Malaysian Healthy Ageing Society

Transcription

1 Organised by: Co-Sponsored: Malaysian Healthy Ageing Society

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3 CAD INVESTIGATIONS PHYSIOLOGICAL / FUNCTIONAL VS ANATOMICAL / STRUCTURAL

4 Disclosure iheal medical centre is a one stop cardiac centre with facilities for Angioplasty and CABG ANATOMICAL OR STRUCTURAL (invasive angiography and prearranged IVUS, noninvasive CT angiogram and Ca score) PHYSIOLOGICAL OR FUNCTIONAL assessment (invasive wireless FFR, non invasive exercise treadmill ECG test, dobutamine and exercise stress echo, CT myocardial perfusion scan)

5 How Good is Good Old Clinical Skills? Depends on EXPERIENCE (different sn and sp) Physical examination- to exclude other Dx Typical Angina pain History, Risk factors Limitation-silent ischemia, high pain threshold

6 Prevalence of CAD (%) in Symptomatic Patients According to Age and Sex Typical angina Atypical angina Non anginal pain AGE Men Women Men Women Men Women False Positive of 3 criteria 2 of 3 criteria 1 of 3 criteria 1) Retrosternal discomfort. 2) Provoked by exercise or stress. 3) Relieved by rest or NTG False Negative

7 Good Tests- Risk Vs Benefit Risk Wrong diagnosis Side effects Invasive High cost Benefit Early Diagnosis Improve outcome-px & QOL Improve compliance

8 Ideal Test- Risk Vs Benefit Accurate= outcome measure no or low risk, non-invasive, low cost, no discomfort, fast, convenient

9 Bayesian Theory The reliability and predictive accuracy of any test/ clinical skill is defined not only by its sensitivity and specificity but also by the prevalence of disease in the population under study. Disease No Disease Positive Test TP FP Negative Test FN TN Sensitivity = TP / (TP + FN) Specificity = TN / (TN + FP)

10 Dr + Pt s Objective for IHD Basic aim = Live long, good QOL (no symptom) NO AMI, NO heart failure, NO sudden death To achieve the above Control IHD risk factors (smoking, BP, DM, lipids) Compliance to Lifestyle changes and Medications Early detection and treatment of subclinical disease

11 SCARY 70% Heart attack Are Caused by MINOR Blockage < 50% NOT SEEN by traditional methods (EST, angiogram) Pooled data from 4 studies: Ambrose et al, 1988; Little et al, 1988; Nobuyoshi et al, 1991; and Giroud et al, (Adapted from Falk et al.) Falk E et al, Circulation, 1995.

12 Concept of Vulnerable Plaque and Plaque burden Most ACS from plaque erosion Concept of vulnerable plaque- TCFA thin fibrous cap large necrotic/lipid core Currently no good test to detect this (may be IVUS)

13 Vulnerable Plaque = prone to thrombosis/ rupture but also at risk for rapid progression 70% of ACS culprit lesions 30% of ACS culprit lesions Naghavi et al. Circulation 2003;108: Gossl M et al. Med Clin N Am 2007;91:

14 Thin Cap Fibroatheroma (TCFA) Virmani R et al. JACC 2006 Most common type of VP Area narrowing <75% (diameter stenosis <50%) in over 75% 3 characteristics = necrotic core, thin cap, intimal inflammation Necrotic Lipid Core Fibrous Cap Intimal Inflammation >10% area of the plaque 3mm 2 in 75% of case Length; 2-17mm (mean 8mm) <65 um Mean cap thickness+2sd of ruptured plaque Macrophage infiltration >25 cells/0.3mm diameter

15 New Methodologies to Detect VP Not proven with outcome studies!! 1. MRI 2. Coronary CT 3. Conventional gray-scale IVUS 4. Angiography 5. OCT 6. Thermography 7. VH-IVUS 8. NIR,..

16 Physiological- Inducible ischemia a person is significantly more likely to die or have a (MI) if they have a lesion causing inducible ischemia than if they do not. % Average Annual Hard Events (Death or MI) in > Patients Iskander S, et al J. Am. Coll. Cardiol. 16 Normal Abnormal Treating a ischemic lesion with a stent there, has high probability that this will relieve the patient s symptoms, improve quality of life and potentially reduce long-term risk of events. Pijls et al. J Am Coll Cardiol 2007;49:

17 Physiological Cascade Rest-Stress with Physical or Drugs Only useful if > 70% block FFR-Stress Invasive OCT MRI / CT stress perfusion (5 msv) Nuclear-Stress (10-12 msv) Echo -Stress ECG- Stress Symptoms = Natural-stress Non Invasive

18 Anatomical cascade (Detect blockages from 20%- 100%) OCT Post Mortem IVUS Histology Angiogram Ca Score Cardiac CTA Non Invasive IVUS -VH Invasive

19 Show me the Evidence Basic aim = Live long, good QOL (no symptom) NO AMI, NO heart failure, NO sudden death Can this test help? To achieve the above Control IHD risk factors (smoking, BP, DM, lipids) Compliance to Lifestyle changes and Medications Early detection and treatment of subclinical disease

20 Coronary flow- Autoregulation The only way to meet increasing demand is to increase blood flow

21 Coronary reserve Flow reduces with > 50 % stenosis at stress Able to maintain resting flow until 80 % stenosis

22 Fractional Flow Reserve (FFR) Definition of FFR: Maximum achievable blood flow in stenotic coronary artery divided by Maximum blood flow in the same artery without stenosis

23 What is FFR (Fractional Flow Reserve)? Aorta coronary artery Myocardium P a P d Q normal Max. Hyperemia=STRESS Normal perfusion pressure 100 P d 0 P a Q stenosis Stenotic perfusion pressure Q stenosis Stenotic perfusion press. P d FFR = = = Q normal Normal perfusion press. P a

24 FFR threshold for ischemia No ischemia Yes ischemia FFR MEDICAL Rx REVASCULARISATION- PCI/CABG FFR < 0.75 inducible ischemia (spec. 100 % ) REVASCULARISATION FFR > 0.75 no inducible ischemia (sens. 90 % ) MEDICAL Rx FFR Strengths FFR is not influenced by changes in blood pressure, heart rate, or contractility FFR has a unique normal value of 1.0 in every patient and every coronary artery FFR incorporates the contribution of collateral flow to myocardial perfusion DEFER study, Bech et al, Circulation 2001 Pijls, De Bruyne et al, NEJM 1996

25 Coronary Blood Flow

26 Intermediate branch, hyperemia pull-back LAD branch, hyperemia pull-back

27 The FAME Study Patient with lesions 50% in at least 2 of the 3 major epicardial vessels (1005 patients) Indicate all lesions 50% amenable for stenting Randomization Angiography-guided PCI Stent all indicated stenoses Exclusion criteria: LM disease, Previous CABG MI < 5 days, unless Cardiogenic shock Pregnancy, Life expectancy < 2 years FFR-guided PCI Measure FFR in all arteries with 1 stenosis Stent only those stenoses with FFR year follow-up

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29 Angiographic vs. Functional Severity of Coronary Stenosis ~20% FFR ~35% Stenosis classification by angiography Of 509 pts with angiographically-defined MVD, 46% had functional MVD Tonino PAL et al. NEJM 2009;360:213 24

30 iheal wireless FFR Wire Receiver PressureWire PressureWire Receiver Hemodynamic recording system Recording system front end P2 AO-transducer P1

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32 Anatomical cascade (Detect blockages from 20%- 100%) OCT Post Mortem IVUS Histology Angiogram Ca Score Cardiac CTA Non Invasive IVUS -VH Invasive

33 False Negative Angiography IVUS vs. Angiography Am J Cardiol 2002;89(suppl):24B-31B

34 Adv: Coronary Calcium 5 mins, Radiation No contrast used Typically < 1 msv, Mammogram 0.7 or 0.8 ms, Nuclear perfusion (10-12m SV) Disadv: Does not define stenosis, not functional, no LVF Clinical benefit If CaSc 0, significant coronary disease is very unlikely (NPV ~ 97%) The higher the CaSc, the more likely a significant stenosis Alters therapeutic goal (LDL, BP, Diabetes etc) Improve Compliance (Adherence)

35 Ca score >1 is not normal

36 48yo man with Ca score of 0 (NPV ~ 97%)

37 Ca score and outcome

38 IT took them > 20 years to accept it as a good test!!!

39 CCTA: Outcome Prognosis Min et.al.eur.heart Jn 2010

40 CCTA: Outcome Prognosis 517/541 pts with an interpretable MSCT, 158 (31%) CAD ( 50% stenosis), 168 (33%) abnl MPI (SSS 4), 439 FU mean 672 days: 2 cardiac death, 8 MI, 6 noncardiac deaths, 7 hospitalizations van Werkhoven et al. JACC 2009; 53:

41 Min, JACC 2011

42 Prognostic value of CCTA extends the at-risk paradigm in non- obstructive coronary stenosis >6-fold higher mortality for patients with 3-vessel mild CAD Increased risk of death for non-obstructive CAD even in pts with low FRS or no medically modifiable CAD RF Min, JACC 2011

43 Ideal Test- Risk Vs Benefit Accurate= outcome measure no or low risk, non-invasive, low cost, no discomfort, fast, convenient

44 Physiological Cascade Rest-Stress with Physical or Drugs Only useful if > 70% block FFR-Stress Invasive OCT MRI / CT stress perfusion (5 msv) Nuclear-Stress (10-12 msv) Echo -Stress ECG- Stress Symptoms = Natural-stress Non Invasive-

45 Anatomical cascade (Detect blockages from 20%- 100%) OCT Post Mortem IVUS Histology Angiogram Ca Score Cardiac CTA Non Invasive IVUS -VH Invasive- Dr Wong Dr Wong Teck Teck Wee Wee

46 心脏病发作 Heart Attack 多种危险因素, 家族史 ROOTS=Risk Factor Control 心脏衰竭 Heart Failure 猝死 Sudden death

47 Take Home Messages: Revascularization Choice for CAD Heart Team approach - (Interventionalist, CT Surgeon and Cardiologist) is needed to make the optimal recommendation for advanced/complex stable CAD; choice to improve survival vs. improve QOL/symptoms. Pt s choice will ultimately prevail Physiological FFR guided selective PCI of significant lesions in presence of multi-lesions, may help to limit stent usage, yet improve long-term outcomes without causing any harm

48 My algorithm Asymptomatic screening if significant risk factors, > 40 yo Symptomatic - Semi typical = Ca score + stress echo, CT angiogram Symptomatic typical = Invasive angiogram, FFR only for intermediate lesion 50-70%

49 Thank You Please Enjoy the next talk: Dr. Francisco Lee Dr. Seidensticker Tan Dr. Bennett Wong

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