Potential recommendations for CT coronary angiography in athletes

Transcription

1 Potential recommendations for CT coronary angiography in athletes B.K. Velthuis Dept. of Radiology UMC Utrecht, the Netherlands EuroPRevent 15 April 2011

2 Declaration of interest Philips Medical Systems Software evaluation Presentations

3 Introduction Regular exercise reduces cardiovascular disease (CVD) Extreme exercise increases short-term risk of cardiovascular events Coronary atherosclerosis main cause of exercise-related CV events > 40 y

4 Coronary CT Coronary Calcium Score (CCS) CT angiography Asymptomatic athletes Symptomatic athletes Conclusions

5 Coronary CT Coronary Calcium Score (CCS) CT angiography Asymptomatic athletes Symptomatic athletes Conclusions

6 Coronary CT Model shows retrospective ECG gating versus prospective ECG gating. Shuman W P et al. Radiology 2008;248: by Radiological Society of North America

7 Coronary Calcium Score - CCS Low dose non-contrast prospective scan (1mSv) Agatston score 0 ~ <10 ~ ~ ~ >400

8 Coronary Calcium Score - CCS MESA: age, sex and ethnic-matched percentile (>45y) MESA comparable to Heinz Nixdof Recall (HNR) cohort McClelland RL et al. MESA results. Circ 2006;113:30-37

9 Coronary Calcium Score - CCS MESA Higher CCS with age men white race McClelland RL et al. MESA results. Circ 2006;113:30-37

10 Coronary Calcium Score - CCS Figure 1. Predicted 7-Year Event Rates From COX Regression Model for CHD Death or Nonfatal Myocardial Infarction for Categories of FRS or CACS The rates are stratified by 4 levels of Framingham Risk Score (FRS) and 4 levels of the coronary artery calcium score (CACS). Greenland, P. et al. JAMA 2004;291: Copyright restrictions may apply. Greenland P et al. JAMA 2004;291:

11 Coronary Calcium Score - CCS CCS improves risk stratification prevent clinical disease and improve outcome CCS screening still controversial do not know which approach is best Overdiagnosis majority CCS >400 remain asymptomatic next 5 yrs anxiety Cannot predict significant stenosis ACCF/AHA 2007 Expert Consensus on CAC. JACC 2007;49(3):

12 Coronary Calcium Score - CCS Recommendations for CCS Asymptomatic persons with intermediate risk Reclassify higher risk and modify pat. management Symptomatic patients with low risk Exclude obstructive CAD in stable pts (NPV 98%) Unclear role of serial CCS for progression Higher risk if > 15% progression / year ACCF/AHA 2007 Expert Consensus on CAC. JACC 2007;49(3):

13 Coronary CT Coronary Calcium Score (CCS) CT angiography Asymptomatic athletes Symptomatic athletes Conclusions

14 Coronary CT angiography Better delineation of Total atherosclerotic burden Non-calcified plaques (1% in asymptomatic pop.) Stenosis and positive remodelling High negative predictive value 0% CV event rate CCS > 400 Overestimates stenosis Many segments inconclusive Can exclude significant stenosis in < 10%

15 Coronary CT angiography CT requirements Prospective ECG triggering At least 64 detector CT HR <65-70 bpm Metoprolol PO or IV Contrast contraindications Renal dysfunction Shot 1 Contrast allergy Shot 1 Less interpretable with very high calcium Shot 2 3 msv Shot 3 Shot 2

16 Coronary CT angiography Meta-analysis 16 studies 960 patients detector Dose 2,7 msv (95% CI 2,2 3,2) Patient-level Sensitivity 1.00 (95% CI, ) Specificity 0.89 (95% CI, ) Pooled vessel- + segment-level Lower sens. and higher spec. than patient-level Potential alternative if clinical suspicion of CAD Van Ballmoos MW et al. Ann Intern Med 2011;154:

17 Coronary CT angiography Recommendations No clear role for screening asymptomatic patients Possible if ECG / XECG abnormal Symptomatic stable patients Exclude obstructive CAD in low-intermediate group Excellent NPV to rule out CAD / significant stenosis

18 Coronary CT Coronary Calcium Score (CCS) CT angiography Asymptomatic athletes Symptomatic athletes Conclusions

19 Essen Marathon Study 108 male marathon runners > 50 y + > 5 marathons All low-risk FRS 36% with CCS 100 = to age-matched males, however much lower FRS to FRS-matched (low-risk) males (22%) All 4 coronary events in CCS 100 group (10%) 12% LGE on MRI associated with higher CAC score Regular marathon running Beneficial effect on CV risk profile (FRS) Underestimation CCS and CV event rate Möhlenkamp S, et al. EHJ 2008; 29:

20 Case: 55 y M asymptomatic marathon runner Screening 6 weeks before participation marathon

21 Case: 55 y M asymptomatic marathon runner Rest ECG neg T III, avf, V5 + 6, exercise ECG: 2 mm ST

22 Case: 55 y M asymptomatic marathon runner CCS: Agatston 548, MESA 96 th percentile

23 Case: 55 y M asymptomatic marathon runner CTA: proximal occlusion RCA CTA - RCA CAG - RCA

24 Case: 55 y M asymptomatic marathon runner CTA: proximal occlusion RCA CTA - RCA CAG - RCA

25 Case: 55 y M asymptomatic marathon runner CTA: proximal occlusion RCA - bridging collaterals CTA - RCA CAG - RCA

26 Case: 55 y M asymptomatic marathon runner CTA: proximal occlusion RCA - distal filling RCA via LCA CTA - LAD CAG - LCA

27 Case: 55 y M asymptomatic marathon runner CTA: proximal occlusion RCA - distal filling RCA via LCA CTA - LAD CAG - LCA

28 Case: 55 y M asymptomatic marathon runner Myocardial scintigraphy No ischemia Fixed decrease perfusion inferior wall old infarct?

29 Case: 55 y M asymptomatic marathon runner Screening 6 weeks before participation marathon Abnormal rest and X-ECG Extensive atherosclerosis on CCS and CTA RCA occlusion with good collaterals Scintigraphy: no ischemia, old infarct Treatment Medical treatment Advised not to participate in marathon Normal undemanding exercise permitted

30 Case: 46 y M asymptomatic tri-athlete CTA (1.3 msv)

31 Case: 46 y M asymptomatic tri-athlete CAG RCA - pre-pci CAG RCA - post-pci

32 Coronary CT Coronary Calcium Score (CCS) CT angiography Asymptomatic athletes Symptomatic athletes Conclusions

33 Case: 15 y M basketball player Acute chest pain while playing basketball

34 Case: 15 y M basketball player Acute chest pain while playing basketball CAG suspect for coronary anomaly LCA - RAO LCA - LAO

35 Case: 15 y M basketball player CTA PA Ao

36 Case: 15 y M basketball player Cardiac MR

37 Case: 15 y M basketball player LCA reimplanted Normal stress scintigraphy 1 month after reimplantation 1st basketball game 1 month later cardiac arrest -

38 Case: 33 y M OHCA due to VF in sportgym Double diagnosis aberrant RCA with malignant course Ao PA CTA RCA RCA

39 Case: 33 y M OHCA due to VF in sportgym Double diagnosis aberrant RCA with malignant course CTA

40 Case: 33 y M RAO LAO

41 Case: 33 y M RAO LAO

42 Case: 33 y M OHCA due to VF during sportgym training Double diagnosis aberrant RCA with malignant course HCM ICD Short axis diastolic phase Short axis systolic phase

43 Case: 33 y M Short axis diastolic phase Short axis systolic phase

44 Coronary CT Coronary Calcium Score (CCS) CT angiography Asymptomatic athletes Symptomatic athletes Conclusions

45 Conclusions Asymptomatic athletes CCS - conform general population No clear role for CCS in all athletes Intermediate risk group Older athletes with extreme exercise (marathon) CCS / CTA Abnormal ECG / X-ECG Suspected coronary anomaly (consider MRA < 40y)

46 Conclusions Symptomatic athletes Typical angina complaints No clear role for CCS / CTA Low to intermediate probability Possibly CCS + CTA if atypical complaints Fatigue, training level (also consider MRI) Middle aged-women Always both CCS and low dose CTA > 40 y CTA if suspected coronary anomaly

47 End