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John L. Tan, MD, PhD North Texas Heart Center Presbyterian Hospital of Dallas. Testing for Coronary Artery Disease. Cardiovascular Disease Mortality Trends United States: 1979-2002. Deaths in Thousands. Year. Source: CDC/NCHS. . Leading Causes of Death United States: 2002.

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john l tan md phd north texas heart center presbyterian hospital of dallas
John L. Tan, MD, PhD

North Texas Heart Center

Presbyterian Hospital of Dallas

Testing for Coronary Artery Disease
slide2

Cardiovascular Disease Mortality Trends

United States: 1979-2002

Deaths in Thousands

Year

Source: CDC/NCHS.

slide3

Leading Causes of Death

United States: 2002

Deaths in Thousands

A Total CVD (Preliminary)

B Cancer

C Accidents

D Chronic Lower Respiratory Diseases

E Diabetes Mellitus

F Alzheimer’s Disease

Source: CDC/NCHS

rate of myocardial infarctions
Rate of Myocardial Infarctions

Number (Annual)

Myocardial Infarction

Heart and Stroke Statistical Update. 2002.

lifetime risk of cad
Lifetime Risk of CAD

Lifetime Risk (%)

Age (Years)

Lloyd-Jones, DM et al. 1999. Lancet. 353:89

growing prevalence of cad
Growing Prevalence of CAD
  • Larger pool
    • Population is growing older
  • Greater Risks
    • Increasing incidence of

Obesity

Diabetes

Metabolic Syndrome

Hypertension

who are at risk
Who Are at Risk?

How Can We Identify Them?

the framingham score for risk prediction
The Framingham Score for Risk Prediction

Risk:

Low <10%

Intermediate 10-20%

High >20%

Greenland and Gaziano, NEJM, 2003

framingham risk score
Framingham Risk Score

50 year-old man

Total cholesterol 240

Non-smoker

HDL 40

SBP 140 mm Hg

Framingham Risk Score

10-year Risk

6

4

0

1

1

12

10% (Intermediate)

framingham risk score10
Framingham Risk Score

45 year-old woman

Total cholesterol 240

Smoker

HDL 50

SBP 140 mm Hg

Framingham Risk Score

10-year Risk

3

8

7

0

3

21

14% (Intermediate)

limitations of the framingham risk score
Limitations of the Framingham Risk Score
  • Family History of Premature CAD
  • CRP Levels
  • Metabolic Syndrome
slide13

Mortality Rates in Adults with

Metabolic Syndrome

NHANES II: 1976-80 Follow-up Study

13 years average follow-up.

Source: Circulation 2004;110:1245-50.

initial assessment
Initial Assessment
  • Framingham Risk Score
  • Family History of Premature CAD
  • CRP Levels
  • Presence of the Metabolic Syndrome

(High triglycerides, Glucose Intolerance, Central Adiposity)

  • Presence of Diabetes
now what
Now What?

“Fear of God”

Modify Risk Factors

Further Risk Stratify

available tests to detect cad
Available Tests to Detect CAD
  • Stress ECG
  • Stress Imaging Study
  • Ultra-fast CT (EBCT)
  • CT Angiography
  • Coronary Angiography
initial considerations
Initial Considerations
  • Symptomatic versus Asymptomatic
  • Diagnosis versus Prognosis
  • Assessment of Risk for CV mortality
  • Physiological/Functional versus Anatomical
clinical classification of chest pain
Clinical Classification of Chest Pain

Typical Angina (definite)

(1) Substernal chest discomfort with a characteristic quality and

duration that is (2) provoked by exertion or emotional stress and

(3) relieved by rest or nitroglycerin

Atypical Angina (probable)

Meets 2 of the above characteristics

Noncardiac Chest Pain

Meets one or none of the typical angina characteristics

ACC/AHA ACP-ASIM Guidelines for Chronic Stable Angina, 1999

pretest likelihood of cad in symptomatic patients percent with significant cad on catheterization
Pretest Likelihood of CAD in Symptomatic Patients: Percent with significant CAD on catheterization

Nonanginal

Chest Pain

Atypical

Angina

Typical

Angina

Age, yrs

Men

Women

Men

Women

Men

Women

30-39 4 2 34 12 76 26

40-49 13351 22 87 55

50-59 20765 319373

60-69 27 14 72 519486

ACC/AHA ACP-ASIM Guidelines for Chronic Stable Angina, 1999

clinically useful bench marks of exercise capacity
Clinically Useful Bench Marks of Exercise Capacity

1 MET Basal activity level (3.5 ml O2 comsumed/Kg/min

< 5 METs Associated with a poor prognosis in patients <65 y/o

5 METs Marks the limit of ADLs, usual limit immediate post MI

10 METs Considered average level of fitness

In patients with angina, no mortality benefit CABG vs

medical Rx

13 METs Good prognosis in spite of any abnormal exercise test

response

18 METs Aerobic master athelete

22 METs Achieved by well-trained competitive atheletes

four year mortality rates with abnormal ett effects of exercise capacity
Four-year Mortality Rates with Abnormal ETT: Effects of Exercise Capacity

4-year Mortality Rates (%)

Weiner, et al, JACC, 1984

exercise parameters associated with advanced cad or poor prognosis
Exercise Parameters Associated with Advanced CAD or Poor Prognosis

1. Duration of ETT <6.5 METS (<5 METS for women)

2. Exercise HR <120 bpm off b-blockers

3. Ischemic ST segment change at HR <120 bpm or <6.5

METS

4. ST segment depression >2 mm, especially in multiple

leads

5. ST segment depression for >6 min in recovery

6. Decrease in BP during exercise

survival according to risk groups based on duke tm scores
Survival According to Risk Groups Based on Duke TM Scores

Risk Group, Score % of Total Survival Mortality, %

Low (5 or greater) 62 0.99 0.25

Moderate (-10 to 4) 34 0.95 1.25

High (-10 or less) 4 0.79 5.0

Duke TM Score = Exercise time - (5 x ST deviation) - (4 x Treadmill angina)

ACC/AHA ACP-ASIM Guidelines for Chronic Stable Angina, 1999

meta analysis of exercise testing
Meta-analysis of Exercise Testing

Number of Sensitivity Specificity Predictive

Grouping Studies (%) (%) Accuracy (%)

Standard exercise test 147 68 77 73

Without MI 58 67 72 69

Without workup bias 3 50 90 69

With ST depression 22 69 70 69

Without ST depression 3 67 84 75

With digoxin 15 68 74 71

Without digoxin 9 72 69 70

With LVH 15 68 69 68

Without LVH 10 72 77 74

Overall ~70 ~80

ACC/AHA Guidelines for Exercise Testing, 1997

the ischemic ladder
The “Ischemic Ladder”

Angina

ECG

Changes

Systolic

Dysfunction

MVO2

Diastolic

Dysfunction

Time

stress imaging studies
Exercise

Dobutamine

Adenosine

(Persantine)

Echocardiography

Perfusion Imaging

Nuclear Scan

Thallium Scan

Sestamibi Scan

Hybrid Scan

MRI

Stress Imaging Studies

Stress Modalities

Imaging Modalities

sensitivity and specificity of cad studies
Sensitivity and Specificity of CAD Studies

Procedure Sensitivity (%) Specificity (%)

Exercise Test 68 77

Stress Echo 76 88

SPECT 88 77

Lee and Boucher. 2001. NEJM. 344:1840

advantages of stress echocardiography
Advantages of Stress Echocardiography

1. Higher specificity

2. Versatility: more extensive evaluation of

cardiac anatomy and function

3. Greater convenience/efficacy/availability

4. Lower cost

advantages of stress myocardial perfusion imaging
Advantages of Stress Myocardial Perfusion Imaging

1. Higher technical success rate

2. Higher sensitivity, especially for one-vessel disease

3. Better accuracy in evaluating possible ischemia

when multiple rest LV wall motion

abnormalities are present

4. More extensive published database, especially in

evaluation of prognosis

patients without symptoms
Patients without Symptoms

High Grade Stenoses

Diabetics

Non-flow Limiting Disease

abnormal perfusion scans in asymptomatic diabetics
Abnormal Perfusion Scans in Asymptomatic Diabetics

% Abnormal Stress Perfusion Scan

A DIAD Study (Wackers et al. 2004. Diabetes Care. 27:1954)

B Rajagopalan et al. (Rajagopalan et al. 2005. J Am Coll Cardiol. 45:43)

C Cedars-Sinai Group (Zellweger et al. 2004. Eur Heart. 25:543)

yield of high risk scans in asymtomatic diabetics
Yield of High-Risk Scans in Asymtomatic Diabetics

Q waves on ECG 43%

Abnormal ECG 26%

Peripheral Vascular Disease 28%

LDL >100 mg/dl 20%

Two or more risk factors 17%

Subgroup

High-risk Scans

Rajagopalan et al. 2005. J Am Coll Cardiol. 45:43

screening of cad ada recommendations
Screening of CAD: ADA Recommendations

In asymptomatic diabetic patients with:

  • Abnormal resting ECG (MI or ischemia)
  • Peripheral vascular disease
  • Two or more additional CAD risk factors
patients without symptoms41
Patients without Symptoms

Mild CAD Not Detectable

by Stress Testing

myocardial infarctions and plaque severity
Myocardial Infarctions and Plaque Severity

Burke et al. NEJM. 1997. 336:1276

Myocardial Infarctions (%)

2/3

1/6

1/6

Plaque Severity

outcomes with mild cad
Outcomes with Mild CAD

TIMI Trials Meta-analysis

% Death or Non-fatal MI

1-year follow-up

5 year incidence of coronary death
5-Year Incidence of Coronary Death

%

n=763

n=274

n=377

MONICA Belgian Substudy

Stenosis by Angiography

available tests to detect cad45
Available Tests to Detect CAD
  • Stress ECG
  • Stress Imaging Study
  • Ultra-fast CT (EBCT)
  • CT Angiography
  • Coronary Angiography
coronary calcium scoring
Coronary Calcium Scoring

Greenland and Gaziano, NEJM, 2003

incremental value of coronary calcium scoring to risk assessment
Incremental Value of Coronary Calcium Scoring to Risk Assessment

Greenland et al, JAMA, 2004

sensitivity and specificity of cad studies48
Sensitivity and Specificity of CAD Studies

Procedure Sensitivity (%) Specificity (%)

Exercise Test 68 77

Stress Echo 76 88

SPECT 88 77

EBCT 80-90 40-50

population versus individual risk
Population versus Individual Risk

“Treating the Herd”

multi detector computed tomography mdct
Multi-Detector Computed Tomography (MDCT)
  • Increased slices per gantry rotation

(currently 64 slices)

  • Faster gantry speed (330 ms/rotation)

resulting in:

          • better spatial resolution (0.4 mm)
          • better temporal resolution (165 ms)
coronary angiography with mdct
Coronary Angiography with MDCT

Fuster V, et al. J Am Coll Cardiol. 2005. 46:1209

coronary angiography with mdct54
Coronary Angiography with MDCT

Raff, et al. J Am Coll Cardiol. 2005. 46:552

64 slice ct angiography per segment analysis
64-Slice CT Angiography: Per Segment Analysis

Sensitivity (%) Specificity (%) PPV (%) NPV (%)

Leschka, et al 94 97 87 99

Leber, et al 80 97 NR* NR*

Raff, et al 86 95 66 98

Pugliese, et al 99 96 78 99

Mollet, et al 99 95 76 99

*NR Not Reported

Leschka, et al. Eur Heart J. 2005. 26:1482; Leber, etl al. J Am Coll Cardiol 2005. 46:147

Raff, et al. J Am Coll Cardiol. 2005. 46:552; Pugliese, et al. Eur Radiol. 2005 16:1

Mollet, et al. Circulation 2005. 112(15):2318

64 slice ct angiography per patient analysis
64-Slice CT Angiography: Per Patient Analysis

Sensitivity (%) Specificity (%) PPV (%) NPV (%)

Raff, et al 86 95 66 98

Pugliese, et al 100 90 96 100

Raff, et al. J Am Coll Cardiol. 2005. 46:552

Pugliese, et al. Eur Radiol. 2005 16:1

detection of soft plaque by ct angiography
Detection of “Soft” Plaque by CT Angiography

Fuster V, et al. J Am Coll Cardiol. 2005. 46:1209

indications for mdct angiography of the heart
Indications for MDCT Angiography of the Heart
  • Facilitation of the diagnostic cardiac evaluation of a patient with chest pain syndrome (e.g. chest pains, anginal equivalent, angina). Depending on the clinical presentation, the MDCT for coronary artery evaluation may precede a perfusion stress test, or it may be used to clarify a perfusion stress test that is non-diagnostic, equivocal, or is inadequate in explaining the patient’s symptoms.
  • Facilitation of the management decision of a symptomatic patient with known coronary artery disease. (e.g. post-stent, post CABG) when the results of the MDCT may guide the decision for repeat invasive intervention.
  • Assessment of suspected congenital anomalies of coronary circulation or great vessels.
radiation exposure of cad studies
Radiation Exposure of CAD Studies

Dose (mSv)

Background (per year) 3.5

Chest X-ray 0.1

CT of Chest 5-7

Procedure

EBCT ~1

Perfusion Imaging ~10

CT Angiography ~10

Coronary Angiography ~2-3

Conti, CR. Clin. Cardiol. 2005. 28:450

Morin RL, et. al. Circulation. 2003. 107:917

sensitivity and specificity of cad studies60
Sensitivity and Specificity of CAD Studies

Procedure Sensitivity (%) Specificity (%)

Exercise Test 68 77

Stress Echo 76 88

SPECT 88 77

(40-60% of patients have attenuation defects)

EBCT 80-90 40-50

MDCT (per patient analysis)

16-Slice 85-100 75-86

64-Slice 86-100 90-95

invasive coronary angiography
Invasive Coronary Angiography
  • ~25% of angiograms performed annually in the US are normal
  • ~8 million angiograms are performed annually in the US at a cost of ~$4,000 per procedure
invasive coronary angiography62
Invasive Coronary Angiography
  • Therefore, there are ~2 million angiograms performed annually on patients with normal coronary arteries
  • These procedures expose patients to the inherent risks of invasive coronary angiography at a cost of ~ $4 billion per year
summary
Summary
  • The incidence and prevalence of CAD is

growing due to aging of the population

and to increases in risk factors.

  • Global clinical assessment, CRP levels,

and calcium scoring may help to further

stratify individual risks.

summary64
Summary
  • Stress testing currently remains the

standard for assessing symptoms.

  • Although a negative stress study most

likely excludes the presence of flow-

limiting disease (stenosis of >70%), it

does not exclude the presence of mild to

moderate disease.

summary65
Summary
  • Mild to moderate disease still confers an

increase in coronary deaths and

infarctions.

  • Invasive coronary arteriography has been

the only method of identifying patients

with mild to moderate disease up to now.

summary66
Summary
  • CT angiography will allow for the non-

invasive identification of at-risk patients

as having (or not having) underlying

coronary atherosclerosis.

summary67
Summary
  • Exercise Test
    • Probable more than we do
  • Stress Echocardiogram
    • Lower pre-test probablility population
    • Valvular or other structural heart disease
summary68
Summary
  • Stress Perfusion Scan
    • Higher pre-test probability population
  • Cardiac MRI
    • When above unhelpful and expertise is available
summary69
Summary
  • Ultra-fast CT (EBCT)
    • No role in symptomatic patients
  • CT Angiography
    • Will play larger role with ability to image coronaries (Triple Rule Out)
  • Coronary Angiography
    • When stress testing is potentially dangerous