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Cardiac Testing: The Bottom Line
Craig Butler MD, MSc, FRCPC
September 29 2018
Outline
• Testing Overview
• Bottom line for Coronary workup
– CV Risk Assessment
– Rule in vs. rule out
• Bottom line for Myopathic workup
- When is MRI needed
CAD Testing Overview
1) Invasive angiography
2) CT angiography
3) (MR angiography)
1) MRI
2) Stress echo
3) Nuclear
1) MRI
2) Echo
3) CT
4) Nuclear
Exercise Stress
1) EKG
2) echo
3) nuclear
Pharmacologic
Stress
1) Dipyridamole
a) nuclear
b) MRI
2) Dobutamine
a) echo
b) MRI
c) nuclear
Ischemia
Guiding Principal 1 - Rational Approach to Investigation
National post Feb 12 2016
Hamilton Spectator Feb 11 2016
Chest Pain Algorithm
Chest PainCreate a
Differential
diagnosis
Rule in
Rule out
Medical or
Surgical
Management
Gather
Information
about CC
(i.e. HPI, PE)
Pre Test Probability Diagnostic Testing
Chest Pain Work up
Typicality of Pain
Pre-test Probability
Patient CV Risk Rule in Disease
Rule out Disease
Chest pain
54 year old man
– DMII
– smoker
– prior TIA/Stroke
– Sedentary
– central abdominal obesity
– Clinic visit with atypical chest pain.
68 year old man, no risk factors, tennis 3-5x/week Clinic visit room with atypical chest pain
Contributing Risk Factors
Interheart Lancet 2004
CV risk Factor Risk
Dyslipidemia 3.3
Smoking 2.9
Psychosocial 2.7
Diabetes 2.4
Hypertension 1.9
WHR 1.1-1.6
Exercise (>4hr/wk) 0.9
Alcohol (>3/week) 0.9
Diet 0.7
Summarizing Risk
• Framingham Risk
• FRS – CVD
• ATP III – FRS – CHD
• Reynolds Risk Score
• AHA-ACC-ASCVD
Ten year vs. Life time risk?
Overestimation of Risk
• Risk Models are generally heavily weighted to age
1900 2015
Diabetes
Lipids
Sedentary
Obesity
Smoking
Age
Diabetes
Lipids
Sedentary
Obesity
Smoking
Age
?
+
Risk Refinement
• CAC adds to FRS and is better than:
– Carotid IMT
– Brachial Flow
– C-reactive protein
– ABI
Yeboah JAMA
2012
FRS +
CAC
CV risk: Reclassificaton
21%
30%
Elias-Smale JACC 56, 1407
Make Our Diet Great Again?
Thompson Horus Study JACC CVI 4;315
Thompson Lancet 2013
• 137 mummies (34% had vascular Calcium)– Ancient Egyptian– Ancient Peruvians– Ancestral Peubloans– Aleutian Islands
Chest Pain Work up
Typicality of Pain
Pre-test Probability
Patient CV Risk Rule in Disease
Rule out Disease
Typicality of Pain
1) Worse with activity
2) Relieved with Rest of Nitro
3) Retrosternal in location
1/3 = non-anginal
2/3 = atypical
3/3 = typical angina
Pre-test prob of Obstructive CAD
Cheng Circulation 2011
Chest Pain Work up
Typicality of Pain
Pre-test Probability
Patient CV Risk Rule in Disease
Rule out Disease
Chest Pain Work up
Typicality of Pain
Pre-test Probability
Patient CV Risk Rule in Disease
Rule out Disease
Ruling in CAD
• Angiogram
– Would you send for CABG if necessary?
• Trial of Medical Therapy
Meta-analysis of PCI vs OMT in Ischemic CAD
JAMA Int Med2014; 172 (4):312
Death MI
Unplanned Revasc Angina in follow-up
What’s at stake with Stable Angina
• Uncertainty remains about which subgroup of stable angina patients receive prognostic benefit of PCI
• Principal therapeutic goal is to:
– reduce symptoms
– treat risk factors
• Peri-procedural risk is an important offset of benefit
– Age - Lung disease - GFR
– PVD - history of CHF
Peterson et al JACC 2010;
55(18)
Chest pain Pre-test probability
Typicality of Pain
Pre-test Probability
Patient CV Risk Rule in Disease
Rule out Disease
Guiding Principle 2 – test Utility
Positive test resultTest with 90% sensitivity and 90% specificity
Basic Principles of Diagnostic test use and interpretation. Nicoll et
al.
Rule in
Rule
out
GP 2 Test Utility –Likelihood ratio
EST: LR+ = 3, LR-=0.5
MIBI: +LR=3, -LR= 0.18
CCTA: LR+ = 7, LR-=0.06
Exercise Echo: LR+ = 8, LR – 0.2
CMRI: LR+= 4, LR-= 0.12
Trop: LR+ = 16, LR-=0.07
Banerjee IJCP 2012;66(5)
De Jong, Euro Rad 2012;22(9)
McArdie JACC 2012; 60(18)
Picano CVUS 2008;6
+LR -LR
EST 3 0.5
MIBI 3 0.2
CMRI 5 0.1
DSE 6 0.2
RbPET 6 0.1
ESE 8 0.2
CCTA 7 0.07
Troponin 16 0.07
2
4
Guiding Principal 3 – Our judgement is better than we think• 400K patients without
known CAD
• ~40% stenosis >50%
• Odds ratio for + NIT = 1.3
RiskRisk +
symptoms
Risk +Symptoms
+ NIT
Patel NEJM 2010
Ruling Out Ischemia
FunctionalAnatomic
CT angiogram
• Pre-test probabailty
• Test Accuracy
• Specific patient variables
Exercise(Echo,EKG)
Pharmacologic
(Echo,Nuc,MRI)
Functional Ischemic TestingStress Sign of Ischemia
EKG Wall motion Perfusion
Exercise EST ESE SPECT
DobutamineDSE/DSMRI Nuclear
MRI
VasodilationNuclear
MRI
Exercise Stress Test
Pro• physiologic
• Non-invasive
• Relatively inexpensive
• Readily Available!
Con• Sens = Spec = ~65%
• MSK contraindications
SPECT Perfusion
ProAccessible
Prognosis data
Sensitive
ConTwo day test
High radiation dose
Prone to artifact
Reader experience
Vasodilator Stress
+ + +++ +
Rubidium PET
Pro• Better specificity than
Spect
• One day test
• Absolute blood flow
Con• Radiation
• Accessibility
• No viability
RadiationTest Dose (mSv)
MIBI 18 – 24
6 - 12
Rubi PET 3-5
Barium Enema 7
Cardiac Cath 2 – 10
Chest CT ~8
Virtual Colon 8-14
Coronary CT (64) 8-10
Dual source 128 2-4
CMR
Pro• No radiation
• Safe
• Accurate perfusion
• Function
• Viability
Con• Accessibility
• Cost
CMR vs SPECT
MR IMPACT EHJ 2008
Stress Echo
Pro
• Physiologic
–Exercise
–Change in function
Con
• Access/wait times
• Expertise
Coronary CT angiogram
Coronary CT angiogram
Pro• Sensitive
• Prognostic data
Con• Radiation
• Heart rate control
• Previous revasc
Scot-Heart
• N=4146
• Referred to chest pain clinic
• 18-75 yrs old
• Standard care + CCTA vs Standard care alone
• Employing CCTA– Increased the certainty
of diagnosis
– Increased diagnosis of CHD
– Decreased frequency of Diagnosis of Angina due to CHD
– Decreased use of anti-anginals
– Reduced planned investigations
Scot Heart Lancet 2015
Coronary CT - Evidence in Stable Angina
• Scot-Heart (n=4146)
– Standard Care + CCTA vs. Standard Care
– Improved Clarity of Diagnosis
– Reduced number of tests required
– Trend to increased revascularization
– Increased preventative medication
– Reduced anti-anginal medication
– Trend to reduced events
Scot Heart NEJM 2018
Scot Heart Lancet 2015
2016 NICE guideline update
Myopathy Workup
• Heart failure reduced ejection fraction (HFrEF)
– Ischemic
– Idiopathic
– Toxin
– Familial
– Other
• Heart Failure preserved ejection fraction (HFpEF)
– Hypertensive
– Hypertrophic
– Infiltrative
Echo is first line and sufficient in most
instances
When to use MRI
• Ischemic
– Diagnostic Confirmation• Mimics
– Myocarditis?
– Tako-Tsubo
– Viability pre-revasc
– Perfusion
• Infiltrative
– Amyloidosis
– Fabry’s disease
– Iron Overload
– Sarcoidosis
– (Hypertrophic)
Bottom Line
CCoronary Artery Disease
Myocardial Disease
Valvular Disease
No Known Disease = CT angioKnown Disease = Nuclear or stress echo
Echo at reputable instituteMRI for Viability or HFpEF
Echo at reputable institute
Questions?