Non-invasive testing for coronary artery disease · FOR CORONARY ARTERY DISEASE Joe Mobley, MD FACC...
Transcript of Non-invasive testing for coronary artery disease · FOR CORONARY ARTERY DISEASE Joe Mobley, MD FACC...
10/9/2019
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NON-INVASIVE TESTING
FOR CORONARY ARTERY
DISEASE
Joe Mobley, MD FACC
Cardiology Consultants PA
October 27, 2019
OBJECTIVES
Review current clinically relevant non-invasive testing
modalities for detecting CAD
Coronary calcium scoring
Exercise stress testing
Stress echo
Stress nuclear
Coronary CT angiography
Strengths, weaknesses, limitations, clinical quirks of each
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Britannica.com
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heartsofjersey.org
ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/
STS 2013 Multimodality Appropriate Use Criteria for
the Detection and Risk Assessment of Stable
Ischemic Heart Disease
A Report of the American College of Cardiology
Foundation Appropriate Use Criteria Task Force, American
Heart Association, American Society of Echocardiography,
American Society of Nuclear Cardiology, Heart Failure
Society of America, Heart Rhythm Society, Society for
Cardiovascular Angiography and Interventions, Society of
Cardiovascular Computed Tomography, Society for
Cardiovascular Magnetic Resonance, and Society of
Thoracic Surgeons
Michael J. Wolk, Steven R. Bailey, John U. Doherty,
Pamela S. Douglas, Robert C. Hendel, Christopher M.
Kramer, James K. Min, Manesh R. Patel, Lisa
Rosenbaum, Leslee J. Shaw, Raymond F. Stainback and
Joseph M. Allen
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WHICH TEST FOR WHICH PERSON?
Pretest Probability
History and Physical Exam!!!
Baseline EKG
Baseline medications
Ability to walk
History of prior non-invasive testing
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ebm.bmj.com
NONINVASIVE TESTING FOR CAD
Asymptomatic Patients
Coronary Calcium Scoring
Symptomatic Patients
Exercise Stress Testing
Stress Echo
Stress Nuclear Perfusion Imaging
Coronary CT Angiography
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CORONARY CALCIUM SCORING
Risk stratification tool in asymptomatic patients with
intermediate risk by traditional risk factor evaluation
Low cost
Low radiation
Can be diagnostic for CAD in a previously
undiagnosed and asymptomatic patient
Can change goals for risk factor modification if
abnormal
prweb.com
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clevelandclinic.org
dicardiology.com
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i0.wp.com
CORONARY CALCIUM SCORING
Does not tell you anything about degree of active ischemia or degree of stenosis, only presence/absence of underlying CAD and the volume of plaque
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SYMPTOMATIC PATIENTS OR ASYMPTOMATIC
PATIENTS WITH HIGH RISK CLINICAL FINDINGS
Non-invasive
Functional
Anatomic
Invasive
FUNCTIONAL TESTING FOR CAD
Stress testing
Stress EKG
Stress echo
Stress SPECT/PET
Stress MRI
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CONTRAINDICATIONS TO STRESS TESTING
Acute MI within 2 days
Pharmacologic Nuclear stress
Unstable angina
Uncontrolled arrhythmia
VT, Atrial fibrillation, etc
Severe symptomatic aortic stenosis
Decompensated CHF
Active Endocarditis/Myocarditis/Pericarditis
Acute aortic dissection
Acute PE
Acute noncardiac conditions that are not stable
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veteranshealthlibrary.gov
Treadmill Stress Test
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STRESS ECHO
Exercise
Pharmacologic Stress
Dobutamine
No radiation
Lower cost
Quick and easy with right equipment and personnel
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STRESS NUCLEAR
SPECT and PET tracers
Exercise
Pharmacologic stress
Dobutamine
Vasodilator (Regadenoson, Adenosine, Persantine)
Higher cost
More time consuming
More costly
Radiation
Useful in patients who cannot walk, cannot be titrated off rate lowering
meds, or have baseline indecipherable EKGs (LBBB, LVH, WPW, marked
baseline STT changes)
STRESS NUCLEAR
Best studied stress imaging modality
Certainly the most quantitative
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ANATOMIC NON-INVASIVE EVALUATION
Coronary CT Angiography
Higher Cost
Contrast
Radiation exposure
More technically difficult
Sinus, controlled Heart Rate, Cooperative,
and able to hold their breath for 8-10 seconds
Zhonghua et al, QIMS Volume 4, Number 5, October 2014, 2223.
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amberusa.com
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helio.com
JACC 2005;46;147-154
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THE FUTURE: PLAQUE IMAGING
Vulnerabe Plaque
CTA – most accepted currently
MRA
Nuclear
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annals.org
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researchgate.net
CONCLUSIONS
CAD is an enormous public health issue
Noninvasive testing preferable when feasible to limit procedural risk and
cost
Numerous options for noninvasive testing based on patient history and
symptoms
Asymptomatic
Symptomatic
Functional
Anatomic
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