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Risk Assessment in the Asymptomatic Patient
Computed Tomography Angiography
Arthur J.H.A. Scholte
Depart. of Cardiology
Leiden University Medical Center
The Netherlands
ESC Munich 2012
NO CONFLICTS OF INTEREST
Case History
• Asymptomatic 64 y old Dutch male
• 1.82 m, 95 kg, BMI 29
• Father died at 45 years AMI
• Systolic blood pressure of 140 mm Hg
• Smoker
• Normal ECG and cholesterol levels
10 year risk of fatal CVD in high risk
regions of Europe
13 %
Next step?
Questions
• Is an asymptomatic adult a patient?
• Should we image asymptomatic patients?
• Is CAD outcome worse in asymptomatics?
• Can we diagnose CAD reliably with CTA?
• Can high risk asymptomatic be identified?
• Can high risk be modified and improve outcome?
• Is it cost effective?
How can CT(A) help our patient?
1. Anatomic information of the coronary arteries
Origin
Dominancy
Interarterial course
Intramural course/bridging
Anomaly
2. Anatomic information of atherosclerosis
% of stenosis
plaque type/length/burden
remoddeling
3. LV function, perfusion, FFR
Studies in the literature (1)
Choi EK JACC 2008
5% ≥ 50% stenosis
2% ≥ 75% stenosis
15 cardiac events, 1 UA, 14 revasc (17±2 mo FU)
Studies in the literature (2)
Hadamitzky M Am J Cardiol 2010
N=451, mean FU 28 mo
54% non-obstr CAD
24% obstr CAD
2 UA, 8 revasc
CONFIRM Registry (7590 Asymptomatics)
Cho I et al. Circulation 2012;126:304-313
No incremental discriminatory value of CTA to
CACs and standard risk factors for
reclassification!
No recommendation: 8
Recommended for intermediate or high risk CAD based on FRS: 6
CAC score: 5
Position statement ESC WG
Nuclear Cardiology and Cardiac
CT
Perrone-Filardi et al. EHJ 2010
2010 ACCCF/AHA Guideline for
assessment of CV Risk in
Asymptomatic Adults
Greenland et al. Circulation 2010
Comparison to other non-invasive
cardiac imaging techniques
CTA CACs MPS
Anatomy + +/- -
Ischemia - - +
Radiation 4 0.7-3.0 3(6)
Costs 250 250 450
Time 90 15 90 + 60
Specific group of asymptomatic
patients with higher risk?
• Diabetes
• Coronary anomaly
• Familial hypercholesterolemia
• Pre-operative risk
• Post-radiotherapy Hodgkin disease
• Professional sporters
48 year old male, 1991 Hodgkin disease,
chemotherapy and radiotherapy of the mediastinum
Pre-operative risk assessment of 65 year old
female with atypical CP, DM, hypertension and
pancreas carcinoma
Screening of asymptomatic 57 year old
diabetic with a normal MPS
3 vessel disease with LM stenosis
LAD LCx
LM
64 year old male with PVI and no CP
Answers to my patient
• Is an asymptomatic individual a patient? No
• Should we image asymptomatic patients? May be some?
• Is CAD outcome worse in asymptomatics? YES
• Can we diagnose silent CAD reliably with CTA? YES
• Can high risk asymptomatic be identified? YES
• Can high risk be modified and improve outcome? YES
• Is it cost effective? ?
Conclusions
• CTA can be used for detection of asymptomatic CAD in subjects
• Routine screening with CTA is not recommended
• There maybe a role in the future for CTA in specific patient groups with increased risk for CAD