Mortality Incidence of Patients With Non-Obstructive Coronary Artery Disease Diagnosed by Computed Tomography

AngiographyNaser Ahmadi, MD, Vahid Nabavi, MD, Fereshteh Hajsadeghi, MD, Ferdinand Flores, BS,

William J. French, MD, Song S. Mao, MD, David Shavelle, MD, Ramin Ebrahimi, MD, Matthew Budoff, MD

American Journal of Cardiology 2011;107:10-16

Presented By:Spencer Peterson MSIII

Mercer University School of Medicine

June 27, 2011

Level B Class 1 Study

• Purpose: Investigate long-term outcomes of patients with non-obstructive CAD on the basis of plaques

• Design/Method: Prospective observational analysis of 3,499 symptomatic CAD subjects in California. 1,102 of which had non-obstructive CAD (luminal stenosis 1-49%), mean age 59+/-14years and 69.9%men were followed for a mean 78+/-12 months

• Exclusions: irregular heart rate, allergies to contrast media, previously known CAD, liver disease, and impaired renal function

• Main Outcome: predicting all-cause mortality in symptomatic individuals with non-obstructive CAD independent of age, gender, and conventional risk factors.

• Limitations: single center, use of all-cause mortality instead of cardiac events, electron beam angiography used when other radiological options are available and radiation exposure consideration.

Coronary Artery Calcium

As Revealed by CTA

CAC Score and Events

http://www.lewrockwell.com/sardi/sardi126.html

Increased CAC = Increased Event Rate

CAC Increases with Age in Men

http://www.rockymountainmedicalimaging.com/PreventiveImaging/HeartScan.aspx

Conclusion

Death rate increased with the severity of CAC. Death rate increased incrementally from calcified plaque(1.4%) to mixed plaque(3.3%) to non-calcified plaque(9.6%) as well as from single to triple vessel disease. The presence and quality of plaque identified by CTA can be used as a predictor in all-cause mortality in symptomatic non-obstructive CAD.

Comment

• Although many patients with symptomatic non-obstructive CAD are able to be D/C’ed home without significant intervention at the time of presentation. This study demonstrates an important predictive value of mortality that can directly relate to the patient’s prognosis. Further studies need to be applied to more regions and more advanced technology should be used with reduced amounts of radiation exposure.

Diagnostic Value of Coronary Artery Calcium Scoring in Low-Intermediate Risk Patients

Evaluated in the Emergency Department for Acute Coronary Syndrome

Leticia Fernandez-Friera, MD, Ana Garcia-Alvarez, MD, Fatemeh Badheriannejad-Esfahani, MD, Waqas Malick, BS, Jesus G. Mirelis, MD, Simonette T. Sawit, MD, Valentin Fuster, MD,

PhD, Javier Sanz, MD, MarioJ. Garca, MD, Luke K. Hermann, MDAmerican Journal of Cardiology 2011;107:17-23

Funding: Instituto de Formacion e Investigacion “Marques de Valdecilla,” the Spanish Society of Cardiology, and Centro Nacional de Investigacion Cardiovascular

Presented By:Spencer Peterson MSIII

Mercer University School of Medicine

June 27, 2011

Level A Class IIa Study

• Purpose: Determine the diagnostic utility of CACS (coronary artery calcium scoring) in low to intermediate risk patients presenting to emergency departments with chest pain and non-diagnostic ECG and cardiac enzyme markers.

• Design/Method: Retrospective study from March 2007 to January 2009 in 225 patients in ED with suspected acute coronary syndrome.

• Exclusions: CAD >50%stenosis and/or previous coronary revascularization

• Main Outcome: CACS providing independent and incremental information to give predictive value in determining prognosis of patients at risk for CAD.

• Limitations: few number of patients underwent coronary angiography and thus severity of CAD not confirmed. CCTA also tends to overestimate actual prevalence of CAD. Prevalence of disease may vary in different geographic regions.

CACS Results

• Of the 225 cases studied for CAD:

• Negative Predictive Value: 99%

• Sensitivity: 91%

• Specificity: 64%

• Positive Predictive Value: 20%

TIMI Score

Comparing Sensitivities and

Specificities

• Detecting Acute Coronary Syndrome Using Cardiac MRI: Prospective Study Using MRI to Detect ACS

Conclusion

CACS has a high negative predictive value similar to that of stress testing without any clinical contraindication (like a-fib, heart defects, or need for contrast). It is inexpensive, faster, simpler, and more available than many other imaging techniques and involves about 10% of the radiation that CCTA does. It is an effective tool in providing additional diagnostic value in ACS.

Comment

• The results of this study and many others show that CACS can be used in formulating a diagnosis and prognosis for patients presenting with ACS, but its limitations to only providing a high negative predictive value limit its use in providing clinical intervention outside of discharging the patient. Although p value was significant, the power of the study was low. A cost analysis needs to accompany this study.

Where Physicians Can Impact CAD

http://healthpromotionadvocates.org/resources/briefing_doc.htm