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TCT Sambu


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TCT Sambu

  1. 1. Ischemia-directed coronary revascularization: a cost effective role for routine cardiac magnetic resonance imaging?<br />Nalyaka Sambu, Christopher Turner, Stephen Harden, Charles Peebles, Nick Curzen<br />
  2. 2. NalyakaSambuMBBCh MRCP<br />Wessex Cardiothoracic Unit<br />Southampton University Hospitals NHS Trust UK<br />No conflicts of interest to declare <br />
  3. 3. Background<br /><ul><li>Revascularization in stable coronary artery disease (CAD) in the absence of myocardial ischemia offers no prognostic benefit over optimal medical therapy (OMT) alone
  4. 4. Data from DEFER, FAME and COURAGE make a persuasive case for ischemia-directed percutaneous coronary intervention (PCI)
  5. 5. PCI and coronary artery bypass grafting (CABG) are associated with procedural risk and should not be routinely undertaken in the absence ofischemia</li></li></ul><li>Non-invasive tests of ischemia<br /><ul><li>Exercise tolerance test (ETT):
  6. 6. inadequate tool to detect objective evidence of ischemia
  7. 7. high rate of false positive, false negative and equivocal results
  8. 8. Other more superior tests are less widely available and more costly
  9. 9. Cardiac magnetic resonance imaging (CMR):
  10. 10. provides precise and superior quality images
  11. 11. higher sensitivity and specificity in detecting myocardial ischemia compared to stress echocardiography¹</li></ul>¹Mahrholdt H et al Heart 2007;93:122-29<br />
  12. 12. Study objectives<br /><ul><li>Observational study
  13. 13. To assess whether the routine use of CMR in patients with suspected angina:
  14. 14. has a significant impact on the management strategy in patients being considered for revascularization
  15. 15. is cost-effective</li></li></ul><li>Methods<br /><ul><li>Retrospective data analysis of all CMR referrals (n=150) from one interventional cardiologist between Jan 2007 and Nov 2009
  16. 16. A database was created which included:
  17. 17. clinical history
  18. 18. indication for CMR
  19. 19. CMR results
  20. 20. post-CMR management</li></li></ul><li>Baseline characteristics (n=150)<br />*mean+/- SD †myocardial infarction ‡left ventricular<br />
  21. 21. Index clinical presentation<br />*Coronary angiogram<br />
  22. 22. CMR results<br />*Late gadolinium (GAD) enhancement<br />
  23. 23. CMR REFERRAL PATHWAY<br />150 patient referrals<br />107 (71%) considered for revascularisation<br />17 (16%) considered for CABG<br />101 (94%) considered for PCI<br />11 (10%) considered for either<br />CMR<br />stress and gadolinium<br />gadolinium only<br />Viability confirmed in 1 <br />↓<br />CABG<br />32 (30%) had inducible ischemia<br />revascularization deferred in 74 (70%) due to lack of ischemia <br />12 (11%) were <br />deferred for <br />other reasons<br />8 (7%) had <br />minimal <br />ischemia<br />12 (11%) underwent revascularization (10 PCI; 2 CABG)<br />
  24. 24. Cost analysis<br /><ul><li>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. 25. Thiswas compared to the cost PCI or CABG that was actually undertaken following CMR (and included the cost of CMR)</li></li></ul><li>Cost analysis<br />
  26. 26. Summary of study findings<br /><ul><li>88% of patients being considered for revascularization were managed with OMT alone instead due to the lack of significant ischemia on CMR
  27. 27. CMR resulted in net cost savings of £362,016
  28. 28. CMR avoided unnecessary potential procedural risk associated with revascularization
  29. 29. An unacceptably high false positive rate was observed with ETT </li></li></ul><li>Conclusion<br /><ul><li>Revascularization in stable CAD with objective evidence of ischemia confers prognostic benefit
  30. 30. Routine use of CMR to detect ischemiasignificantly influences the management of patients being considered for revascularization
  31. 31. Despite the relative expense of CMR, its routine use leads to significant overall cost savings
  32. 32. ETT is an unreliable non-invasive test of ischemia with low specificity for detecting myocardial ischemia</li>