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The Efficacy of Non-invasive Diagnostic for CAD in PMK Hospital
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The Efficacy of Non-invasive Diagnostic for CAD in PMK Hospital
Maj. Hutsaya Prasitdumrong, M.D.
Cardiovascular Division, Department of Internal Medicine,Phramongkutklao Hospital
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Coronary atherosclerosisCoronary artery disease (CAD)Ischemic heart disease (IHD)
Foam cells Fatty streak Intermediatelesion Atheroma Fibrous
plaque
Complicatedlesion/rupture
From FirstDecade
From ThirdDecade
From FourthDecade
Endothelial Dysfunction
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Investigations for CAD
Anatomical Tests
CT angiographyMR angiographyCoronary angiography
Functional Tests
Exercise stress testStress ECHOStress CMRMPI: SPECT PET
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Coronary Angiography
• GOLD standard for detection of CAD• Identify coronary arteries stenosis and its severity
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Diagnostic Accuracy of Non-invasive Modalities for Detection of CAD
Applied Radiology 2011;40(5):13-22
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Coronary Angiography VS Coronary CT Angiography
Coronary Angiography• Invasive• Require day care admission• Iodine contrast• Radiation• Cost• Resume normal activity
after 24 hours• Risk: death, stroke, CA
dissection about 1:1000
Coronary CT Angiography
• Non-invasive• Out patient visit• Iodine contrast• Radiation• Cost• Resume normal activity
right after scanning• Risk: safer
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Coronary Angiography VS Coronary CT Angiography
Coronary Angiography Coronary CT Angiography
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Non-invasive or Invasive Test
Circulation 2002;106:1883-92
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Coronary CT Angiography
• Coronary artery calcified plaque is nearly 100% specific for atheromatous coronary plaque
• Can develop early in the course of subclinical atherosclerosis
• Present in the intima of both obstructive and non-obstructive lesion
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Coronary Calcium Score
Developed by David KingPublished by Agatston and coworker
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• Coronary calcium by EBCT and atherosclerotic plaque by histopathology
Rumberger, j.a. et al. Circulation 1995;92:2157-62
Coronary Calcium VS Atherosclerosis
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Coronary Calcium & Coronary Events
Detrano et al. NEJM 2008;358(13):1336-45
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Risk StratificationCAC score Plaque
burdenProbability of
CADCardiac event
riskManagement
0 No Very unlikely<1%
10 yr risk <2%<0.11% annually
ReassureRepeat scan
5 yrs0-80 Small Low 0.2% annually Risk factors
modificationRepeat scan
2-5 yrs
81-400 Moderate Possible 1% annually (2° prevention)± EST
ASA, statin
>400 extensive High likelihood
Up to 4.8% annually
(2° prevention)ASA, statin
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640-SLICE CT SCANNER
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MRI CT
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64-Slice VS 640-Slice CT Angiography
64-Slice CTA• 32 mm area detector• Scanning is in helical
mode• Longer exposure time• Higher dose of radiation• Higher dose of contrast
(80-100 cc)• More artifact
640-Slice CTA• 160 mm wide area
detector• Scanning in 1 rotation• Shorter exposure time• Radiation dose reduced
by up to 50%• Less contrast (50 cc)• Less artifact• Available in AF patient
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PMK Heart Center Protocol
Take history of previouscontrast allergy and PDE5
drug use
Target HR 60 bpm prior to scanMed: Metoprolol up to 100 mg keep BP > 110/70Alt: Ivabradine 5 mg bid for 3 days
0.4 mg Nitroglycerine oral spray 1 puff
CTA scan: Prospective scan 100-120 kVp Contrast 40-45 cc Effective dose 3.5-4.5 mSv
At observation room
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Effective Dose for Cardiovascular Imaging Tests
Catheterization and Cardiovascular Intervention 2011;77:546-56
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Appropriate Criteria for Calcium Scan and Coronary CTA
• Calcium scan– Intermediate risk for CAD– Low risk for CAD with family history of premature
coronary heart disease• Coronary CTA– Symptomatic patient with low or intermediate risk– Reduced LVEF with low or intermediate risk– Pre-op evaluation for non-cardiac surgery– Post revascularization
JACC 2010;56(22):1864-1894
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