Seeing is Believing: From stress test with imaging to coronary angiography

How to effectively use Imaging in clinical practice

Michael Freeman No conflicts

Objectives

•  To develop an approach for assessing risk in patients with atypical symptoms and stable angina pectoris •  To critically appraise the utilization of imaging in our patients •  To choose wisely and appropriately patients who would benefit from radionuclide imaging studies

Mrs. A.B. •  •  •  •  •  • 

64 y/o grandmother, atypical angina hypertension treated with ACE inhibitor postmenopausal, not on HRT, LDL 3.1, HDL 0.9 No FH of CAD, no DM, smoker BP 150/90, HR 78, P/E Normal, BMI 35 Normal ECG

What Should We Do? •  •  •  •  •  •  • 

Reassure Coronary Calcium Score Exercise ECG Stress Myocardial Perfusion imaging Stress echocardiography CTA Cardiac Catheterization

Growth in Imaging

Risk vs Benefit

Treadmill Exercise

8.5 minutes Bruce Protocol No Symptoms HR 133 (85% predicted)

DUKE SCORE = -1 Minutes – 5xST – 2(AS) Event rate 1.25%/year

Duke Treadmill Score Risk Assignment

Low (62%)

Intermediate (34%)

High (4%)

>5

-10 to +4

0.75, FFR >0.75, FFR INT risk •  Aggressive risk factor modification if NI risk < INT risk

AUC On-Line •  http://www.astellasapps.com/webapp.php