Risk Assessment in the Asymptomatic Patient

Computed Tomography Angiography

Arthur J.H.A. Scholte

Depart. of Cardiology

Leiden University Medical Center

The Netherlands

ESC Munich 2012

NO CONFLICTS OF INTEREST

Case History

• Asymptomatic 64 y old Dutch male

• 1.82 m, 95 kg, BMI 29

• Father died at 45 years AMI

• Systolic blood pressure of 140 mm Hg

• Smoker

• Normal ECG and cholesterol levels

10 year risk of fatal CVD in high risk

regions of Europe

13 %

Next step?

Questions

• Is an asymptomatic adult a patient?

• Should we image asymptomatic patients?

• Is CAD outcome worse in asymptomatics?

• Can we diagnose CAD reliably with CTA?

• Can high risk asymptomatic be identified?

• Can high risk be modified and improve outcome?

• Is it cost effective?

How can CT(A) help our patient?

1. Anatomic information of the coronary arteries

Origin

Dominancy

Interarterial course

Intramural course/bridging

Anomaly

2. Anatomic information of atherosclerosis

% of stenosis

plaque type/length/burden

remoddeling

3. LV function, perfusion, FFR

Studies in the literature (1)

Choi EK JACC 2008

5% ≥ 50% stenosis

2% ≥ 75% stenosis

15 cardiac events, 1 UA, 14 revasc (17±2 mo FU)

Studies in the literature (2)

Hadamitzky M Am J Cardiol 2010

N=451, mean FU 28 mo

54% non-obstr CAD

24% obstr CAD

2 UA, 8 revasc

CONFIRM Registry (7590 Asymptomatics)

Cho I et al. Circulation 2012;126:304-313

No incremental discriminatory value of CTA to

CACs and standard risk factors for

reclassification!

No recommendation: 8

Recommended for intermediate or high risk CAD based on FRS: 6

CAC score: 5

Position statement ESC WG

Nuclear Cardiology and Cardiac

CT

Perrone-Filardi et al. EHJ 2010

2010 ACCCF/AHA Guideline for

assessment of CV Risk in

Asymptomatic Adults

Greenland et al. Circulation 2010

Comparison to other non-invasive

cardiac imaging techniques

CTA CACs MPS

Anatomy + +/- -

Ischemia - - +

Radiation 4 0.7-3.0 3(6)

Costs 250 250 450

Time 90 15 90 + 60

Specific group of asymptomatic

patients with higher risk?

• Diabetes

• Coronary anomaly

• Familial hypercholesterolemia

• Pre-operative risk

• Post-radiotherapy Hodgkin disease

• Professional sporters

48 year old male, 1991 Hodgkin disease,

chemotherapy and radiotherapy of the mediastinum

Pre-operative risk assessment of 65 year old

female with atypical CP, DM, hypertension and

pancreas carcinoma

Screening of asymptomatic 57 year old

diabetic with a normal MPS

3 vessel disease with LM stenosis

LAD LCx

LM

64 year old male with PVI and no CP

Answers to my patient

• Is an asymptomatic individual a patient? No

• Should we image asymptomatic patients? May be some?

• Is CAD outcome worse in asymptomatics? YES

• Can we diagnose silent CAD reliably with CTA? YES

• Can high risk asymptomatic be identified? YES

• Can high risk be modified and improve outcome? YES

• Is it cost effective? ?

Conclusions

• CTA can be used for detection of asymptomatic CAD in subjects

• Routine screening with CTA is not recommended

• There maybe a role in the future for CTA in specific patient groups with increased risk for CAD