PALAIS DES CONGRES DE VICHY. 20 au 22 Juin 2019 TESTING IN PATIENTS WITH SUSPECTED CAD: CCTA PERFORMS BETTER THAN FUNCTIONAL TESTS? Dr L. MACRON, Dr J. FEIGNOUX, Dr J-L. SABLAYROLLES Centre Cardiologique du Nord (CCN). Saint-Denis. France.
PATIENTS WITH SYMPTOMS SUGGESTIVE OF CORONARY ARTERY DISEASE (CAD) NON INVASIVE DIAGNOSTIC TEST = RISK STRATIFICATION NON INVASIVE STRESS TEST LOW RISK HIGH RISK INVASIVE CORONAY ANGIOGRAPHY ( ± REVASC)
PATIENTS WITH SYMPTOMS SUGGESTIVE OF CORONARY ARTERY DISEASE (CAD) ? 1. EXISTE T’IL UNE CORONAROPATHIE? 2. QUELLE EST LA SÉVÉRITÉ DE LA CORONAROPATHIE? 3. FAUT-IL INTRODUIRE UN TRAITEMENT MEDICAL? 4. FAUT-IL REVASCULARISER CE PATIENT?
2014 ESC/EACTS Guidelines on myocardial revascularization
Pre-test likelihood of CAD according to the updated Diamond-Forrester risk model score ESC guidelines 2013 on the management of stable CAD
ASSESSMENT OF PTP: HOW FAR WE ARE FROM… CONFIRM registry Observed vs Expected Prevalence of coronary stenosis >50% . Overall population: 18% vs 51% . Atypical angina: 15% vs 47% . Typical angina: 29% vs 86%
ACCURACY OF STRESS TESTING FOR DETECTING OBSTRUCTIVE CAD Arbab-Zadeh. Heart International 2012; vol 7:e2 Results from: Underwood et al. Eur J Nucl Med Mol Imaging 2004 – Gianrossi et al. Circulation 1989 – Fleischmann et al. JAMA 1998 – Geleinjnse et al. J Am Soc Echocardiogr 2009 Se 80-90% ; Sp 70-80% (stress test with imaging)
ESC guidelines 2013 on the management of stable CAD
From Patel et al. N Engl J Med 2010. 362; 10 83.9% of NIT prior ICA = LOW DIAGNOSTIC YIELD OF ELECTIVE ICA
CCTA DIAGNOSTIC VALUE Arbab-Zadeh. Heart International 2012 Results from the Meta-analysis of Paech et. BMC Cardiovasc Disord 2011including 3,674 symptomatic patients without history of coronary artery disease enrolled in 28 studies. 97-99% 64-83% 42-81% 94-99% From Marwick et al. JACC 2015 “A CT-based approach can effectively rule out anatomic CAD”
CCTA PROGNOSTIC VALUE No CAD-specific events in the group of normal CCTA n=9592pts; median follow-up 20 months Hulten et al. JACC 2011
CCTA PROGNOSTIC VALUE Annual event rate 0.16% normal CCTA ≈ background event rate among healthy low-risk individuals No CAD-specific events in the group of normal CCTA Hulten et al. JACC 2011
PROGNOSTIC VALUE OF STRESS TESTING Arbab-Zadeh. Heart International 2012; vol 7:e2 Results from: Navare et al. J Nucl Cardiol 2004 – Metz et al. JACC 2007 – Peteiro et al. Am Heart J 2006 – Bangalore et al. J Am Soc Echocardiogr 2007 10M stress tests/year in the US 70% normal test ≈ 18%MI and CV death/10y. 7M normal stress tests/year AER 1% after normal test 70000 MI and cardiac death/year AFTER A NORMAL STRESS TEST
HIGH RISK FOR CARDIAC EVENTS DESPITE NORMAL STRESS TEST NORMAL SPECT >2% AER if CAC>400 Chang SM JACC 2009; Arbab Zadeh Circulation 2014
“Absence d’ischémie myocardique au cours d’une épreuve d’effort maximale négative”
CCTA PROGNOSTIC VALUE Event rate ≈ 4% for CCTA obstructive similar to abnormal SPECT Hulten et al. JACC 2011
CCTA PROGNOSTIC VALUE Non obstructive CAD ≈ 1% death/MI per year Hulten et al. JACC 2011
CCTA PROGNOSTIC VALUE Annualized event rate 1% for NON-OBSTRUCTIVE CAD ≈ normal stress test BENEFITS OF CCTA vs. STRESS TESTING 1.Categorization of no CAD, non-obstructive CAD and obstructive-CAD 2.Identification of a subgroup (38%) of patients who are at exceedingly low risk of adverse events (No CAD) 3.Identification of a subgroup (34%) of patients who may benefit from medical treatment
RISK STRATIFICATION IN SUSPECTED CAD : THE PARADIGM OF ISCHEMIA ? Schwitter J. Eur Heart J 2011 INCREASE IN CARDIAC DEATH/MYOCARDIAL INFARCTION AS A FUNCTION OF ISCHEMIA IS IT REALLY ISCHEMIA THAT CONFERS RISK OF ADVERSE EVENTS?
HIGH RISK FOR CARDIAC EVENTS DESPITE NORMAL STRESS TEST NORMAL SPECT >2% AER if CAC>400 Chang SM JACC 2009; Arbab Zadeh Circulation 2014
RISK STRATIFICATION IN SUSPECTED CAD : THE PARADIGM OF ATHEROSCLEROTIC BURDEN
RISK STRATIFICATION IN SUSPECTED CAD : THE PARADIGM OF ATHEROSCLEROTIC BURDEN MORTALITY is strongly related to PRESENCE/EXTENT of CAC CV EVENTS are strongly related to PRESENCE/EXTENT of CAD Adapted from Budoff et al. JACC 2009 Ostrom et al. JACC 2008
RISK STRATIFICATION IN SUSPECTED CAD : THE PARADIGM OF ATHEROSCLEROTIC BURDEN >10 000 pt. ICA >3 000 pt. CCTA. Median FU 3.6y Events: CV death, MI, HF, stroke Extensive non-obstructive = at least 4 segments
RISK STRATIFICATION IN SUSPECTED CAD : THE PARADIGM OF ATHEROSCLEROTIC BURDEN
« anatomic burden was a consistent predictor of death, MI, and NSTE-ACS, whereas ischemic burden was not » Mancini et al JACC CV interv. 2014 Ischemic burden Anatomic burden
Low event rate (1.05%/y) Short follow-up (>12 months; median 25 months) Fewer ICA without obstructive CAD . CCTA + >>> 72.1% obstructive CAD . Functional test + >>> 47.5% obstructive CAD = HIGHER ACCURACY for CCTA Lower radiation exposure compared to SPECT group (12.0 ± 8.4 mSv vs. 14.1 ± 7.6 mSv) Lower MI rates (borderline statistical significance)
Lancet. June 2015 n = 4142 patients Diagnosis of CHD: 27% reclassification Changes in investigations: 15% Changes in treatments: 23% 38 % reduction in fatal and non fatal MI (1.7y follow up – p=0.0527) ≈ 50% reduction CV event rate at 3 years follow up (1.7 vs 2.5%) Fordyce, C.B. et al. J Am Coll Cardiol. 2016
Median FU: 8y - Similar rates of ICA & revasc. 41% MI reduction CCTA vs UC
“64-slice (or above) for all patients”
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