Munich, 15-17 October 2014 JUSTIFICATION OF THE USE OF COMPUTED TOMOGRAPHY FOR INDIVIDUAL HEALTH ASSESSMENT (IHA) OF ASYMPTOMATIC PEOPLE Eugenio Picano CNR, Institute of Clinical Physiology Pisa, Italy
The detection of coronary artery calcification on electron beam computed tomography (EBCT) and its quantitative expression with the CAC Score seems to be an important predictor of atherosclerotic disease and events AGATSTON CALCIUM SCORE
Coronary Artery Calcium Score All-cause survival in 4474 men and 3219 women with >1 risk factor by EBCT coronary calcium measurements
Normal coronary arteries LAD stenosis Fig. 3 Agatston Score <100 Agatston Score >400
Risk vs Benefit: The code of appropriateness Fig. 1 B>>>R I (appropriate indication) B>>R IIa (probably appropriate) B R IIb (possibly appropriate) R B III (inappropriate) AHA-ACC-ESC Guidelines 2007
Why When How
The pathophysiology reasons of screening Symptoms Pain Exercise-ECG test Stress echo Stress scintigraphy MDCT IMT Endothelial Dysfunction ECG Function Malperfusion Coronary anatomy and wall structure Epicardial Coronary Artery Normal 0% 20% 50% 75% 90% 100% Patients status Well Worried well Suspected sick Sick Very sick Sickest of the sick Timeline 30 40 60 70 80 Years
The political reasons of screening The early diagnosis is always to be recommended, in every case. (Livia TURCO, Health Minister of the Prodi cabinet) La Repubblica, 4 April 2007 This screening test likely exposed Mr Obama to significant radiation unnecessarily, increasing his risk of future cancer. Redberg R. First Physical. Arch Intern Med. 2010;170:583
The screening : the money factor Certi dottori, disse Kojo, pagandoli il giusto ti fanno qualunque cosa hungry. (La fame che abbiamo) 2005 Dave Eggers. How we are Some doctors are capable to do everything to you if you pay enough Non so se hai capito bene, Guido. Non è necessario che il cliente che mi mandi abbia davvero bisogno di una radiografia. Basta che ne abbia bisogno secondo te. E il bello è che il cliente paga ed è soddisfatto. G. D Agata, Il medico della mutua. Feltrinelli, Milano, 1964 It is not necessary that your patient really needs the exam, it is enough that he or she needs it according to you. The nice thing about it is that the patient pays and is also happy with it. Più esami fai, più il paziente è contento
Why When How
Indication to stress echo and competing techniques in symptomatic subjects
Indication to stress echo and competing techniques in asymptomatic (without symptoms or ischemic equivalent) subjects
Use of coronary computed tomography angiography for the diagnosis of stable coronary artery disease
Why When How
The radiation issue in For each clinical scenario, tests that impact ionizing radiation will be performed by labs that have adopted contemporary doseradiation techniques. Wolk MJ, et al.. J Am Coll Cardiol. 2014;63:380-406 Education, justification, and optimization are the cornerstones to enhance the radiation safety of medical imaging. Limiting the use of imaging to appropriate clinical indications can ensure that the benefits of imaging outweigh any potential risks. The continually expanding repertoire of techniques that allow high quality imaging with lower radiation exposure should be used when available to achieve safer imaging. Fazel R et al, Circulation, 4 November 2014. A scientific Statement of American Heart Association The actual delivered dose should always be recorded and included in patients records. Because of the numerous sources of variability, there is no threshold between acceptable and unacceptable exposure for any given examination, but the dose that is not even considered is certainly unacceptable. Picano E, et al. Eur Heart J. 2014;35:665-72
Reduction in Radiation SAME TECHNOLOGY Marraccini P et al. Acta Radiol. 2014;54:42-7 NEW TECHNOLOGY
The pandemics of inappropriateness CCT (250 cases) CXr (250 cases) PCI (250 cases) CA (250 cases) Appropriate Partially inappropriate Inappropriate Carpeggiani C et al. PLoS One. 2013;8:e81161
Take-home message X-rays and gamma-rays used in radiology and nuclear medicine are proven (class 1) carcinogens, and cardiologists should make every effort to give the right imaging exam, with the right dose, to the right patient. The priority given to radioprotection in every cardiology department is an effective strategy for primary prevention of cancer, a strong indicator of the quality of the cardiology division, and the most effective shielding to enhance the safety of patients, doctors, and staff. A smart cardiologist cannot be afraid of the essential and often life-saving use of medical radiation, but must be very afraid of radiation unawareness.