What Tests Should I Be Having Anyway? - Cedars-Sinai · What Tests Should I Be Having Anyway?...
Transcript of What Tests Should I Be Having Anyway? - Cedars-Sinai · What Tests Should I Be Having Anyway?...
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What Tests Should I Be Having Anyway?
Daniel S. Berman, MDDirector, Cardiac Imaging
Cedars-Sinai Heart Institute
Professor of MedicineDavid Geffen School of Medicine at UCLA
2011
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What Tests Should I Be Having Anyway?
• Why Test?• What Test?• Whom to Test?• How is there benefit?
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Magnitude of the Burden—Causes of Death in the United States
0100200300400500600700800900
1,000
Death
s (tho
usan
ds)
CHD Cancer Accidents HIV/AIDS
959.2
544.7
93.832.7
American Heart Association. Heart and Stroke Statistical Update.
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Heart attack is not an earthquake!
It can be predicted, therefore prevented.
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In >50% of victims, the first symptom of asymptomatic atherosclerosis is sudden cardiac death or acute MI.
Heart Attack: Often No Warning
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Slide Source:Lipids Onlinewww.lipidsonline.org
Men
Women
0 10 20 30 40 50 60 70Patients Diagnosed with CHD (%)
Murabito et al Circulation 1993
Sudden Cardiac Death or Heart Attack As Initial Presentation
62%
42%
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~50-60% of heart attacks could be prevented by optimal diet, exercise and currently available medications
PK Shah, MD
Heart Attacks Can Be Prevented
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•
Prevention of heart attacks need to look beyond traditional risk factors
Heart Attacks Can Be Prevented
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•
Prevention of heart attacks need to look beyond traditional risk factors
•
Why?
Heart Attacks Can Be Prevented
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•
Prevention of heart attacks need to look beyond traditional risk factors
•
Why?•
Because traditional risk factor based screening frequently fails
to identify the
vulnerable “at risk”
patient
Heart Attacks Can Be Prevented
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Sachdeva et al. AHJ, Vol 157, 111‐117 Jan 2009
Of 136,905 patients hospitalized with CAD:More than 75% had LDL levels below 130 mg/dl
Heart attack with normal LDLLipid levels in patients hospitalized with
coronary artery disease: An analysis of
136,905 hospitalizations in Get With The
Guidelines
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Of 136,905 patients hospitalized with CAD:More than 75% had LDL levels below 130 mg/dl
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Sachdeva et al. AHJ, Vol 157, 111‐117 Jan 2009
HDL levels in patients hospitalized with
coronary artery disease: An analysis of 136,905
hospitalizations in Get With The Guidelines
Heart attack with normal HDL
Of 136,905 patients hospitalized with CAD:Nearly 50% had HDL Over 40
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Components•
Age
•
Sex•
Total cholesterol
•
HDL cholesterol•
BP
•
Diabetes
FRS risk levels for MI or CD•
Low <10 (or <6)
•
Intermediate (10-20 or 6 20)
•
High >20
Guidelines for Rx and Testing of Asymptomatic Patients
Framingham Risk Score (FRS)
Wilson, et al, Circulation 1998;97:1837
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Framingham Risk Score (FRS)
•
Important risk factors:–
Family history
–
Activity, fitness–
Obesity
•
Chronicity of risk factors (RF)•
Magnitude of RF over time (how much smoking, how high the BP)
Limitations: Not Included
Guidelines for Rx and Testing of Asymptomatic Patients
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“BLACK BOX” WARNING
Asymptomatic Individuals
Asymptomatic patients
Framingham Risk ScoreBeware:This score may not be applicableto patient populations
A Rozanski
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Sir Winston Churchill, 91 Sir Winston Churchill, 91 Jim Fixx, 53Jim Fixx, 53 Who Has More Cardiovascular Risk Factors?Who Has More Cardiovascular Risk Factors?
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Status Quo Unacceptable!
CONCLUSION:
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• Identification of the patient at risk
• Individualized therapeutic recommendations
• Tools to optimize patient “compliance”: changing behavior
Heart Attack PreventionNeeds
:
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Atherosclerotic Plaque Development
Subclinical Atherosclerosis
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Carotid Intima Media Thickness (CIMT)Carotid Intima Media Thickness (CIMT)
Near wall
Far wall
IntimaMediaAdventitia
IntimaMediaAdventitia
Normal Abnormal
CCA
ICA
ECA
CCAbulbbulb
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Nambi V et al J Am Coll Cardiol 2010
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NonNon--Contrast EBCT Scans at theContrast EBCT Scans at theBase of the HeartBase of the Heart
No CalcificationNo Calcification Moderate Moderate CalcificationCalcification
Severe Severe CalcificationCalcification
Left MainLeft Main LADLADRamusRamusLCXLCX
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EBCT Coronary Calcium Scoring
Hn x-factor(Agatston Scoring)
130-199 1
200-299 2
300-399 3
>400 4
Area = 15 mm2
Peak CT = 450Score = 15 x 4 = 60
Area = 8 mm2
Peak CT = 290Score = 8 x 2 = 16
Total Score =
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Coronary
Artery Calcification (CAC)•
CAC=coronary atherosclerosis
•
Extent of coronary atherosclerosis built up over lifetime– Accounts for chronicity and degree of risk
factors•
Low radiation dose (0.9 mSv ~3x background)
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Coronary Artery Calcium (CAC) Score (Agatston)
Magnitude of Coronary Atherosclerosis
•
0 None•
1-99
Mild
•
100-399 Moderate•
400-999 Extensive
•
≥1000
Very extensive
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0.0 2.0 4.0 6.0 8.0 10.0 12.0Time to Follow-up (Years)
0.75
0.80
0.85
0.90
0.95
1.00
0.0 1.0 2.0 3.0 4.0 5.0Time to Follow-up (Years)
0.75
0.80
0.85
0.90
0.95
1.00
Near-
& Long-Term Survival by CAC Socre Nashville, TN and Los Angeles, CA
n=10,377 n=25,25799.4%97.8%95.2%
90.4%
81.8%
99.4%97.8%94.5%
87.8%
76.9%
2=1503, p<0.0001, interaction p<o.0001
CAC Score Difference
0-10 0.0% (-)11-100 0.0% (-)101-400 0.7% (0.0073)401-1,000 2.6% (<0.0001)>1,000 4.9% (<0.0001)
Budoff, et al JACC, 2007
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MESA STUDY FU 3.9 yrs; 127 events
CAC predictive beyond FRS in all ethnicities
(p<0.001)
Detrano et al. NEJM 2008;358:1336-45
CD or MI
Any coronary event
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Cardiovascular Events with Absent or Minimal Coronary Calcification: The Multi-Ethnic Study of
Atherosclerosis (MESA)
Budoff et al. Am Heart J 2009;158:554-61
3415 CAC=0, 508 CAC=1-10, FU 4.1 yrs, 28 all CHD events
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•
50 year old woman referred by her doctor for coronary calcium scanning
•
Risk factors: Family history of coronary heart disease
•
Blood testing: TC 194;LDL 90; HDL 96; Glucose 84
•
Blood pressure: 144/80•
Self-reported lifestyle–
Exercise: 5/10
–
Low saturated fat diet: 5/10
Patient last week: Coronary Artery Calcium Scan
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Treatment Recommendations by Guidelines
F 50
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Nothing
Treatment Recommendations by Guidelines
F 50
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Coronary Artery Calcium ScanJuly 2011 F 50
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Coronary Artery Calcium Scan
Coronary artery calcium score: 17.4 (82nd
percentile)
July 2011 F 50
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July 2011 F 50
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Aggressive preventive treatment
• Low saturated fat diet
• Regular aerobic exercise
• Reduce blood pressure to 120-130/80
• Reduce LDL cholesterol to <70
Treatment Recommendations with Scan
July 2011 F 50
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SHAPE: Screening for Heart Attack Prevention and EradicationNaghavi, et al Am J Cardiol July 2006
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20%
29%36% 37%
20%
61%
88%96%
0%
20%
40%
60%
80%
100%
NCEP SHAPE
(n=1021) (n=660) (n=271) (n=167)
Statin Therapy by NCEP vs. SHAPE Guidelines
CAC=0 CAC 1-99 CAC 100-399 CAC 400+
(Test for trend for both p<0.0001)
(p=0.78)
(p<0.001)
(p<0.001)
(p<0.001)
% R
ecom
men
ded
for S
tatin
Berman et al, AHA 2007EISNER: 2119 volunteers with risk factors
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CAC SCANNINGWho could benefit from testing?
Men over age 45 and women over age 55 with at least one additional risk factor
• High LDLcholesterol
• Low HDL cholesterol
• Diabetes
• High blood pressure
• Smoking
• Family history of premature heart disease
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2137 middle age subjects with risk factors: randomized to CAC scan and no scan groups
and followed up for 4 years
Rozanski…Berman: J Am Coll Cardiol 2011
EISNER Trial
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Conclusions
•
CAC scanning led to improved risk factor profile–
greater reduction in systolic BP
–
LDL cholesterol–
waist circumference
–
weight•
Degree of risk factor modification increased as CAC score increased
Rozanski…Berman: J Am Coll Cardiol 2011
EISNER Trial
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Concern about Cost
•
Overall rates of downstream medical testing and procedures did not differ among the scan and no-scan groups, resulting in comparable costs during follow-up.
Rozanski…Berman: J Am Coll Cardiol 2011
EISNER Trial
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Monitoring CAC Progression
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Monitoring CAC Progression
•
Increased rates of CAC progression have been shown to increase the risk for future cardiac events.
•
Yearly testing NOT recommended•
Repeat testing recommendations:–
0 score: 5 years
–
Non-zero scores: 3-5 years
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“EBCT has the greatest potential for further determination of risk in patients at intermediate risk of developing CHD (i.e., patients in the appropriate age group with multiple risk factors)”
ACC/AHA O’Rourke et al. JACC 2000;36:326-40
Expert Consensus Document on EBCT
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Recommendations for CAC Scoring•
Class IIa: reasonable for CV risk assessment in asymptomatic adults at intermediate risk (10% to 20% 10-year risk (Evidence B)
•
Class IIb: reasonable for CV risk assessment in asymptomatic adults at low to intermediate risk (6% to 20% 10-year risk (Evidence B)
ACCF/AHA Guidelines for Assessment of CV Risk in Asymptomatic Adults
JACC 2010:56:2182-99
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Recommendations for CAC ScoringDiabetes
•
In asymptomatic adults with diabetes, 40 years of age and older, measurement of CAC is reasonable for CV risk assessment (Evidence B)
ACCF/AHA Guidelines for Assessment of CV Risk in Asymptomatic Adults
JACC 2010:56:2182-99
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•
Young or no risk factors •
Known heart disease–
Myocardial infarction
–
Coronary angioplasty–
Bypass surgery
•
Patients with chest pain symptoms
Who Does NOT
Need CAC Scanning?
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65 M
Asymptomatic CACS 4350 (99th
percentile)
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•
Patients with coronary artery blockages may have “silent”
ischemia (inadequate
heart muscle blood flow)•
EISNER study: –
Patients with CAC scores more than 400 have higher frequency of ischemia
–
Patients with ischemia need additional medications and may be candidates for cardiac catheterization
Further Testing in AsymptomaticIndividuals with High CAC Scores
Berman, et al JACC 2004
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Clinical Value of CAC Scanning
Unanswered questions•
Does preventive therapy based on CAC reduce events?
•
Does ischemia testing prompted by high CAC alter outcomes?
•
No randomized trial has been done–
But sometimes the data is compelling and trials aren’t needed
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Cedars‐Sinai Heart Institute SHAPE Program
•
Calcium scanning/carotid IMT scanning combined with lipid profile
•
Calcium scan: cost of dinner for two (***)•
Can self‐refer, but must give name of your
physician•
310 423 8000
(Society for Heart Attack Prevention and Eradication)
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Temporal resolution
0.28 ms gantry rotation(~75 msec imaging)2 x 128 slices
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ACS
LAD
Positive remodeling (+), Soft plaque (+),Fibrous plaque (+), Calcification (-)
Motoyama et al. JACC 2007;50:319- 26
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Coronary CT Angiography
•
Not recommended for screening because of cost
•
Quote PK: “if you had a test for $500 and 2 mSv radiation, you would have a screening test: we are almost there
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Imaging for Atherosclerosis
•
Predicts risk more accurately than risk factors•
Helps guide recommended treatment
•
Increases motivation/helps change behavior•
Likely prevents heart attacks
•
Widely available, inexpensive
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Imaging for Atherosclerosis
•
Predicts risk more accurately than risk factors•
Helps guide recommended treatment
•
Increases motivation/helps change behavior•
Likely prevents heart attacks
•
Widely available, inexpensive
•
Consider getting in SHAPE!
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Thank you very much