21st Annual Contemporary Therapeutic Issues in Cardiovascular Disease

Transcription

1 21st Annual Contemporary Therapeutic Issues in Cardiovascular Disease 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

2 No Conflict or Disclosure

3 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

4 Coronary Artery Disease

5 Hansson G NEJM 2005;352: Libby P NEJM 2013;368:

6 Libby P, Theroux P, Circulation 2005;111:

7

8 When seeking an answer, begin with the right question

9 Detection vs. Management? Diagnosis vs. Prognosis? Anatomy vs. Function?

10 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

11 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?

12 What Now? Reassurance? Medical therapy? Stress echocardiography? Myocardial perfusion imaging? CT coronary angiography? Invasive coronary angiography?

13 The Ischemic Cascade

14 The Ischemic Cascade

15 The Ischemic Cascade

16 The Ischemic Cascade

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18 Will this information: change health behaviour? change management? Is this investigation: cost effective? worth the risk?

19 Case - cont. Referred for stress echocardiography

20 STRESS IMAGING Rest Stress Exercise Pharmacological

21 STRESS ECHO Rest Stress Exercise Dobutamine

22 STRESS ECHO Advantages Cheap No radiation Specific Disadvantages Operator-dependent Not very sensitive e.g. circumflex ischemia Special Considerations Extensive literature on pre-op evaluation (dobutamine) Poor images = poor accuracy Inadequate stress = nondiagnostic test Challenging when baseline wall motion abnormality

23 STRESS ECHO Ideal Patient Rule-in scenario Interpretable ECG Good image quality Capable of reaching max HR Normal baseline LV function (Serial follow-up) Ideal Lab Direct MD supervision Excellent equipment Excellent sonographer

24 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?

25 Case - cont. Referred for myocardial perfusion imaging

26 MYOCARDIAL PERFUSION IMAGING Rest Stress Exercise Persantine Adenosine

27 MYOCARDIAL PERFUSION Advantages Sensitive Quantitative Less operator dependent IMAGING Disadvantages Expensive Radiation Less specific (Breast, diaphragm attenuation) Special Considerations Very extensive literature on prognosis Applicable to known CAD LBBB (pharmacological) Inadequate stress = nondiagnostic test

28 MYOCARDIAL PERFUSION IMAGING Ideal Patient Rule-out scenario Intermediate body habitus (Not serial follow-up) Ideal Lab Excellent equipment Excellent analysis Case correlation

29 Einstein A et al. Circulation 2007;116:

30 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?

31 Boiten H et al. J Nuc Card 2016

32 Case - cont. Referred for CT coronary angiography

33 CT CORONARY ANGIOGRAPHY

34 CT CORONARY ANGIOGRAPHY Advantages Excellent anatomical information Sensitive & specific Quantitative Less operator dependent Disadvantages Relatively expensive Radiation Contrast Does not provide functional information Special Considerations Heart rate-dependent Beta-blocker, NTG pre-treatment

35 CT CORONARY ANGIOGRAPHY Ideal Patient Bradycardia Rule-out scenario Not previous PCI Not extensive Ca++ (Not serial follow-up) Ideal Lab Excellent equipment Excellent analysis Case correlation

36 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?

37 NEJM 2015;372(14)

38 PROMISE STUDY NEJM 2015;372(14)

39 Lancet 2015;385:9985:

40 J Am Coll Cardiol Img 2011;4:740 51

41 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,

42 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,

43 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

44 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?

45 What Now? Reassurance? Medical therapy? Repeat stress testing? Invasive coronary angiography?

46 What Now? Reassurance? Medical therapy? Repeat stress testing? Invasive coronary angiography? Advised to take ASA, statin, ACEinhibitor patient declined

47 6 weeks later

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50 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.

51 SUMMARY

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