The document discusses non-invasive coronary disease evaluation techniques, emphasizing the limitations and biases in diagnostic accuracy. It highlights the importance of pre-test probabilities and various imaging modalities such as CT and echocardiography in identifying significant coronary artery disease. The text also addresses the need for advanced strategies to detect high-risk patients to improve cardiovascular outcomes.

1. CD VI VD Evaluación No Invasiva de la enfermedad coronaria Dr. JL Zamorano Instituto Cardiovascular Hospital Clínico San Carlos

2. IMAGEN CARDIACA EN LA ENFERMEDAD CORONARIA FUNCIONAL IMAGEN NUCLEAR (SPECT) ECOCARDIOGRAFIA DE ESTRES RESONANCIA MAGNETICA ANATOMICA CARDIO CRMN CT MULTICORTE ELECTROM BEAM CT

3. Ecocardiograma de estrés.

4. Prevalencia enfermedad Coronaria: 84% SESGO SELECCION Update to Guidelines for clinical echocardiography. JAAC 2003; vol 42: 953-70 Limitaciones Estudios Precisión Diagnóstica Prevalencia:sesgo selección

5. La selección de pacientes a la técnica “patrón oro” se realiza en base a : Resultados del test no invasivo : Muchos Test positivos son referidos a Coronariografia Pocos test negativos son referidos a Coronariografia No diagnosticamos muchos falsos negativos Características del paciente : Los pacientes mas enfermos son los remitidos a coronario Aumentamos la sensibilidad Disminuimos especificidad S = VP VP+ FN E = VN VN+FP Sesgo verificación

6. Limitaciones estudios precisión diagnóstica Sesgo verificación

7. Evaluación de dolor torácico 1.- Morise et al.Am Heart J 1995;130:741-747 2.- Diamond. Am J Cardiol 1990;57:1175-1180 3.- Schwartz et al Circulation 1993;87:165-172 4.- Roger et al. Circulation 1997;95:405-410 Efecto del sesgo sobre diversas tecnicas Sen. sesgada Sen No sesgada Esp sesgada Esp. No sesgada Ergometria 1 H 56 40 81 96 M 47 33 73 89 Isotopos Ejercicio 2 77 57 48 70 Talio ejercicio 3 67 45 59 78 Talio 2 91 68 34 71 ECO ejer 4 H 78 42 37 83 M 79 32 34 86

8. IMAGEN CARDIACA EN LA ENFERMEDAD CORONARIA FUNCIONAL IMAGEN NUCLEAR (SPECT) ECOCARDIOGRAFIA DE ESTRES RESONANCIA MAGNETICA ANATOMICA CARDIO CRMN CT MULTICORTE ELECTROM BEAM CT

9. CT Evaluation of CAD Influence of Pre-Test Probability Pre-test Probability Post-test Probability 0 50 50 Stress MPI Stress Echo

10. Probabilidad Pretest de Enfermedad Coronaria ACC/AHA 2002 Guideline Update for Exercise Testing: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) 2002

12. Influencia de la TAC en la probabilidad Pre-Test Meijboom et al, J Am Coll Cardiol 2007;50:1469-75

13. CT Evaluation of CAD Influence of Pre-Test Probability Pre-test Probability Post-test Probability 0 50 50 Stress MPI Stress Echo Meijboom et al, J Am Coll Cardiol 2007;50:1469-75 100

14. Preguntas clave Es preciso en su diagnóstico. En qué pacientes es útil. Asintomáticos ?.

15. SENSIBILIDAD Y ESPECIFICIDAD Mollet et al. J Am Coll Cardiol 2004; 43 : 2265-70

16. CORE 64: Objectives To evaluate the diagnostic performance of 64 detector MDCT in the ability to identify patients with significant CAD compared with coronary angiography. Significant:>50% stenosis by quantitative coronary anglography Per vessel diagnostic accurancy with QCA

17. CORE 64: Study Design Eligible patients Calcium score MDCT Angiography Standarized protocol Sublingual nitroglycerine B-blocker heart rates > 70bpm Rotation: 0.4 sec, Pitch: 12-16 Tube voltage: 120KV, 240-400 mA 80-100ml iopamidol 370 Acquisition time:8-10 sec Gender specific radiation dose Training certified technologist MDCTA 64-slice (0.5mm) Cardiac Catheterization <30 days Clinical follow-up 30 day revasculari-zation Conventional Invasive Angiography OCA quality/certification Standarized IC nitroglycerine Catheter Recommended views Digital (Dicom) Ca+>600 Registry Angiographic Core Lab MDCT Core Lab

18. Consented n=405 CORE 64 Results: Patient Flow Agatson Calcium Score <600 N =316 10 Excluded due to CT Technical Limitations 291 Patients Analyzed 868 Vessels 4 Major Protocol Deviations 1 catch prior to MDCT 2 Prior cardiac surgery 1 catch > 30 days Ca score > 600 (n=89) Registry 11 Excluded due to Cath Technical Limitations

19. CORE 64 Baseline Characteristics n=291 Age, median (IQR) 59 (52,66) Men 216 (74%) BMI, median (IQR) 27 (25,30) Hypertension 192 (66%) Diabetes 68 (23%) Dysplidemia 175 (60%) Previous MI 58 (20%) Smoking (current + past) 175 (60%) Prior PCI 28 (10%) Angina (30 days) N (%) 169 (58%) Creatinine (mg/dl) median (IQR) 0.9 (0.8, 1.1) Prior Stress Test (30 day) 109 (30%) Unstable anginal / ACS (<48 hrs) 78 (27%)

20. CORE 64: Primary Results Patient Analisysis MDCT with QCA Sensitivity Specificity PPV NPV Quantitative 0.85 0.90 0.91 0.83 MDCT (0.79-0.90) (0.83-0.94) (0.86-0.95) (0.75-0.89) Prevalence of Disease = 56% (163/291) Quantitative MDCT > 50% Stenosis with Reference Standard QCA > 50% Stenosis

21. CTA Diagnostic Accuracy Issues of vessel size (↓sensitivity) Handling “non-visualised” vessels (↓ specificity) Issues of artifact Se Sp Prev. PPV NPV 93% 81% 63% 86% 88% 93% 81% 30% 68% 96% 93% 81% 15% 46% 98%

22. CTA Diagnostic Accuracy Issues of vessel size (↓sensitivity) Handling “non-visualised” vessels (↓ specificity) Issues of artifact Se Sp Prev. PPV NPV 93% 81% 63% 86% 88% 93% 81% 30% 68% 96% 93% 81% 15% 46% 98%

23. Preguntas clave Es preciso en su diagnóstico. En qué pacientes es útil. Asintomáticos ?.

24. Estratificación del riesgo CV Riesgo relativo población asintomática (12 años FU) Fuente: Framingham Wilson P y cols. Circulation 1998;97;1837-1847

25. 10 Year Risk of Fatal CVD in High Risk Regions of Europe by Gender, Age, Systolic Blood Pressure, Total Cholesterol and Smoking Status 190 160 140 120 190 160 140 120 190 160 140 120 190 160 140 120 190 160 140 120 Systolic blood pressure 4 5 6 7 8 4 5 6 7 8 Non-smoker Smoker Women 15% and over 10–14% 5–9% 3–4% 2% 1% <1% 10-year risk of fatal CVD in populations at high CVD risk 190 160 140 120 190 160 140 120 190 160 140 120 190 160 140 120 190 160 140 120 Systolic blood pressure 4 5 6 7 8 4 5 6 7 8 Non-smoker Smoker Age Men 65 60 55 50 40 Cholesterol mmol 150 200 250 300 mg/dl 7 8 9 10 12 5 5 6 7 8 3 3 4 5 6 2 2 3 3 4 4 4 5 6 7 3 3 3 4 5 2 2 2 3 3 1 1 2 2 2 2 2 3 3 4 1 2 2 2 3 1 1 1 1 2 1 1 1 1 1 1 1 1 2 2 1 1 1 1 1 0 1 1 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 13 15 17 19 22 9 10 12 13 16 6 7 8 9 11 4 5 5 6 7 8 9 10 11 13 5 6 7 8 9 3 4 5 5 6 2 3 3 4 4 4 5 5 6 7 3 3 4 4 5 2 2 2 3 3 1 1 2 2 2 2 2 3 3 4 1 2 2 2 3 1 1 1 1 2 1 1 1 1 1 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 14 16 19 22 26 9 11 13 15 16 6 8 9 11 13 4 5 6 7 9 9 11 13 15 18 6 7 9 10 12 4 5 6 7 9 3 3 4 5 6 4 4 5 6 7 2 3 3 4 5 2 2 2 3 3 1 1 2 2 2 1 1 1 2 2 1 1 1 1 1 0 1 1 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 26 30 35 41 47 18 21 25 29 34 13 15 17 20 24 9 10 12 14 17 18 21 24 28 33 12 14 17 20 24 8 10 12 14 17 6 7 8 10 12 7 8 10 12 14 5 6 7 8 10 3 4 5 6 7 2 3 3 4 5 2 2 3 3 4 1 2 2 2 3 1 1 1 1 2 1 1 1 1 1 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

26. 60 años de edad No Fuma No Diabetes No HVI TA: 160/90 mmHg Colesterol Total: 225mg/dl HDL Colesterol: 40mg/dl 10 años. Riesgo CV : 28%

27. “ Posibildiad de un evento en los próximos 10 años en 100 personas como usted” Eventos Cardiovasculares sin TTO

28. “ Posibildiad de un evento en los próximos 10 años en 100 personas como usted” Eventos que prevengo con TTo antihipertensivo

29. Eventos prevenidos con AntiHTA Eventos prevenidos al añadir una estatina “ Posibildiad de un evento en los próximos 10 años en 100 personas como usted”

30. El Hiato Preventivo ( Detection Gap) Wilson P y cols. Circulation 1998;97;1837-1847 Infraestimados Aprox 30% Sobreestimados Aprox 30% Curva ROC de predicción CHD en hombres Fuente: Framingham Entre un 10-15% de la población en riesgo entre 40 y 70 años y que sufrirá un evento no es identificado por la tablas

31. Imagen CV y Gap N Engl J Med 2008;358:1336-45 . En población caucásica, un CS >100 JUNTO CON FRCV tradicional incrementó la predicción de cualquier evento coronario en un 5% frente al empleo EXCLUSIVO de variables epidemiológicas

32. TC coronario vs Calcio Score Entre el 5-10% tiene lesión ≥50% y CaSc de cero ( Cheng, 2007) Los pacientes con Calcio Score < 100 presentan (menos) prevalencia de placas “vulnerables” (*) HCSC/2008 Placas blandas. CaS=0 p<0,001

33. TCMD y Prevención de ECV Información anatómica: implicaciones pronósticas J Am Coll Cardiol 2007;50:1161 TC-64

34. 68% de pacientes con coro previa a IM tienen coronarias normales Ziada Curr Prob Cardio1999:24 541 40 % de pacientes la cardiopatía isquémica debuta como IAM -Valoración de ateroesclerosis

35. JACC ,Vol. 52, No. 3, 2008 En pacientes que se presentan con dolor torácico agudo, las placas no calcificadas son altamente prevalentes. La ausencia de calcio no excluye fiablemente la presencia de CAD , aún CAD obstructiva.

36. Es desconocido el riesgo de IAM en pacientes con placa blanda detectados con TAC multicorte. Es desconocido el valor aditivo de encontrar una placa blanda sobre el valor del score calcio No sabemos cual es la estrategia adecuada para la prevención de complicaciones cardiovasculares en los pacientes con placa no calcificada - Los grandes interrogantes

37. Gran iniciativa/estudio: Identificar paciente considerados actualmente “Riesgo Medio” que en realidad son “Alto” =>Tratamiento temprano=> Reducir morbi-mortalidad y costes sanitarios DETECCION PRECOZ ENFERMEDAD SHAPE

38. Foreword Valentin Fuster, MD PhD It is a pleasure to provide this Foreword to the Screening for Heart Attack Prevention and education (SHAPE) task Force report. The contributors to the SHAPE initiative must be congratulated for their original, ambitious, and provocative approach to the number 1 problem in the cardiovascular field, a problem that affects millions of lives annually. Since the landmark Framingham Heart Study introduced the concept of cardiovascular risk factors. Nonetheless, atherosclerotic cardiovascular disease has remained the primary cause of mortality and morbility in most countries. It is obvious that new strategies are needed to fight the growing epidemic of atherosclerosis is a leading candidate to fulfill that role. Early observations in the 1980s sparked the concept of the vulnerable or high-risk plaque, and generated the search for the immediate underlying cause of acute coronary events. Subsequent advances in the field of cardiology constitute a long list of major developments that are likely to change the practice of cardiology. I believe that advances in noninvasive imaging head this list. The notion of the vulnerable or high-risk plaque is rightly evolving into the more comprehensive concept of the “vulnerable patient”, as evidenced by the plurality of vulnerable plaques and the total burden of atherosclerotic disease. In addition, other sources of vulnerability from thrombogenic blood and ischemic or arrythmogenic myocardium must be considered. Despite questions regarding the feasibility and practicality of such an ambitious proposal, the SHAPE Guideline is a worthy and timely effort that goes beyond traditional risk assessment and has the potential to transform the field of preventive cardiology. The driving passion and commitment of the members of the SHAPE Task Force is commendable. It serves as an example to all of us who wish to stop and reverse the epidemic of atherosclerotic cardiovascular disease. I will certainly feel proud to contribute to the SHAPE initiative’s call for future studies that will validate and accelerate the adoption of screening for subclinical atherosclerosis as proposed by the SHAPE Guideline. The driving passion and commitment of the members of the SHAPE Task Force is commendable. It serves as an example to all of us who wish to stop and reverse the epidemic of atherosclerotic cardiovascular disease . I will certainly feel proud to contribute to the SHAPE initiative’s call for future studies that will validate and accelerate the adoption of screening for subclinical atherosclerosis as proposed by the SHAPE Guideline. Valentin Fuster, MD, PhD

39. 0% 20% 45% 75% 95% Grado de estenosis TAC / IVUS Isotopos-eco estress Ecg stress clínica - Valoración de ateroesclerosis

40. Conclusión Entre el 30 y 50% de la población, según su edad, presentará un episodio cardiovascular grave o mortal Las exploraciones FUNCIONALES son claves en el estudio de la aterosclerosis. El TAC aporta sin duda estudios morfológicos de gran precisión diagnóstica Datos preliminares en pacientes seleccionados apoyan el uso de TC coronario como add-on en la estratificación del riesgo CV y potencialmente superior al Calcio Score Ensayos o redes colaborativas son necesarias para demostrar de modo definitivo la justificación del uso del TC coronario en PP asintomáticos en riesgo

41. Reflexión. “” Awaiting overt signs and symptoms of coronary disease before treatment is no longer justified.” “ In some respects, the occurrence of symptoms may be regarded more properly as a medical failure than as the initial indication for treatment.” William B. Kannel, MD Boston University Medical Center