Potential recommendations for CT coronary angiography in athletes B.K. Velthuis Dept. of Radiology UMC Utrecht, the Netherlands EuroPRevent 15 April 2011
Declaration of interest Philips Medical Systems Software evaluation Presentations
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
Coronary CT Coronary Calcium Score (CCS) CT angiography Asymptomatic athletes Symptomatic athletes Conclusions
Coronary CT Coronary Calcium Score (CCS) CT angiography Asymptomatic athletes Symptomatic athletes Conclusions
Coronary CT Model shows retrospective ECG gating versus prospective ECG gating. Shuman W P et al. Radiology 2008;248:431-437 2008 by Radiological Society of North America
Coronary Calcium Score - CCS Low dose non-contrast prospective scan (1mSv) Agatston score 0 ~ <10 ~ 10-100 ~ 100-400 ~ >400
Coronary Calcium Score - CCS MESA: age, sex and ethnic-matched percentile (>45y) MESA comparable to Heinz Nixdof Recall (HNR) cohort www.mesa-nhlbi.org McClelland RL et al. MESA results. Circ 2006;113:30-37
Coronary Calcium Score - CCS MESA Higher CCS with age men white race McClelland RL et al. MESA results. Circ 2006;113:30-37
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;291:210-215 Copyright restrictions may apply. Greenland P et al. JAMA 2004;291:210-215
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):378-402
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):378-402
Coronary CT Coronary Calcium Score (CCS) CT angiography Asymptomatic athletes Symptomatic athletes Conclusions
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%
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
Coronary CT angiography Meta-analysis 16 studies 960 patients 64-320 detector Dose 2,7 msv (95% CI 2,2 3,2) Patient-level Sensitivity 1.00 (95% CI, 0.98-1.00) Specificity 0.89 (95% CI, 0.85-0.92) 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;154:413-420
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
Coronary CT Coronary Calcium Score (CCS) CT angiography Asymptomatic athletes Symptomatic athletes Conclusions
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; 29:1903-1910
Case: 55 y M asymptomatic marathon runner Screening 6 weeks before participation marathon
Case: 55 y M asymptomatic marathon runner Rest ECG neg T III, avf, V5 + 6, exercise ECG: 2 mm ST
Case: 55 y M asymptomatic marathon runner CCS: Agatston 548, MESA 96 th percentile
Case: 55 y M asymptomatic marathon runner CTA: proximal occlusion RCA CTA - RCA CAG - RCA
Case: 55 y M asymptomatic marathon runner CTA: proximal occlusion RCA CTA - RCA CAG - RCA
Case: 55 y M asymptomatic marathon runner CTA: proximal occlusion RCA - bridging collaterals CTA - RCA CAG - RCA
Case: 55 y M asymptomatic marathon runner CTA: proximal occlusion RCA - distal filling RCA via LCA CTA - LAD CAG - LCA
Case: 55 y M asymptomatic marathon runner CTA: proximal occlusion RCA - distal filling RCA via LCA CTA - LAD CAG - LCA
Case: 55 y M asymptomatic marathon runner Myocardial scintigraphy No ischemia Fixed decrease perfusion inferior wall old infarct?
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
Case: 46 y M asymptomatic tri-athlete CTA (1.3 msv)
Case: 46 y M asymptomatic tri-athlete CAG RCA - pre-pci CAG RCA - post-pci
Coronary CT Coronary Calcium Score (CCS) CT angiography Asymptomatic athletes Symptomatic athletes Conclusions
Case: 15 y M basketball player Acute chest pain while playing basketball
Case: 15 y M basketball player Acute chest pain while playing basketball CAG suspect for coronary anomaly LCA - RAO LCA - LAO
Case: 15 y M basketball player CTA PA Ao
Case: 15 y M basketball player Cardiac MR
Case: 15 y M basketball player LCA reimplanted Normal stress scintigraphy 1 month after reimplantation 1st basketball game 1 month later cardiac arrest -
Case: 33 y M OHCA due to VF in sportgym Double diagnosis aberrant RCA with malignant course Ao PA CTA RCA RCA
Case: 33 y M OHCA due to VF in sportgym Double diagnosis aberrant RCA with malignant course CTA
Case: 33 y M RAO LAO
Case: 33 y M RAO LAO
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
Case: 33 y M Short axis diastolic phase Short axis systolic phase
Coronary CT Coronary Calcium Score (CCS) CT angiography Asymptomatic athletes Symptomatic athletes Conclusions
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)
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
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