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Initial diagnostic management of patients with suspected SCAD 2 Assess pre-test-probability PTP for the presence of coronary stenoses This slide corresponds to Figure 1 in the full

CAP NHAT CHAN DOAN BENH TIM

THIEU MAU CUC BO MAN TINH

TS.BS Nguyén Quéc Thai Viện Tim Mạch Việt Nam

Traditional clinical classification

of chest pain

Typical angina (definite) Meets all three of the following characteristics:

° substernal chest discomfort of characteristic quality and

duration;

* provoked by exertion or emotional stress;

e relieved by rest and/or nitrates within minutes

Classification of angina severity according to

the Canadian Cardiovascular Society

blocks on the level and climbing more than one flight of ordinary stairs ata normal pace and in normal conditions

Class IV Inability to carry on any physical activity without discomfort, angina

syndrome may be present at rest

Clinical pre-test probabilities? in patients

with stable chest pain symptoms

Typical angina Atypical angina Non-anginal pain

# Probabilities of obstructive coronary disease shown reflect the estimates for patients aged 35, 45, 55, 65, 75, and 85 years This slide corresponds to Table 13 in the full text

From: Genders TS, et al Eur Heart J 2011:32:1316- 1330

@

www.escardio.org/guidelines 4:294t -3003 doi:10.1093/eurheartj/eht296 EUROPEAN SOCIETY OF

Ne | Yes Yes revascularization suitable

LVEF <50%? — Typical angina?

No | No See Fig 2 for selection

This slide corresponds to Figure 1 in the full text

2May be omitted in very young and healthy patients with a high suspicion of an extracardiac cause of chest pain and in multimorbid

patients in whom the echo result has no consequence for further patient management ‘lf diagnosis of SCAD is doubtful, establishing a EUROPEAKM

diagnosis using pharmacological stress imaging prior to treatment may be reasonable — ‹

CA ME W3 Cw 2y *

Initial diagnostic management of patients with suspected SCAD (2)

Assess pre-test-probability (PTP) for the presence of coronary stenoses

This slide corresponds to Figure 1 in the full text

ICA= invasive coronary angiography

www.escardio.org/guidelines

Proceed to risk stratification

In patients with severe symptoms or clinical constellation suggesting high risk coronary anatomy initiate guideline-directed medical therapy and offer ICA

Patients with suspected SCAD and

intermediate PTP of 15% - 85% Non-invasive testin g in

Consider: Su S pe cted S CA D W ith ng Xe tr Tin

* Patient criteria’/suitability for given test Stress test) | suitable when

+ Availability j n te rmed iate PTP (if not patientf 'necessary)

* Local expertise done | (if not done

|: Exercise ECG if feasible - stress before)’ t before)° | |

Stress testing PTP 15-65% imaging testing* preferred 1

»| for ischaemia › and —> (echo®, CMR‘, SPECT®, PET?) — Unie |— Determine patient

LVEF 750% if local expertise and characteristics and

Stress imaging’ (echo”, CMR‘,

PTP 66-85% or SPECT”, PET); ECG exercise

LVEF <50% without |») stress testing possible if — No ischaemia typical angina resources for stress imaging

Unclear ————— lschaemia testing using stress

imaging if not done before’

Consider age of patient versus radiation exposure

In patients unable to exercise use echo or SPECT/PET with pharmacologic stress instead

CMR is only performed using pharmacologic stress

Patient characteristics should make a fully diagnostic coronary CTA scan highly probable (see section 6.2.5.1.2) consider result to

be unclear in patients with severe diffuse or focal calcification

Proceed as in lower left coronary CTA box EUROPEAN

Proceed as in stress testing for ischaemia box This slide corresponds to Figure 2 inthe fulltext ?2hororocre

Non Invasive Testing for diagnosis of

¢ Stressor — dobutamine stress echocardiogrpahy

¢ Vasodilator - adenosine, dipyridamole or regadenoson used

for nuclear perfusion imaging

Anatomic testing

° CCTIA

Characteristics of tests commonly used to

diagnose the presence of CAD

Diagnosis of CAD

Sensitivity (%) Specificity (%)

Exercise stress echocardiography 80-85 80-88

Dobutamine stress echocardiography 79-83 82-86

Dobutamine stress MRI> 79-88 81-91

Vasodilator stress echocardiography 12-79 92-95

CAD = coronary artery disease; CTA = computed tomography angiography, ECG = electrocardiogram; MRI = magnetic resonance imaging:

PET = positron emission tomography; SPECT = single photon emission computed tomography

?Results without/with minimal referral bias; "Results obtained in populations with medium-to-high prevalence of disease without

compensation for referral bias; “Results obtained in populations with low-to-medium prevalence of disease

This slide corresponds to Table 12 in the full text

www.escardio.org/guidelines :

9~3003 doi :10.1093/eurheartj/eht296 TW

Combination of cardiac CT and perfusion imaging in

evaluation of CAD

Hybrid device:

PET/SPECT + 64-rowCT

Evaluation of anatomy and function

Gaemperli,Saraste,Knuuti Eur Heart J Cardiovasc Imaging 2012 al

Obstr CAD Suspected perfusion perfusion

excluded obstr CAD n=195 nz207

by CCTA

n=462 n=402 Maaniitty et al ICNC 2015

CT-Fractional Flow Reserve

FFR-.; uses Computational Fluid Dynamics (CFD) to noninvasively estimate FFR

CFD applies the laws of physics to model fluid flow

Broadly applicable and widely accepted

— Water flow in a river

— Air tlow around an airplane or automobile —

— Detine boundary conditions

oss 7

— Solve ditferential equations to determine

tlow and velocity at any point

CT-Fractional Flow Reserve

CTA data

Anatormc model extracted from ¢

Governing equations of blood flow solved using CFD Patient-specific mod

<=

C.A Taylor, T.A Fonte, J.K Min (2013) Computational Fluid Dynamics Applied to Cardiac Computed Tomography for

Noninvasive Quantification of Fractional Flow Reserve: Scientific Basis Journal of the American College of Cardiology

Vol 61, Issue 22, pp 2233-2241

CT-Fractional Flow Reserve

Resting coronary blood flow proportional to

rest

Q > Minyor

CT-Fractional Flow Reserve

Resistance of microcirculatory vascular bed at rest

is inversely proportional to size of feeding vessel

1 Healthy and diseased vessels

adapt to amount of flow they Carry

2 Mean pressure (P) is essentially

constant down the length of the coronary arteries at rest

CT-Fractional Flow Reserve

Microcirculatory resistance has a predictable response

to adenosine

Exogenous administration of

Adenosine elicits the maximum

hyperemic response by forcing

relaxation lễ | ms

intravenous Adernowne (yg /hg/men)

Intravenous administration of adenosine elicits remarkably consistent vasodilatory response in normal subjects at sufficient

doses

CT-Fractional Flow Reserve

3D Modeling of Blood Flow Requires Solving the

Governing Partial Differential Equations

Mass Conservation (1 equation):

where 1s the fluid density, and w is the fluid viscosity (both assumed known)

We solve these for v, (x, y,2.0),V)(X,¥.2,0,V-2(X, ¥,2,0), POX 52,0)

for every point in the 3D model and over whatever time interval we are interested in

59 yo post with CP: CT-FFR

Summary: The Left Anterior Descending System and Left Circumfiex System each have an FF Re, <

0.80

Frto CORONARY ARTERIES 4 SYSTEME

Left Main Artery

Left Anterior Descending System Left Cưcumflex System

Right Coronary Artery System — naa

MAY BE FUNCTIONALLY SiGNAPICANT 123

88 yo post with CP: CT-FFR

Summary: The Left Anterior Descending System and Right Coronary Artery System each have an FF Re,

< 0.80

©YV*MtvY AIIFLIA 9á 9v9!twM$ FÍf;

Left Main Artery

Left Anterior Descending System

Left Circumfiex System

Right Coronary Artery System

MAY BF FUNCTIONALLY GxiheriCANT “**

FFfL ; avaiatxo

Prognostic implications of stress-CMR vs MPS

and NICE guidelines in patients with suspected CAD

© Design:

» N=1,202 patients

3T CMR stress guided care vs

current best clinical practice

with suspected CAD is superior

to current best clinical practice*

6, 12, 24 & 36 month foll0w-up

Secondary Ti MACE, Qol & Health Economic Analysis

J Greenwood (Leeds, UK), FP 4154

Coronary CTA for selective ICA: effect on cardiovascular g

Adult Individuals With Suspected But no Know CAD

At the point of considering invasive diagnostic testing

9 Hypothesis: `Selective Catherlzation” Strategy "Direct Catherization” Strategy

CCTA -guided CCTA — ICA

compared to ICA: <50% 250% Non- <50% 250%

stenosis stenosis evaluable stenosis stenosis

Median follow-up period: 12.3 months

(IQR, 117 - 13.2 months) ICA (Index + Downstream) <0.001

Selective Direct Downstream)

referral referral Non-invasive testing

CV hospitalizations 0.04 0.04 0.95 Outpatient visits 3.04 2.82 0.018 Cardiovascular Costs* (USD) 6,740 3,338 <0.001

H J Chang (Seoul, KR) F fp 66

HỘI NGHỊ TIM MẠCH

T0ÀN 0UữC 20QIG

KET LUAN

1 Các phương pháp chẩn đoán không xâm lấn có vai

trò quan trọng trong chẩn đoán bệnh tim thiếu

máu cục bộ mạn tính

2 Việc áp dụng chẩn đoán hình ảnh đánh giá giải

phẫu cũng như chức năng ĐMV góp phần làm

giảm đáng kể tỷ lệ chụp ĐMV qua da và giảm chỉ

phí cho BN

I said you had

acute angina!

bã

x