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Role of MSCT and MRI in High Risk Patients

Role of MSCT and MRI in High Risk Patients. Tadeusz Przewłocki, Piotr Klimeczek, Mieczysław Pasowicz. Institute of Cardiology, Collegium Medicum Jagiellonian University John Paul II Hospital in Krakow. Risk of Cardiovascular Incidence. Multiple atherosclerosis risk factors

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Role of MSCT and MRI in High Risk Patients

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  1. Role of MSCT and MRIin High Risk Patients Tadeusz Przewłocki, Piotr Klimeczek, Mieczysław Pasowicz Institute of Cardiology, Collegium Medicum Jagiellonian University John Paul II Hospital in Krakow

  2. Risk of Cardiovascular Incidence • Multiple atherosclerosis risk factors • Stable coronary artery disease • Acute coronary syndrome • Post myocardial infarction • Multilevel atherosclerosis required revascularization

  3. Multiple atherosclerosis risk factors High risk patients: • 10 years death risk ł 5% by Risc Score • At least one very strong risk factor (TC ł 320 mg/dl, LDL-C ł 240 mg/dl, BP ł 180/110) • DM t. II or t. I with microalbuminuria ESC guidelines ATP III guidelines • 10 years risk of CAD > 20 % (PAOD, aortic aneurysm, supraaortic arteries disease, DM, at least 2 other atherosclerosis risk factors)

  4. High risk group

  5. Stable Coronary Artery Disease No definite risk stratification guidelines however Patients with stable angina and: • Proven myocardial ischemia at low work load • Exercise induced ventricular arrhythmia or complex severe ventricular arrhythmia • EF < 40 % and / or worsening of heart failure • Recurrent angina following coronary revascularization Should be considered as high risk patients

  6. Acute Coronary Syndrome STEMI – Morrow scale NSTEMI - Antman Scale, ESC Guidelines D/MI/UR by 14 Days (%); p<0,001 2 for trend Points 60 1. Age > 65 2. ł3 CAD Risk Factors 3. Known CAD (stenosis ł50%) 4. ASA use in past 7 days 5. Recent (<24H) secere angina 6. ST deviation ł 0.5 mm 7.  Cardiac Markers RISK SCORE = Total Points 1 1 1 1 1 1 1 (0-7) 50 40,9 40 30 26,2 19,9 20 13,2 8,3 4,7 10 0 0/1 2 3 4 5 6/7 Risk Score

  7. Post myocardial infarction patient • Severe or progressive angina • EF < 40 % • Significant ischaemia in non-invasive evaluation (stress test, scintigraphy) • Ventricular tachycardia or complex ventricular arrhythmia Modified ACC AHA Guidelines

  8. Age-standardized mortality in diabetic and non-diabetic individuals Mortality per 1000 person-years WOMEN MEN Diabetes mellitus Non-diabetic Diabetes mellitus Non-diabetic All heart disease Ischaemic heart disease Other heart disease All heart disease Ischaemic heart disease Other heart disease Gu et al. Diabetes Care 1998, 21: 1138-1145

  9. SMC Proliferation Inflammation Vasoconstriction Thrombosis • NO  NF-kB •  AP-1 •  Cytokines •  Chemokines  NO  Endothelin-1  NO  Endothelin-1 • NO  Tissue Factor • Prostacyclin Endothelial Dysfunction in Diabetes Diabetes Mellitus Hyperglycaemia Excess Free Fatty Acids Insulin Resistance Endothelial Dysfunction SMCMigration • Protein Kinase C  NO Atherogenesis Restenosis Illustration based on: Beckman JA et al JAMA 2002, 287: page 2572

  10. Atherosclerosis in diabetics • Greater plaque volume - contains more macrophages • (Kornowski i wsp. – Int. J. Cardiovasc. Interv. 1999, 2, 13, Moussa JACC 1999,33,78A) • Lack of the positive remodelling in coronary arteries • (Vavuranakis i wsp. – Eur. H. J. 1997, 18, 1090, Kornowski i wsp. – AJC 1998, 81, 298) • Insufficiently developed collateral circulation • (Abaci i wsp., Circulation 1999, 99, 2239) • More frequently thrombus andulcerated plaques • (Silva i wsp. Circulation 1995, 92, 1731) P.R. Moreno et al Circ 2000; 102:2180-2184 Diabetes No Diabetes

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