadmill ECG
  • Stress Echo
  • Myocardial perfusion
  • Anatomic
  • CTA
  • Coronary angiography
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SLIDE 12

Treadmill ECG

  • Exercise: preferred if possible
  • Treadmill
  • Good for detecting ischemia and arrhythmia
  • Cheap
  • Readily available
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SLIDE 13

Treadmill ECG

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SLIDE 14

Stress Echo and Outcomes

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SLIDE 15

Stress Echo

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SLIDE 16

MPI and Outcomes

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SLIDE 17

MPI

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SLIDE 18

MPI

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SLIDE 19

Test Performance

  • Stress echo:
  • Sensitivity = 85%
  • Specificity = 77%
  • Stress MPI:
  • Sensitivity = 87%
  • Specificity = 64%
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SLIDE 20

Bayes’ Theorem

  • The probability of a patient having the

disease after a test is performed depends

  • n pretest probability and the test

characteristics

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SLIDE 21

Bayes’ Theorem

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SLIDE 22

Bayes’ Theorem

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Bayes’ Theorem

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SLIDE 24

Bayes’ Theorem

Use Clinical Judgment!

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RWC Case #1

  • 56 year old female with a history of hypertension, dyslipidemia,

fibromyalgia and chronic L-sided upper chest pain who reports 3 months mid-chest burning with exertion.

  • What is her pre-test probability of obstructive CAD?
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SLIDE 26

Bayes’ Theorem

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SLIDE 27

RWC Case #1

  • Treadmill Test:
  • 6:55 Bruce Protocol
  • chest burning at peak exercise
  • 1mm horizontal ST depression
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SLIDE 28

Invasive Coronary Angiography

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SLIDE 29

Invasive Coronary Angiography

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SLIDE 30

RWC Case #2

  • 43 y.o. woman without CAD risk factors

presents with 2 week history of sharp chest pain lasting 1-2 min

  • ECG is normal
  • What is the pre-test probability?
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SLIDE 31

Bayes’ Theorem

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SLIDE 32

RWC Case #2

  • Treadmill test:
  • 8 min on Bruce protocol
  • Borderline ST depressions
  • Equivocal test
  • Stress thallium was (-) for ischemia
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RWC Case #3

  • 43 year old male smoker with h/o dyslipidemia presents to ED with 1-2 week

history of chest pain with and without exertion

  • Ruled out for MI in ED, EKG normal
  • What is his pre-test probability of obstructive CAD?
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SLIDE 34

Bayes’ Theorem

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SLIDE 35

RWC Case #3

  • Same-day treadmill test
  • 4:20 seconds Bruce Protocol (7.0 METs)
  • 118 bpm (66% of MPHR)
  • Normal blood pressure response
  • Chest pain after 2 minutes
  • No ischemic ST-T changes were noted
  • Referred for CT angiogram
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SLIDE 36

Coronary CT Angiography

LV RV

LAD

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SLIDE 37

Invasive Coronary Angiography

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SLIDE 38

Cardiac CT Invasive Angiography

RWC Case #3

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SLIDE 39

PCI of the LAD

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Coronary CT Angiography

  • Non-invasive diagnostic imaging test

using CT technology and contrast to diagnose the presence and severity of coronary artery disease

  • Significant improvement in diagnostic

accuracy because of increase in detector rows from 4 to 16 to 64

  • High negative predictive value (NPV)
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Coronary CT Angiography

  • 28 studies (>2,400 patients) evaluating the sensitivity and specificity coronary

artery disease (>50% stenosis) in CTA when compared with coronary angiography

  • Sensitivity: 99%
  • Specificity: 89%
  • PPV: 93%
  • NPV: 100%
  • Mowatt G., Heart 2008 94; 1386-1393
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Coronary CT Angiography

  • Indications:
  • Equivocal stress test
  • Symptomatic patients with an intermediate probability of obstructive

CAD

  • Young patient prior to valve surgery
  • Anomalous coronary artery
  • Avoid when:
  • No symptoms
  • CKD (GFR<60)
  • Atrial fibrillation or frequent PAC’s/PVC’s
  • Pregnant
  • Dye hypersensitivity
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SLIDE 43

Coronary CT Angiography

  • Experience at Kaiser RWC
  • 64 slice CT scanner
  • First CTA in 2007
  • >200 CTA’s performed
  • Preparation:
  • Renal Function <30 days prior to scan
  • Hold Metformin 48 hours prior
  • Metoprolol 25mg the night before and 50mg morning of scan
  • Prior to Scan
  • 18 gauge iv started in antecubital vein of L arm
  • +/- iv metoprolol at time of scan
  • SL NTG
  • 90 cc of contrast
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Coronary CT Angiography

  • >9,000 patients who underwent coronary CTA
  • Followed for 20 months
  • Endpoints
  • Major adverse cardiac events
  • Death
  • MI
  • Revascularization
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SLIDE 45

Coronary CTA- Prognosis

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SLIDE 46
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Radiation Exposure

  • Experimental and epidemiologic evidence show strong link between low-

dose ionizing radiation and solid cancers and leukemia

  • Medical uses of radiation are the largest source exposure to public
  • Measured in sieverts (Sv)
  • Unit of ionizing radiation absorbed
  • Attempts to reflect the biological effect rather than the physical

aspects

  • Background radiation in one year (3mSv)
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Radiation

  • Retrospective study of >950,000 patients enrolled in United Health Care
  • Utilization data were used to estimated:
  • cumulative effective dose
  • 3 year study period
  • NEJM 2009;361:849-57
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SLIDE 49

Radiation

  • Background

Radiation: 3 mSv/year

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SLIDE 50

Radiation

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Radiation Exposure

  • Shuman, W,Radiology 248;2:431-37
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SLIDE 52

RWC Case #4

  • 76 year old male with known CAD with a history of NSTEMI in

July 2009 -> stent placement to the LAD and LCx who reports:

  • 3 months of non-exertional L shoulder and upper arm

discomfort

  • What is his pre-test probability of obstructive CAD?
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Bayes’ Theorem

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SLIDE 54

RWC Case #4

  • Referred for treadmill EKG test
  • Bruce Protocol
  • 6 minutes
  • L arm pain and diaphoresis
  • 130/90 mmHg (rest)  96/70 mmHg at peak exercise
  • 1 mm ST segment elevation in the inferior leads
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SLIDE 55

Invasive Coronary Angiography

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SLIDE 56

Safety of Stress Echo

  • Exercise > dipyridamole > DSE

1/6,574 1/557 N=85,997 1/1,294

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SLIDE 57

RWC Case #5

  • 92 year old active female with a h/o CAD, s/p CABG x 3 in 1980

who lives alone presented to the ED with 12 hours of chest

  • pressure. No improvement with sl ntg or asa.
  • Ruled out for MI in ED, EKG normal; cxr normal
  • What is her pre-test probability of obstructive CAD?
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SLIDE 58

Bayes’ Theorem

90-99

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SLIDE 59

RWC Case #5

  • Same-day treadmill test
  • 9:30 seconds on modified Bruce Protocol (4.6 METs)
  • 128 bpm (100% of MPHR)
  • Normal blood pressure response
  • Pt did not report cp or dyspnea with exercise
  • Non-specific st-t changes that did not meet criteria for ischemia
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SLIDE 60

RWC Case #5

  • She presented to the RWC ED about two weeks later with recurrent chest

pain and nausea

  • EKG showed changes consistent with acute posterior ST segment elevation MI
  • Heart Alert activated; patient taken urgently to RWC cath lab
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SLIDE 61

Invasive Coronary Angiography

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SLIDE 62

Invasive Coronary Angiography

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Case Discussion

  • Why was this patient’s treadmill test negative?
  • Non-obstructive disease (true negative)
  • Obstructive disease (false negative)
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Stress Testing in CABG patients

  • Exercise echo and coronary angiography performed in 182 CABG patients
  • JACC 1995;25:1019-23
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Stress Testing in CABG Patients

“The exercise ECG has a number of limitations after coronary bypass surgery. Resting ECG abnormalities are frequent, and if an imaging test is not incorporated in the study, more reliance must be placed on symptom status, hemodynamic response, and exercise capacity. Because of these considerations, together with the need to document the site of ischemia, stress imaging tests are more favored in this group, although there are insufficient data to justify recommending a particular frequency of testing.”

  • ACC/AHA 2002 Guideline Update for Exercise Testing
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SLIDE 66

Plaque Rupture

  • Circulation. 1995 Aug 1;92(3):657-71.

86%

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SLIDE 67

Plaque Rupture

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Subclinical Coronary Atherosclerosis

  • How do we identify patients who may have subclinical (non-
  • bstructive) coronary artery disease?
  • Framingham Risk Score (FRS)
  • Age
  • HTN
  • Sex
  • Dyslipidemia
  • Smoker
  • Diabetic
  • FRS calculates a 10 year risk of death of MI
  • Low <10%
  • Intermediate 10-20%
  • High >20%
  • Wilson PW. Prediction of coronary heart disease using risk factor
  • categories. Circulation. 1998; 97 : 1837-47
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SLIDE 69

Coronary Calcium Score

  • Limited CT scan to assess calcification of coronary arteries
  • Coronary calcification is marker of atherosclerosis
  • 1-2 mSv (plain film lumbar spine)
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SLIDE 70

Coronary Calcium Score

  • High sensitivity for CAD but low specificity for obstructive CAD
  • Incremental predictive value over Framingham risk score
  • Indication:
  • Asymptomatic
  • Intermediate FRS (10-20% 10 year risk)
  • 60 year old non-smoking male with:
  • Hypertension
  • Total cholesterol 190
  • HDL 40
  • LDL 125
  • FRS: 11% (10 years) or 1.1 % in 1 year
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SLIDE 71

Coronary Calcium Score

  • ACCF/AHA 2007 Clinical Expert Consensus on Coronary

Artery Calcium Scoring

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SLIDE 72

Conclusions

  • Functional versus anatomic
  • Obstructive CAD versus the presence of CAD
  • Bayes’ theorem and intermediate risk
  • Treadmill test is safe and effective and should be first-line

in appropriate patients

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Conclusions

  • CT Coronary Angiography
  • Radiation
  • CABG patients consider stress testing with imaging
  • Framingham Score
  • Intermediate risk population consider coronary

calcium score

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Bonus Clinical Case

  • 51 year old asymptomatic obese female with DM II referred for persantine

SPECT (stress test) for “pre-op evaluation for bariatric surgery.”

  • Is pre-operative cardiac stress test indicated?
  • Results
  • A mildly abnormal study with:

1) small reversible area (ischemia) over the anteroseptal wall 2) a fixed area (infarct) over the inferolateral wall 3) normal left ventricular (LV) systolic function

  • Referred for cardiac CT because of abnormal SPECT
  • 1) Normal coronary arteries