JUSTIFICATION OF THE USE OF COMPUTED TOMOGRAPHY FOR INDIVIDUAL HEALTH

ASSESSMENT (IHA) OF ASYMPTOMATIC PEOPLE

Eugenio Picano

CNR, Institute of Clinical Physiology

Pisa, Italy

Munich, 15-17 October 2014

AGATSTON CALCIUM SCORE

The detection of coronary artery calcification on electron beam computed tomography (EBCT) and its quantitative expression with the CAC Score seems to be an important predictor of atherosclerotic disease and events

All-cause survival in 4474 men and 3219 women with >1 risk factor by EBCT coronary

calcium measurements

Coronary Artery Calcium Score

Agatston Score 400

Normal coronary arteries LAD stenosis

Fig. 3

B>>>R

IIb (possibly appropriate)

IIa (probably appropriate)

I (appropriate indication)

B>>R

III (inappropriate)

BR

RB

Risk vs Benefit: The code of appropriateness

AHA-ACC-ESC Guidelines 2007

Fig. 1

• Why

• When

• How

Exercise-ECG test

Stress echo

Stress scintigraphy

MDCT

Symptoms

Epicardial Coronary Artery

Patients status

Timeline

Normal 0% 20% 50% 75% 90% 100%

Well Worried well

Suspected sick

Sick Very sick

Sickest of the sick

Years 30 40 60 70 80

Pain

Function

ECG

Malperfusion

Coronary anatomy and wall structure

The pathophysiology reasons of screening

Endothelial Dysfunction

IMT

The political reasons of screening

“The early diagnosis is always to be

recommended, in every case”. (Livia TURCO, Health Minister of the Prodi cabinet) La Repubblica,

4 April 2007

…This screening test likely exposed Mr Obama to significant radiation unnecessarily, increasing his risk of future cancer.

Redberg R. First Physical. Arch Intern Med. 2010;170:583

http://images.google.com/imgres?imgurl=http://www.repubblica.it/speciale/2006/dossier_governo/ministri/4.jpg&imgrefurl=http://www.repubblica.it/speciale/2006/dossier_governo/ministri/4.html&h=324&w=303&sz=22&hl=it&start=1&tbnid=8dUk18SCMvwgfM:&tbnh=118&tbnw=110&prev=/images?q=livia+turco&gbv=2&svnum=10&hl=it

The screening : the money factor

“Certi dottori, disse Kojo, pagandoli il giusto ti fanno qualunque cosa” Dave Eggers. “How we are

hungry”. (La fame che abbiamo) 2005

“Some doctors are capable to do everything to you – if you pay enough”

“Più esami fai, più il paziente è contento”

“Non so se hai capito bene, Guido. Non è necessario che il cliente che mi mandi abbia davvero bisogno di una radiografia. Basta che ne abbia bisogno secondo te. E il bello è che il cliente paga ed è soddisfatto”.

G. D’Agata, Il medico della mutua. Feltrinelli, Milano, 1964 “It is not necessary that your patient really needs the exam, it is

enough that he or she needs it according to you. The nice thing about it is that the patient pays and is also happy with it. “

• Why

• When

• How

Indication to stress echo and competing techniques in symptomatic subjects

Indication to stress echo and competing techniques in asymptomatic

(without symptoms or ischemic equivalent) subjects

Use of coronary computed tomography angiography for the

diagnosis of stable coronary artery disease

• Why

• When

• How

The radiation issue in

• For each clinical scenario, tests that impact ionizing radiation will be performed by labs that have adopted contemporary dose-radiation techniques.

Wolk MJ, et al.. J Am Coll Cardiol. 2014;63:380-406 Education, justification, and optimization are the

cornerstones to enhance the radiation safety of medical imaging. Limiting the use of imaging to appropriate clinical indications can ensure that the benefits of imaging outweigh any potential risks. The continually expanding repertoire of techniques that allow high quality imaging with lower radiation exposure should be used when available to achieve safer imaging.

Fazel R et al, Circulation, 4 November 2014. A scientific Statement of American Heart Association

• The actual delivered dose should always be recorded and included in patients’ records. Because of the numerous sources of variability, there is no threshold between acceptable and unacceptable exposure for any given examination, but the dose that is not even considered is certainly unacceptable .

Picano E, et al. Eur Heart J. 2014;35:665-72

Reduction in Radiation

Marraccini P et al. Acta Radiol. 2014;54:42-7

SAME TECHNOLOGY

NEW TECHNOLOGY

The pandemics of inappropriateness

Inappropriate Appropriate Partially inappropriate

Carpeggiani C et al. PLoS One. 2013;8:e81161

CA (250 cases)

CXr (250 cases)

PCI (250 cases)

CCT (250 cases)

Take-home message

• X-rays and gamma-rays used in radiology and nuclear medicine are proven (class 1)

carcinogens, and cardiologists should make every effort to give ‘the right imaging

exam, with the right dose, to the right patient’.

• The priority given to radioprotection in every cardiology department is an

effective strategy for primary prevention of cancer, a strong indicator of the quality

of the cardiology division, and the most effective shielding to enhance the safety

of patients, doctors, and staff.

• A smart cardiologist cannot be afraid of the essential and often life-saving use of

medical radiation, but must be very afraid of radiation unawareness.