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TCT Sambu

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  • 1. Ischemia-directed coronary revascularization: a cost effective role for routine cardiac magnetic resonance imaging?
    Nalyaka Sambu, Christopher Turner, Stephen Harden, Charles Peebles, Nick Curzen
  • 2. NalyakaSambuMBBCh MRCP
    Wessex Cardiothoracic Unit
    Southampton University Hospitals NHS Trust UK
    No conflicts of interest to declare
  • 3. Background
    • Revascularization in stable coronary artery disease (CAD) in the absence of myocardial ischemia offers no prognostic benefit over optimal medical therapy (OMT) alone
    • 4. Data from DEFER, FAME and COURAGE make a persuasive case for ischemia-directed percutaneous coronary intervention (PCI)
    • 5. PCI and coronary artery bypass grafting (CABG) are associated with procedural risk and should not be routinely undertaken in the absence ofischemia
  • Non-invasive tests of ischemia
    • Exercise tolerance test (ETT):
    • 6. inadequate tool to detect objective evidence of ischemia
    • 7. high rate of false positive, false negative and equivocal results
    • 8. Other more superior tests are less widely available and more costly
    • 9. Cardiac magnetic resonance imaging (CMR):
    • 10. provides precise and superior quality images
    • 11. higher sensitivity and specificity in detecting myocardial ischemia compared to stress echocardiography¹
    ¹Mahrholdt H et al Heart 2007;93:122-29
  • 12. Study objectives
    • Observational study
    • 13. To assess whether the routine use of CMR in patients with suspected angina:
    • 14. has a significant impact on the management strategy in patients being considered for revascularization
    • 15. is cost-effective
  • Methods
    • Retrospective data analysis of all CMR referrals (n=150) from one interventional cardiologist between Jan 2007 and Nov 2009
    • 16. A database was created which included:
    • 17. clinical history
    • 18. indication for CMR
    • 19. CMR results
    • 20. post-CMR management
  • Baseline characteristics (n=150)
    *mean+/- SD †myocardial infarction ‡left ventricular
  • 21. Index clinical presentation
    *Coronary angiogram
  • 22. CMR results
    *Late gadolinium (GAD) enhancement
  • 23. CMR REFERRAL PATHWAY
    150 patient referrals
    107 (71%) considered for revascularisation
    17 (16%) considered for CABG
    101 (94%) considered for PCI
    11 (10%) considered for either
    CMR
    stress and gadolinium
    gadolinium only
    Viability confirmed in 1

    CABG
    32 (30%) had inducible ischemia
    revascularization deferred in 74 (70%) due to lack of ischemia
    12 (11%) were
    deferred for
    other reasons
    8 (7%) had
    minimal
    ischemia
    12 (11%) underwent revascularization (10 PCI; 2 CABG)
  • 24. Cost analysis
    • We calculated the hypothetical cost of revascularization if those patients being considered for PCI or CABG had all procedures undertaken (without the use of CMR)
    • 25. Thiswas compared to the cost PCI or CABG that was actually undertaken following CMR (and included the cost of CMR)
  • Cost analysis
  • 26. Summary of study findings
    • 88% of patients being considered for revascularization were managed with OMT alone instead due to the lack of significant ischemia on CMR
    • 27. CMR resulted in net cost savings of £362,016
    • 28. CMR avoided unnecessary potential procedural risk associated with revascularization
    • 29. An unacceptably high false positive rate was observed with ETT
  • Conclusion
    • Revascularization in stable CAD with objective evidence of ischemia confers prognostic benefit
    • 30. Routine use of CMR to detect ischemiasignificantly influences the management of patients being considered for revascularization
    • 31. Despite the relative expense of CMR, its routine use leads to significant overall cost savings
    • 32. ETT is an unreliable non-invasive test of ischemia with low specificity for detecting myocardial ischemia