Chest pain. One problem different approaches... Question 1 what is your choice? In-/Exclusion Criteria

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1 Chest pain Die letzten relevanten Studien, praktische Umsetzung: Bildgebung Michael J. Zellweger, Universitätsspital Basel, Kardiologische Klinik; 6y old male patient Atypical angina Pretest probability of CAD 53% Question 1 what is your choice? One problem different approaches... a. My first choice is anatomical testing (CTCA) b. My first choice is functional testing (ergometry or stress imaging) c. My first choice is invasive coronary angiography (still the gold- standard) Oculo stenotic community hemodynamic community Atherosclerosis/ stenosis Ischemia, scar In-/Exclusion Criteria 1

2 PROMISE Trial Design Symptoms suspicious for significant CAD Requiring non-emergent noninvasive testing Baseline characteristics 1:1 Randomization 1, patients Stratified by site and intended functional test Anatomic strategy Functional strategy 64+ slice CTA Exercise ECG or exercise imaging Pharmacologic stress imaging Tests read locally; Results immediately available Subsequent testing/management by site care team, per guidelines Minimum follow-up 12 months Outcome in PROMISE Conclusions n=13 Symptomatic No prior CAD Age 61±8y Pretest prob 53% Question 2 PROMISE a promise? Question 3 what is your interpretation? a. This study is useful for my daily practice a. The choice of the non-invasive test does not matter b. This study doesn t add much for my daily practice b. Let s make it easier and use more cath c. Let s use a patient tailored approach 2

3 Why didn t the study demonstrate any difference? The overall event rate was very low (death rate 1.5%). The benefit of revascularization in stable CAD patients is overestimated The follow-up was too short They did not use the most recent techniques... Da steh ich nun, ich armer Tor, und bin so klug als wie zuvor. Johann Wolfgang von Goethe Non-invasive testing in suspected SCAD with intermediate PTP A patient tailored approach a. Consider age of patient versus radiation exposure. b. In patients unable to exercise use echo or SPECT/PET with pharmacologic stress instead. c. CMR is only performed using pharmacologic stress. d. Patient characteristics should make a fully diagnostic coronary CTA scan highly probable (see section ) consider result to be unclear in patients with severe diffuse or focal calcification. e. Proceed as in lower left coronary CTA box. This slide corresponds to Figure 2 in the full text f. Proceed as in stress testing for ischaemia box. It s about the individual needs It s not primarily about the methods... 3

4 anatomy 6 prevention anatomy function 4 6 Silent prevention Symptoms therapy Rb-PET CT Calciumscore 269 4

5 Rb-Pet Perfusion Extent of abnormality by PET and prognosis Dorbala et al. J Am Coll Cardiol Img 29;2: A courageous and deeper look Myocardial ischemia and coronary flow reserve n=2783 n=314 Courage trial Boden et al. N Engl J Med 27;356 Shaw et al. Circulation 28;117: Murthy et al. Circulation. 211;124: Conclusions What do I need to know for the patient s best benefit? A patient tailored approach Complimentary roles of different techniques It s not only about pathologic or not (e.g. ischemia) but also about the extent of the abnormality michael.zellweger@usb.ch 5