Dr.Ravi PrakashModerator- Dr Roopa Salwan                    13-04-12
INTRODUCTIONCAC Scoring  - in asymptomatic pt.          CAD burden          CV risk prediction - in symptomatic pt.       ...
ACC/AHA GUIDELINE–  CAC scoring (CACs) as a filter for coronary angiography in atypical ACS.  CAC s –> as binary test     ...
Recently question mark raised    - in population of high pre test risk of CAD     - incremental prognostic value of score ...
AIM OF STUDYTo describe the prevalence and severity of CAD in relation to prognosis in           - symptomatic patients   ...
METHODThe CONFIRM registry (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter)  inter...
 Symptomatic patients who underwent concomitant  CAC scoring and CCTA were included.  Individuals with known CAD were exc...
Lesion quantification       LESION   LUMINAL    CLINICAL       GRADE    STENOSIS   SIGNIFICANCE       NONE     0%       MI...
FOLLOW UP AND OUTCOMEEND POINTS Primary-     Death due to any cause  Secondary- Consisting of              -all-cause mort...
RESULTS     27125 Patients screened      10,037 Patients selected   (symptomatic, without known CAD,    undergoing CAC sco...
PROFILE OF STUDY GROUP Mean age =57 Male =56 % Among 10,037 pt. 51% has CAC score of 0.                  - young       ...
Among CAC score=0 group     13% have non obstructive CAD     3.5% have obstructive CAD     1.4% have severe obstructive CAD
In group of obstructive CAD and CACs = 0                 82% have SVD                12% have DVD                 6% have ...
 For the detection of any stenosis> 50% on CCTA, the  presence of measurable CAC on calcium scoring  demonstrated a sensi...
MORTALITY ADVERSE EFFECT
SURVIVAL WITH CACs=0
MACE stratified by CACs and stenosis
FOLLOW UP During a median follow-up of 2.1 years,  patients with any obstructive CAD by CCTA  experienced a significantly ...
FOLLOW UP FOR SECONDARY ENDPOINT Among the 8,907 patients with complete follow-up for the secondary endpoints of coronary ...
COMPARATIVE PROGNOSTIC VALUE OF CLINICAL VARIABLES, CACSCORING AND CCTA. Independent predictor of adverse events        ...
DISCUSSION Absence of calcification decreases the likelihood Of  CAD ,but does not exclude it. Rate of obstructive CAD i...
LIMITATIONS OF STUDY1.Definition of CAD was made using CCTA, the  possibility of false-positive and false-negative CCTA  fin...
CONCLUSION1.Absence of calcification decreases the likelihood Of  CAD but does not exclude it. 2. Among patients without C...
THANKS.
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Confirm trial

  1. 1. Dr.Ravi PrakashModerator- Dr Roopa Salwan 13-04-12
  2. 2. INTRODUCTIONCAC Scoring - in asymptomatic pt. CAD burden CV risk prediction - in symptomatic pt. high sensitivity and –ve predictive value to exclude CAD.
  3. 3. ACC/AHA GUIDELINE– CAC scoring (CACs) as a filter for coronary angiography in atypical ACS. CAC s –> as binary test CAC+ve=further test considered. CAC –ve=no further test required.
  4. 4. Recently question mark raised - in population of high pre test risk of CAD - incremental prognostic value of score -significant incidence of CAD in pt. having zero CACs.
  5. 5. AIM OF STUDYTo describe the prevalence and severity of CAD in relation to prognosis in - symptomatic patients -without known CAD - without coronary artery alcification - undergoing CCTA
  6. 6. METHODThe CONFIRM registry (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter) international, multicenter, observational registry collecting clinical, procedural, and follow-up data on patients who underwent 64-detector row CCTA between 2005 and 2009 at 12 centers in 6 countries(Canada, Germany, Italy, Korea, Switzerland, and United States)
  7. 7.  Symptomatic patients who underwent concomitant CAC scoring and CCTA were included. Individuals with known CAD were excluded. CAC s with Agatston method 1 130-199 HU 2 200-299 HU 3 300-399HU 4 >400HU
  8. 8. Lesion quantification LESION LUMINAL CLINICAL GRADE STENOSIS SIGNIFICANCE NONE 0% MILD 1-49% NON OBSTRUCTIVE MODERA 50-69% OBSTRUCTIVE TE SEVERE > 70% SEVERELY OBSTRUCTIVE
  9. 9. FOLLOW UP AND OUTCOMEEND POINTS Primary- Death due to any cause Secondary- Consisting of -all-cause mortality, -nonfatal MI, and -coronary revascularizations done 90 days after CCTA.
  10. 10. RESULTS 27125 Patients screened 10,037 Patients selected (symptomatic, without known CAD, undergoing CAC scoring and CCTA)
  11. 11. PROFILE OF STUDY GROUP Mean age =57 Male =56 % Among 10,037 pt. 51% has CAC score of 0. - young - female - low CV risk
  12. 12. Among CAC score=0 group 13% have non obstructive CAD 3.5% have obstructive CAD 1.4% have severe obstructive CAD
  13. 13. In group of obstructive CAD and CACs = 0 82% have SVD 12% have DVD 6% have TVD 0.3% have LMD
  14. 14.  For the detection of any stenosis> 50% on CCTA, the presence of measurable CAC on calcium scoring demonstrated a sensitivity of 89%, specificity of 59%, negative predictive value of 96%, and positive predictive value of 29%. When using a threshold of 70% stenosis for obstructive CAD, a CAC score> 0 demonstrated a sensitivity, specificity, negative predictive value and positive predictive value of 92%, 55%, 99%, and 16%, respectively.
  15. 15. MORTALITY ADVERSE EFFECT
  16. 16. SURVIVAL WITH CACs=0
  17. 17. MACE stratified by CACs and stenosis
  18. 18. FOLLOW UP During a median follow-up of 2.1 years, patients with any obstructive CAD by CCTA experienced a significantly increased rate of all-cause mortality . When restricted to individuals with a CAC score of 0, there was no difference in all-cause mortality despite the presence of non obstructive or obstructive CAD
  19. 19. FOLLOW UP FOR SECONDARY ENDPOINT Among the 8,907 patients with complete follow-up for the secondary endpoints of coronary revascularization and MI, patients with evidence of obstructive CAD had significantly increased rates of early coronary revascularization, both among patients with and without coronary artery calcification.
  20. 20. COMPARATIVE PROGNOSTIC VALUE OF CLINICAL VARIABLES, CACSCORING AND CCTA. Independent predictor of adverse events  Increasing CAC scores,  The presence of nonobstructive CAD,  Any stenosis >50%, and  the number of coronary territories with 50% stenosis.
  21. 21. DISCUSSION Absence of calcification decreases the likelihood Of CAD ,but does not exclude it. Rate of obstructive CAD in person with zero calcification varies between 7 – 38% Pt. with CACs=0 and obstructive CAD do not show increased mortality due to predominent SVD.
  22. 22. LIMITATIONS OF STUDY1.Definition of CAD was made using CCTA, the possibility of false-positive and false-negative CCTA findings exists.2. Patients diagnosed with obstructive CAD on CCTA are more likely to undergo PCI/CABG, especially in early days.3. Differences in the application of medical therapies after CCTA were not assessed4.Individual plaque character was not studied.
  23. 23. CONCLUSION1.Absence of calcification decreases the likelihood Of CAD but does not exclude it. 2. Among patients without CAC, the presence of stenosis of > 50% is predictive of increased rates of late coronary revascularizations and nonfatal MIs during an intermediate-term follow-up period.3. CAC scoring performed at the time of CCTA does not appear to offer significant incremental prognostic information
  24. 24. THANKS.

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