the absence of coronary calcification does not exclude obstructive CAD or the need for clinically indicated coronary revascularization both in the outpatient department as well as in the ED among patients with a high enough suspicion of CAD prompting an indication for CCA. The absence of coronary calcification should not be used as a gatekeeper and should not prevent a symptomatic patient from undergoing angiography. Furthermore, a large percentage of totally occluded vessels had no evidence of calcium by CT, emphasizing that calcification is not indispensable for plaque rupture and acute coronary events
In any event, the findings by Gottlieb et al. ( 4 ) squarely raise a key question: what is the added value of a CS? In particular, does a CS add, even incrementally, to the predictive value for CAD established 30 years ago based simply on demographics and type of chest pain? This question cannot be answered precisely, because the studies of the CS as a predictor of CAD or cardiac events have not analyzed the incremental risk prediction over clinical assessment. However, the conflicting results from Gottlieb et al. ( 4 ) and Sarwar et al. ( 2 ) suggest that more data, from populations of varying pre-test probability of CAD with angiographic and meaningful clinical end points such as nonfatal myocardial infarction and cardiac death, are needed to answer this question. Until then, a CS of 0 cannot be interpreted as a reassurance of the absence of CAD. The findings by Gottlieb et al. ( 4 ) reinforce the importance of comparing new diagnostic tests to more traditional clinical predictors, especially when the tests expose patients to known risks but uncertain benefits. The CS, in particular, may yet have its place in the clinician’s arsenal for evaluation
Although mortality from coronary heart disease (CHD) has fallen substantially over the past three decades, it remains the leading cause of death in adults. In a study of 7733 participants in the Framingham Heart Study who were initially free of CHD, the lifetime risk of CHD for individuals at age 40 was 49 percent in men and 32 percent in women [ 1 ]. The lifetime risk was also appreciable in those free of CHD at age 70: 35 percent in men and 24 percent in women. There is considerable interest in the diagnosis of CHD when patients are still asymptomatic. An increasing number of physicians are screening for asymptomatic CHD; in addition, many participants in wellness programs also are requesting screening for themselves because of the belief that there are legitimate screening methods for the early detection of CHD that are necessary before beginning an exercise program. However, critical questions remain regarding the appropriateness of screening and the optimal screening test. Efforts are underway to educate health professionals, the insurance industry, and the general public regarding the appropriate use of exercise electrocardiogram (ECG) tests in screening for CHD.
CT coronary angiography Pay Now, Benefits May Follow
Contro: A. Erlicher (Bolzano) La diagnosi appartiene all’imaging: oggi la coro-TAC pone in modo incruento diagnosi di patologia coronarica e va considerata un esame di routine nella gestione clinica
Devo far qualcosa per la mia salute <ul><li>Un 52enne mi chiede di fargli eseguire una TC per calcio coronarico (CC) per valutare il suo rischio di eventi dopo aver letto un articolo su un a rivista. Non ha sintomi cardiaci non ha mai fumato, non è sovrappeso ma non fa alcuna attività fisica. Suo padre, forte fumatore, è morto di infarto a 45 anni. La pressione è 130/85, il colesterolo è 220 mg per decilitro LDL e HDL 160 mg e 38 mg per decilitro rispettivamente, il glucosio 92 mg. Cosa gli consiglio? </li></ul>
Should Coronary Calcium Screening Be Used in Cardiovascular Prevention Strategies? The goal of CAC scanning in asymptomatic persons is to refine the risk assessment in order to determine whether preventive strategies should be intensified, not to identify persons with asymptomatic coronary artery stenoses.
The 7-Year Rate of Major Coronary Events Predicted on the Basis of the Framingham Risk Score and the Coronary-Artery Calcium Score. <ul><li>Rates are based on a Cox regression analysis of data from 1029 initially asymptomatic adults who were followed for a median of 7.0 years. </li></ul><ul><li>A coronary- artery calcium (CAC) score of 0 indicates no detectable calcium; higher CAC scores indicate more severe degrees of coronary calcification, with the extent of severity influenced by age, ethnicity, and sex. </li></ul><ul><li>A major coronary event was defined as death or nonfatal myocardial infarction. </li></ul>
<ul><li>the studies of the CS as a predictor of CAD or cardiac events have not analyzed the incremental risk prediction over clinical assessment. </li></ul><ul><li>Until then, a CS of 0 cannot be interpreted as a reassurance of the absence of CAD. </li></ul>
Appropriateness <ul><li>CAC screening is inappropriate in asymptomatic patients who are at low risk for coronary events according to the ATP III criteria; </li></ul><ul><li>uncertain about the appropriateness of screening for those at intermediate or high risk. </li></ul>
Should Coronary Calcium Screening Be Used in Cardiovascular Prevention Strategies? No <ul><li>In the absence of data on outcomes, the CAC score does not meet the criterion for population screening </li></ul><ul><li>Widespread CAC screening runs the risk of increasing the number of unnecessary tests and procedures downstream — and of escalating health care costs </li></ul>
Getting the Best Bang for the Rad In 1980, medical imaging was responsible for only about 15% of the total radiation exposure to the U.S. population from all sources; now the proportion is about 50% Up to 30% of the radiation exposure to the U.S. population that is associated with medical diagnostic imaging now comes from cardiac imaging Currently, approximately 9 million myocardial-perfusion-scintigraphic imaging studies are performed each year in the United States, and this test represents one of the single largest man-made contributors to radiation exposure in the U.S. population.
..e il nostro 52enne <ul><li>Il nostro 52enne ha un basso rischio CV (meno del 10% di rischio di eventi CV nei prossimi 10 anni). </li></ul><ul><li>Sconsiglio una TC lo informo dell’assenza di evidenza che l’uso di quel test migliori l’outcome e delle possibili conseguenze svantaggiose del test quali il rischio radiologico e un possibile catena di ulteriori accertamenti inutili </li></ul><ul><li>Consiglio l’assunzione di aspirina a basse dosi, probabilmente una statina e sicuramente un programma di regolare esercizio fisico. </li></ul>
DIRECT-TO-CONSUMER MARKETING OF HIGH-TECHNOLOGY SCREENING TESTS <ul><li>We recommend aspirin, a statin, and exercise, but we advise against a CAC scan </li></ul><ul><li>What if the patient responds, “Thanks, Doc, but I’m not worried about radiation and I really don’t want to take those drugs or exercise if my coronaries are clean”? </li></ul><ul><li>However, since even “clean coronaries” on a calcium scan would not change the recommendations, the test would not be cost-effective at any level of cost. </li></ul>
<ul><li>CT angiography is accurate in identifying coronary stenoses and characterizing disease severity in symptomatic patients </li></ul><ul><li>However, multidetector CT angiography cannot be used as a simple replacement for conventional coronary angiography, given its negative predictive value of 83% and positive predictive value of 91% in this population of patients </li></ul>
<ul><li>To date, the explosive growth of imaging has not been associated with any improvement in patients’ outcomes, and it is difficult to justify imaging scans without knowing how the additional information they provide will improve the care patients receive. </li></ul><ul><li>Obstacles to implementing an evidence-based approach include our faith in technology, the mistaken belief that tests can prevent heart attacks, the influence of lobbying </li></ul><ul><li>The continued unrestrained use of new technology, in the absence of evidence-based criteria, portends a bleak future for our health care system. </li></ul>