Download
rate of obstructive coronary disease in elective diagnostic cath n.
Skip this Video
Loading SlideShow in 5 Seconds..
Rate of Obstructive Coronary Disease in Elective Diagnostic Cath PowerPoint Presentation
Download Presentation
Rate of Obstructive Coronary Disease in Elective Diagnostic Cath

Rate of Obstructive Coronary Disease in Elective Diagnostic Cath

113 Views Download Presentation
Download Presentation

Rate of Obstructive Coronary Disease in Elective Diagnostic Cath

- - - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript

  1. Rate of Obstructive Coronary Disease in Elective Diagnostic Cath Manesh R. Patel, MD Assistant Professor of Medicine Director Cath Lab Research – Duke University Medical Center

  2. Disclosures • Interventional cardiologist • Clinical Cardiovascular MRI and Vascular Ultrasound • Division of Cardiology • Majority of Revenue from cardiovascular imaging • Genzyme • Advisory Board • Chair of Writing Group for ACC/AHA Coronary Revascularization Appropriateness Criteria

  3. The Challenge in Cardiology Practice

  4. Patient Case - Mrs. M • 58 years old with DM • Lives independently • Shops, Cleans, works in bank • 7/08 seen by PCP • Occasional Chest “ache” with walking at grocery store • Cramping in calves • Referred to Duke Cardiology / Vascular Clinic for evaluation

  5. What would you do? • How do you determine risk and identify disease? • What data do you need to determine if invasive angiography and subsequent coronary revascularization will improve here symptoms and/or longevity

  6. Step 1 - How do you decide pre-test probability

  7. Clinical Decision Making - Question 1 • Which is the best model to calculate pretest probability of CAD in this patient? • A. Framingham Risk Score • B. Diamond Forrester Score • C. TIMI UA/NSTEMI Score • D. GRACE Score

  8. Decision Question 2 • Based on the Diamond-Forrester classification, the pretest probability of this patient having CAD is: • Very Low • Low • Intermediate • High

  9. Stratifying patients with Chest pain Intermediate Probability = 10-90% ACC/AHA Chronic Stable Angina Guidelines

  10. Question # 1 • In patients with intermediate pre-test probability of coronary artery disease - what cardiovascular test should be done to diagnose and risk stratify for coronary artery disease?

  11. Imaging Use • Non-invasive cardiac imaging has improved assessment of cardiac function, anatomy, and pathology.

  12. Imaging Use • Medicare spending on imaging services more than doubled from 2000 through 2006 Dollars (billions) 13% annual growth Source: GAO Analysis of Medicare Data, Report GAO-08-452.

  13. How good are we at identifying obstructive CAD? Rate of Obstructive CAD* All ACC-NCDR patients who had cardiac catheterization 1,989,779 patients at 663 sites 60.3% Exclude: Prior MI, PCI, CABG, Cardiac Transplant, Valve surgery 51.7% 1,148,405 patients at 663 sites Exclude: Emergent admission symptoms (AMI and ACS) and cardiogenic shock 36.2% 629,325 patients at 663 sites Exclude: other diagnostic cath indications 37.5% 397,954 patients at 663 sites January 2004-April 2008

  14. Rate of Obstructive CAD • Obstructive CAD • ≥ 50% LM or ≥ 70% Epicardial Vessel • 38% • ≥ 50% Any vessel • 41% • Minimal CAD • < 20% stenosis in any vessel • 39%entire cohort

  15. Obstructive CAD Disease At Cath (NCDR data) • 397,954 patients 2004-2008 without known CAD/MI or prior PCI/CABG undergoing diagnostic cath to R/O CAD • 59% of patients with positive non-invasive tests have no obstructive CAD on invasive angiography (False positive)

  16. Obstructive CAD over time

  17. ACC-NCDR Study • Current risk stratification including non-invasive testing used to inform decisions to perform angiography to identify obstructive CAD need significant improvement