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Patients with SIHD who have survived sudden cardiac death or potentially life-threatening ventricular arrhythmia should undergo coronary angiography to assess cardiac risk.. Coronary art

Hoàng Văn Sỹ MD, PhD

University of Medicine & Pharmacy, Ho Chi Minh City

Selective coronary angiography:

should be first choice for

angina patients?

All roads lead to Rome !

Appropriateness of diagnostic catheterization for suspected coronary artery disease in New York State

Hannan E L et al Circ Cardiovasc Interv 2014;7:19-27

Appropriateness of diagnostic catheterization for suspected coronary artery disease in New York State

Hannan E L et al Circ Cardiovasc Interv 2014;7:19-27

24,9%

64%

90%

2012 AUC for diagnostic catheterization

no prior noninvasive stress testing

Patel MR et al J Am Coll Cardiol 2012;59(22):1-33

Determination of Appropriateness Score

Parikh MA TCT 2014

Appropriateness

Designation score

AHA/ACC Rec

Levele of Evid

Additional Published Characteristics of Appropriate

Imaging Tests

Appropriate

IIa IIb

Reproducible accquisition and

No Clear Benefit

To Guide Therapeutic Decision Making

RISK

BENEFIT

Added Benefit To Guide Therapeutic Decision Making

Exposure Risk Is Farless Than Potential CV Risk Reduction Following Targeted Treatment

But how many “inappropriate PCI’s”

were really getting done ?

Wall Street Journal, July 6, 2011 Data from P Chan et al, JAMA 2011

Revascularization appropriateness in stable

CAD and 3-year death/recurrent ACS

Ko et al ACC 2012

1,625 pts from the VRPO Cohort Study Pts with stable CAD and a significant stenosis (50% angio)

Adj HR 0.99 (0.48-2.02)

Adj HR 0.57 (0.28-1.16)

Adj HR 0.61 (0.42-0.88)

%

Approach to diagnosis of suspected IHD

OR Prior sudden death or serious ventricular arrhythmia

OR Prior stent in unprotected lef main coronary artery

Initiate guideline directed medical therapy

Consider coronary revascu

Comprehensive clinical assessment of risk, including

personal characteristics, coexisting cardiac and

medical condition and health status

Intermediate or high risk UA ?

Suspected Ischemic Heart Disease

(or change in clinical status in a patient with known IHD)

Invasive coronary angiography

• Plays a very limited role in the diagnosis of CAD

• Diagnosis in patients with suspected SIHD who:

1 Have survived sudden death or serious ventricular

Invasive coronary angiography

• Non-invasive testing can establish the likelihood of the presence of

obstructive coronary disease with an acceptable degree of certainty

• ICA will only rarely be necessary in stable patients with suspected CAD, for the sole purpose of establishing or excluding the diagnosis :

1 Patients who cannot undergo stress imaging techniques,

2 Patients with reduced LVEF < 50% and typical angina

3 Patients with special professions, such as pilots (however, be indicated

following non-invasive risk stratification for determination of options for revascularization

4 Patients have a high PTP and severe symptoms, or a clinical constellation

suggesting high event risk, early ICA without previous non-invasive risk stratification maybe a good strategy to identify lesions potentially

amenable to revascularization

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European Heart Journal (2013) 34, 2949–3003

Noninvasive Risk Stratification

*Although the published data are limited; patients with these findings will probably not be at low risk in the presence

of either a high-risk treadmill score or severe resting LV dysfunction (LVEF <35%)

Fihn SD et al JACC 2012;24: 2564–603

Invasive coronary angiography

• ICA should not be performed in patients with angina

1 Refuse invasive procedures, prefer to avoid

revascularization,

2 Not candidates for PCI or CABG,

3 Or revascularization is not expected to improve

functional status or quality of life

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European Heart Journal (2013) 34, 2949–3003

Patients with SIHD who have survived sudden cardiac death or potentially life-threatening ventricular

arrhythmia should undergo coronary angiography to assess cardiac risk

Patients with SIHD who develop symptoms and signs of heart failure should be evaluated to determine

whether coronary angiography should be performed for risk assessment

I IIa IIb III

Coronary Angiography as an Initial

Testing Strategy to Assess Risk

I IIa IIb III

Fihn SD et al JACC 2012;24: 2564–603

Coronary arteriography is recommended for patients with SIHD whose clinical characteristics and results of

noninvasive testing indicate a high likelihood of severe IHD and when the benefits are deemed to exceed risk

Coronary angiography is reasonable to further assess risk in patients with SIHD who have depressed LV function (EF

<50%) and moderate risk criteria on noninvasive testing with demonstrable ischemia

I IIa IIb III

Coronary Angiography to Assess Risk After Initial

Workup With Noninvasive Testing

I IIa IIb III

Fihn SD et al JACC 2012;24: 2564–603

Coronary angiography is reasonable to further assess risk in patients with SIHD and inconclusive prognostic information after noninvasive testing or in patients for whom

noninvasive testing is contraindicated or inadequate

Coronary angiography for risk assessment is reasonable for patients with SIHD who have unsatisfactory quality of life due to angina, have preserved LV function (EF >50%), and have intermediate risk criteria on noninvasive testing

I IIa IIb III

Coronary Angiography to Assess Risk After Initial

Workup With Noninvasive Testing (cont.)

I IIa IIb III

Fihn SD et al JACC 2012;24: 2564–603

Coronary angiography for risk assessment is not recommended in patients with SIHD who elect not to undergo revascularization or who are not candidates for revascularization because of comorbidities or

Coronary Angiography to Assess Risk After Initial

Workup With Noninvasive Testing (cont.)

I IIa IIb III

No Benefit

Fihn SD et al JACC 2012;24: 2564–603

Coronary angiography is not recommended to assess risk in patients who are at low risk according to clinical criteria and who have not undergone noninvasive risk testing

Coronary angiography is not recommended to assess risk in asymptomatic patients with no evidence of ischemia on noninvasive testing

I IIa IIb III

No Benefit

Coronary Angiography to Assess Risk After Initial

Workup With Noninvasive Testing (cont.)

I IIa IIb III

No Benefit

Fihn SD et al JACC 2012;24: 2564–603

SPARC Registry: Therapeutic

changes after non-invasive testing

Hachamovitch et al JACC 2012;59:462-474

1%

1,703 int/high risk pts with CCTA, SPECT or PET Among pts referred for cath, 63% had obstractive CAD

Adverse outcomes related to underutilization of coronary angiography

Hemingway et al Annals if Int Med 2008

9356 UK pts with recent onset chest pain in whom angina was suspected

2 panels rated appropriateness using RAND methodology

57% (Panel A), 71% (Panel B) underuse of angiography for appropriate pts

Adjusted HR of death/ACS if angiography was NOT performed

Inappropriate (0.47-1.01) 0.69 (0.26-1.03) 0.52

Uncertain (1.17-3.36) 1.98 (0.79-1.72) 1.16

Appropriate (1.77-4.01) 2.67 (1.72-3.55) 2.47

Cornerstone of management of stable CAD

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European Heart Journal (2013) 34, 2949–3003

1 First make the diagnosis: is this really CAD ???

2 Risk-stratify the patient and institute therapeutic

maesures that:

 Improve prognosis

 Improve symtoms

Clinical assessment of the probability that SCAD is present in

a particular patient (determination of PTP)

Non-invasive testing to establish the diagnosis of SCAD

or non-obstructive atheroslerosis

Stratification for risk of subsequent events - usually on the basis of available non-invasive tests - in order to select pts who may benefit from invasive investigation

Approach to diagnosis of suspected IHD

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European Heart Journal (2013) 34, 2949–3003

Recent implementation of the AUC

Newsweek 8/1/11