PATIENT WITH CHEST PAIN AND POSSIBLE CAD CCTA VS. SPECT

PATIENT WITH CHEST PAIN AND POSSIBLE CAD CCTA VS. SPECT Vasilis Argyris, MD Dimitrios N. Nikas, MD, PhD, FESC Ioannina University Hospital Ioannina, Greece

Possible CAD Low <30% Intermediate 30-70% High >70% Type and quality of chest pain Age DN1 Gender Presence of traditional risk factors Diagnosis Outcome

Slide 2 DN1 and this why....because we know from the early years of CTA that pretest probability plays an important role in the PPV and NPV in patients with CAD. Dimitrios Nikas; 25/10/2015

Differences in CCTA performance according to CAD probability Meijboom et al. JACC 2007; 50:1469-1475

Differences in CCTA performance according to CAD probability Coronary angiography performed in all patients and served as reference Meijboom et al. JACC 2007; 50:1469-1475

Differences in CCTA performance according to CAD probability DN2 Meijboom et al. JACC 2007; 50:1469-1475

Slide 5 DN2 you can appreciate here that as the pre-test probability increases, so the post -probability increases as well. But with bets performance only at high risk patents. Dimitrios Nikas; 25/10/2015

Differences in CCTA performance according to CAD probability DN3 Specificity was lower in high pre-test probability patients Sensitivity was lower in per-segment analysis group Meijboom et al. JACC 2007; 50:1469-1475

Slide 6 DN3 escellent NPV in low and intermediate patietns, so no further diagnostic test. but you can appreciate lower sensitivity of the per-segment group. which is because calcium overestimates lesions. in CCTA Dimitrios Nikas; 25/10/2015

Differences in CCTA performance according to CAD probability and there is a reason for that...calcium Multicenter, prospective, multivendor study involving 360 patients with stable and unstable anginal pain. DN4 Meijboom et al. JACC 2008; 52:2165-2154

Slide 7 DN4 this is another in patients with moderate and high calcium there ware the highest numbers of moderate lesions. Ουσιαστικά κάνει υπερδιαγνωση. Dimitrios Nikas; 25/10/2015

Differences in CCTA performance according to CAD probability and there is a reason for that...calcium Multicenter, prospective, multivendor study involving 360 patients with stable and unstable anginal pain. DN5 Meijboom et al. JACC 2008; 52:2165-2154

Slide 8 DN5 and that the overestimation of the lesion is usually in lesions around 50% this is somenthing that we have to keep in mind. Dimitrios Nikas; 25/10/2015

Chest pain in Low <30% Intermediate 30-70% probability patient 376 symptomatic patients (254 men, 122 women, mean age 60.4 ± 10.0 years) referred for noninvasive stress testing (exercise bicycle test and/or SPECT) and invasive coronary angiography were included. All patients underwent additional 64-slice CTCA. The mean pretest probability was 61 ± 30%. 120 Overall Performance % 100 80 60 76% 89% 98% 77% 82% DN6 70% 91% 91% 92% 99% 40 47% 20 0 30% Sensitivity Specificity PPV NPV XECG SPECT CCTA Weustink et al. Int J Cardiovasc Imaging. 2012 Mar; 28(3): 675 684

Slide 9 DN6 better NPV of CTA. Dimitrios Nikas; 25/10/2015

Chest pain in Low <30% Intermediate 30-70% probability patient Consecutive CTA patients (without history of revascularization or cardiac transplantation) were prospectively enrolled and compared with a Tc-99m SPECT cohort (matched for age, gender and Morice Score) Each CTA and SPECT was evaluated for obstructive CAD and patients were followed for downstream ICA and revascularization. 1221 patients in each cohort The mean pretest probability was <10% - Morice Score Model. TP FP % patients with Cor Angio CCTA 81 10 p=0.009 SPECT 70 26 0 20 40 60 80 100 120 Tandon et el. Eur Heart J 2012;33:776 82

Chest pain in Low <30% Intermediate 30-70% probability patient Consecutive CTA patients (without history of revascularization or cardiac transplantation) were prospectively enrolled and compared with a Tc-99m SPECT cohort (matched for age, gender and Morice Score) Each CTA and SPECT was evaluated for obstructive CAD and patients were followed for downstream ICA and revascularization. 1221 patients in each cohort The mean pretest probability was <10% - Morice Score Model. 20 Diagnosis & Outcome 15 10 11 p=ns 10 DN7 p=ns CCTA SPECT 5 6 6 0 Referral Rate Revasc Rate Tandon et el. Eur Heart J 2012;33:776 82

Slide 11 DN7 even though the performance of CCTA was better to SPECT this was not resulted in lower rates of revascularization or diagnosis of CAD. Dimitrios Nikas; 25/10/2015

Chest pain in Low <30% Intermediate 30-70% probability patient 541 patients (59% male, age 59 +/- 11 years) referred for further cardiac evaluation, both MSCT and MPI were performed. The following events were recorded: all-cause death, nonfatal infarction, and unstable angina requiring revascularization. DN8 mainly low-intermediate risk patients (79%) van Werkhoven et al. J Am Coll Cardiol 2009;53:623-65

Slide 12 DN8 αυτή ήταν μια μελέτη που μελέτησε τον συμπληρωματικό ρόλο των δύο μεθόδων. είχε 517 ασθενείς κυρίως χαμηλού και μέσου κινδύνου με τους κλασσικούς παράγοντες κινδύνου... Dimitrios Nikas; 25/10/2015

Chest pain in Low <30% Intermediate 30-70% probability patient 541 patients (59% male, age 59 +/- 11 years) referred for further cardiac evaluation, both MSCT and MPI were performed. The following events were recorded: all-cause death, nonfatal infarction, and unstable angina requiring revascularization. DN9 van Werkhoven et al. J Am Coll Cardiol 2009;53:623-65

Slide 13 DN9 εδειξε ένα καλό correlation του SPECT με τη CTA. Dimitrios Nikas; 25/10/2015

Chest pain in Low <30% Intermediate 30-70% Clinical Follow-up SPECT results probability patient p< 0.001 van Werkhoven et al. J Am Coll Cardiol 2009;53:623-65

Chest pain in Low <30% Intermediate 30-70% Clinical Follow-up CCTA results probability patient p< 0.001 van Werkhoven et al. J Am Coll Cardiol 2009;53:623-65

Chest pain in Low <30% Intermediate 30-70% Clinical Follow-up probability patient CCTA + SPECT results p< 0.005 van Werkhoven et al. J Am Coll Cardiol 2009;53:623-65

Chest pain in Low <30% Intermediate 30-70% Clinical Follow-up probability patient CCTA + SPECT results Annual Event Rate Annual Hard Event Rate 10 hard events defined as cardiac death / MI 8 9% Annual Rate (%) 6 4 2 0 DN10 4% 4% 4% 2% 1% 1% CCTA -/SPECT - CCTA - / SPECT + CCTA +/ SPECT - CCTA +/ SPECT + 6% van Werkhoven et al. J Am Coll Cardiol 2009;53:623-65

Slide 17 DN10 hard events περιλαμβάνει μόνο τα θανατος έμφραγμα και επειγουσα αναγκη για επαναγγειωση. Dimitrios Nikas; 25/10/2015

Chest pain in Low <30% Intermediate 30-70% probability patient 541 patients (59% male, age 59 +/- 11 years) referred for further cardiac evaluation, both MSCT and MPI were performed. The following events were recorded: all-cause death, nonfatal infarction, and unstable angina requiring revascularization. DN11 van Werkhoven et al. J Am Coll Cardiol 2009;53:623-65

Slide 18 DN11 και το πιο σημαντικό είναι ότι η παρουσά μελέτη έδειξε ότι υπάρχει μία σταδιακή προγνωστική αξία όταν όλα και περισσότερα στοιχεία προστιθενται το ένα μαζί με το άλλο. κλινικά.. στεκτ, και CTA. Dimitrios Nikas; 25/10/2015

Chest pain in Low <30% Intermediate 30-70% probability patient The combination of SPECT + CCTA provides complementary information about the presence, extent and composition of atherosclerosis improved risk stratification than using SPECT alone

Chest pain in Intermediate 30-70% High >70% probability patient 114 patients, mainly with intermediate likelihood of CAD, underwent both MSCT and MPI. The MSCT studies were classified as having no CAD, nonobstructive (<50% luminal narrowing) CAD, or obstructive CAD. Myocardial perfusion imaging examinations were classified as showing normal or abnormal (reversible and/or fixed defects). In a subset of 58 patients, invasive coronary angiography was performed Relation CCTA and SPECT Obstructive and non-obstructive disease DN12 Shcuijf et al. J Am Coll Cardiol 2006;48:2508-2514

Slide 20 DN12 στο συνολο των ασθενών με φυσιολογικές και παθολογικές CCTAs η πλειοψηφία των ασθενών που είχαν φυσιολογι αξονική είχαν και φυσιολογικό SPECT. Οι ασθενείς που είχαν παθολοιγκή αξονιική είχαν στη πλειοψηφία φυσιολογικό SPECT. Dimitrios Nikas; 25/10/2015

Chest pain in Intermediate 30-70% High >70% probability patient 114 patients, mainly with intermediate likelihood of CAD, underwent both MSCT and MPI. The MSCT studies were classified as having no CAD, nonobstructive (<50% luminal narrowing) CAD, or obstructive CAD. Myocardial perfusion imaging examinations were classified as showing normal or abnormal (reversible and/or fixed defects). In a subset of 58 patients, invasive coronary angiography was performed Relation CCTA and SPECT Obstructive vs. non-obstructive disease Shcuijf et al. J Am Coll Cardiol 2006;48:2508-2514

Chest pain in Intermediate 30-70% High >70% probability patient 114 patients, mainly with intermediate likelihood of CAD (85% intermediate + 9-10% high risk), underwent both MSCT and MPI. The MSCT studies were classified as having no CAD, nonobstructive (<50% luminal narrowing) CAD, or obstructive CAD. Myocardial perfusion imaging examinations were classified as showing normal or abnormal (reversible and/or fixed defects). In a subset of 58 patients, invasive coronary angiography was performed DN13 Shcuijf et al. J Am Coll Cardiol 2006;48:2508-2514

Slide 22 DN13 επιπλεόν σε αυτή τη παλια μελέτη έγινε και μία σχετική σύγκριση σχετικά μετ αποτε λεσματα των νέων με τους παλίοτερους CTs, και δεν φάνηκε διαφορά. Dimitrios Nikas; 25/10/2015

Chest pain in Intermediate 30-70% High >70% probability patient Multicenter trial, randomly assigned patients 40 to 74 years of age with symptoms suggestive of acute coronary syndromes but without ischemic electrocardiographic changes or an initial positive troponin test to early CCTA or to standard evaluation in the emergency department DN14 Hoffmann et al. N Eng J Med 2012;367:299-308

Slide 23 DN14 patients at emergency departement with suspected ACS obviously high risk patients. 1/4 of those patients underwent SPECT. Dimitrios Nikas; 25/10/2015

Chest pain in Intermediate 30-70% High >70% probability patient Multicenter trial, randomly assigned patients 40 to 74 years of age with symptoms suggestive of acute coronary syndromes but without ischemic electrocardiographic changes or an initial positive troponin test to early CCTA or to standard evaluation in the emergency department CCTA = 201 pts, Standard Evaluation = 499 pts DN15 higher discharge rate directly from the emergency department Hoffmann et al. N Eng J Med 2012;367:299-308

Slide 24 DN15 the primary end point was the time of patiens stay at emergency department. Showed that patients were discharged in shorter time and at higher rates from the emergency department. Dimitrios Nikas; 25/10/2015

Chest pain in Intermediate 30-70% High >70% probability patient Multicenter trial, randomly assigned patients 40 to 74 years of age with symptoms suggestive of acute coronary syndromes but without ischemic electrocardiographic changes or an initial positive troponin test to early CCTA or to standard evaluation in the emergency department CCTA = 201 pts, Standard Evaluation = 499 pts DN16 Hoffmann et al. N Eng J Med 2012;367:299-308

Slide 25 DN16 but with the cost of higher rate of functional tests downstream of the index admission. and slightly higher numner of coronary angios. and definetely higher radiation. οι ασθενείς με CCTA κάναν περισσότερα τεστ Περαν της CCTa A ΚΑΙ ΕΊΧΑΝ ΠΕΡΙΣΣΟΤΕΡΗ ΑΚΤΙΝΟΒΟΛΙΑ Dimitrios Nikas; 25/10/2015

Chest pain in Intermediate 30-70% High >70% probability patient Multicenter trial, randomly assigned patients 40 to 74 years of age with symptoms suggestive of acute coronary syndromes but without ischemic electrocardiographic changes or an initial positive troponin test to early CCTA or to standard evaluation in the emergency department CCTA = 201 pts, Standard DN17Evaluation = 499 pts Hoffmann et al. N Eng J Med 2012;367:299-308

Slide 26 DN17 but at no further costs. LESS hospital cost same overall cost. Dimitrios Nikas; 25/10/2015

Chest pain in Low <30% Intermediate 30-70% probability patient Randomly assigned 10,003 symptomatic patients to a strategy of initial anatomical testing with the use of coronary computed tomographic angiography (CCTA) or to functional testing (exercise electrocardiography, nuclear stress testing, or stress echocardiography). DN18 Mean Pre-test probability was calculated at 53.3 +/- 21 Douglas et al. N Eng J Med 2015;372:1297-1300

Slide 27 DN18 και αυτή είναι η τελευταία μελέτη που ανακοινωθηκε φέτος.είχε τους περισσότερους ασθενείς 10000 και συνεκρινε τη CCTA με όλες τις μορφές της μη επεμβατικής διαγνωσης ΣΝ όπως treadmill test, echo stess and spect. Dimitrios Nikas; 27/10/2015

Chest pain in Low <30% Intermediate 30-70% probability patient Randomly assigned 10,003 symptomatic patients to a strategy of initial anatomical testing with the use of coronary computed tomographic angiography (CTA) or to functional testing (exercise electrocardiography, nuclear stress testing, or stress echocardiography). Douglas et al. N Eng J Med 2015;372:1297-1300

Slide 28 DN19 στη κλινική παρακολούθηση που ήταν και το πρωτογενές καταληκτικό σημείο δεν υπήρχαν διαφορές. Dimitrios Nikas; 27/10/2015

Chest pain in Low <30% Intermediate 30-70% probability patient Randomly assigned 10,003 symptomatic patients to a strategy of initial anatomical testing with the use of coronary computed tomographic angiography (CTA) or to functional testing (exercise electrocardiography, nuclear stress testing, or stress echocardiography). DN21 DN20 Douglas et al. N Eng J Med 2015;372:1297-1300

Slide 29 DN20 DN21 εδω όμως υπήρχαν κάποιες διαφορές. ΟΙ ασθενείς που υποβληθήκαν σε CTA είχαν μικρότερο αριθμό στεφανιογραφίων σε σχεση με αυτούς με functional tests. αν και στις πρώτες 90 ημέρες οι ασθενείς αυτοί ήταν περισσότεροι, τελικά η συνολική δόση ακτινοβολίας ήταν σημαντικά μιρκότερη στους ασθενεείς που υποβλήθηκαν σε CCTA. Dimitrios Nikas; 27/10/2015 λιγοτεροι ασθενείς με CTA τελικά κάναν στεφανιογραφία. και αυτό γιατί αποκλείστηκαν αυτοί που είχαν αρνητική στεφανιογραφία. Dimitrios Nikas; 27/10/2015

Chest pain in Low <30% Intermediate 30-70% probability patient Randomly assigned 10,003 symptomatic patients to a strategy of initial anatomical testing with the use of coronary computed tomographic angiography (CTA) or to functional testing (exercise electrocardiography, nuclear stress testing, or stress echocardiography). 20,0 Radiation Exposure 15,0 p<0.01 p<0.01 CCTA FT 14,1 msv msv 10,0 12,0 msv 12,0 msv 10,1 msv DN22 5,0 0,0 All pts SPECT only pts Study Patients CCTA : Coronary Computer Tomography Angiography FT: Functional Testing Douglas et al. N Eng J Med 2015;372:1297-1300

Slide 30 DN22 και ενώ η συνολική ραδιενέργεια ήταν μικρότερη στους ασθενείς με functional testing, αν συγκρίνουμε τη ραδιενέργεια αυτή με αυτή που έλαβαν οι ασθενείς με SPECT οι τελευταιόι εκτέθηκαν σε μεγαλύτερη ραδιενέργεια. Dimitrios Nikas; 27/10/2015

Chest pain in Low <30% Intermediate 30-70% probability patient Randomly assigned 10,003 symptomatic patients to a strategy of initial anatomical testing with the use of coronary computed tomographic angiography (CTA) or to functional testing (exercise electrocardiography, nuclear stress testing, or stress echocardiography). DN23 Douglas et al. N Eng J Med 2015;372:1297-1300

Slide 31 DN23 συνολικά σε όλη τη περιόδο παρακολούθησης η χρήση ανατομικής απεικόνισης σε σχέση με της λειτουργικής, σε ασθενείς με ενδιάμεσου - υψηλού κινδύνου pre-test probability για την διάγνωση ΣΝ, δεν υπήρχε διαφορά στα κλινικά συμβάματα σε 3 χρόνια και πλέον παρακολούθησης. Dimitrios Nikas; 27/10/2015

Conclusions CCTA provides better anatomical information regarding patients with various degrees of suspected CAD CCTA in low-intermediate patients can provide some more, but not much, prognostic information comparing to SPECT In patients with suspected ACS can reduce time to diagnosis and safely help discharge pts earlier and directly form ER

Conclusions CCTA SPECT Anatomical Functional Information

Combination Anatomical CCTA Functional SPECT makes the best!