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The Efficacy of Non-invasive Diagnostic for CAD in PMK Hospital

The Efficacy of Non-invasive Diagnostic for CAD in PMK Hospital. Maj. Hutsaya Prasitdumrong , M.D. Cardiovascular Division, Department of Internal Medicine, Phramongkutklao Hospital. Endothelial Dysfunction. Coronary atherosclerosis Coronary artery disease (CAD)

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The Efficacy of Non-invasive Diagnostic for CAD in PMK Hospital

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  1. The Efficacy of Non-invasive Diagnostic for CAD in PMK Hospital Maj. HutsayaPrasitdumrong, M.D. Cardiovascular Division, Department of Internal Medicine, Phramongkutklao Hospital

  2. Endothelial Dysfunction Coronary atherosclerosis Coronary artery disease (CAD) Ischemic heart disease (IHD) Atheroma Complicated lesion/ rupture Foam cells Fatty streak Fibrous plaque Intermediate lesion From First Decade From Third Decade From Fourth Decade

  3. Investigations for CAD Functional Tests Exercise stress test Stress ECHO Stress CMR MPI: SPECT PET Anatomical Tests CT angiography MR angiography Coronary angiography

  4. Coronary Angiography • GOLD standard for detection of CAD • Identify coronary arteries stenosis and its severity

  5. Diagnostic Accuracy of Non-invasive Modalities for Detection of CAD Applied Radiology 2011;40(5):13-22

  6. Coronary Angiography VS Coronary CT Angiography Coronary Angiography Coronary CT Angiography Non-invasive Out patient visit Iodine contrast Radiation Cost Resume normal activity right after scanning Risk: safer • Invasive • Require day care admission • Iodine contrast • Radiation • Cost • Resume normal activity after 24 hours • Risk: death, stroke, CA dissection about 1:1000

  7. Coronary Angiography VS Coronary CT Angiography Coronary Angiography Coronary CT Angiography

  8. Non-invasive or Invasive Test Circulation 2002;106:1883-92

  9. Coronary CT Angiography • Coronary artery calcified plaque is nearly 100% specific for atheromatous coronary plaque • Can develop early in the course of subclinical atherosclerosis • Present in the intima of both obstructive and non-obstructive lesion

  10. Coronary Calcium Score Developed by David King Published by Agatston and coworker

  11. Coronary Calcium VS Atherosclerosis Coronary calcium by EBCT and atherosclerotic plaque by histopathology Rumberger, j.a. et al. Circulation 1995;92:2157-62

  12. Coronary Calcium & Coronary Events Detrano et al. NEJM 2008;358(13):1336-45

  13. Risk Stratification

  14. 640-Slice ct scanner

  15. 64-Slice VS 640-Slice CT Angiography 64-Slice CTA 640-Slice CTA 160 mm wide area detector Scanning in 1 rotation Shorter exposure time Radiation dose reduced by up to 50% Less contrast (50 cc) Less artifact Available in AF patient • 32 mm area detector • Scanning is in helical mode • Longer exposure time • Higher dose of radiation • Higher dose of contrast (80-100 cc) • More artifact

  16. PMK Heart Center Protocol Take history of previous contrast allergy and PDE5 drug use 0.4 mg Nitroglycerine oral spray 1 puff Target HR 60 bpm prior to scan Med: Metoprolol up to 100 mg keep BP > 110/70 Alt: Ivabradine 5 mg bid for 3 days CTA scan: Prospective scan 100-120 kVp Contrast 40-45 cc Effective dose 3.5-4.5 mSv At observation room

  17. Effective Dose for Cardiovascular Imaging Tests Catheterization and Cardiovascular Intervention 2011;77:546-56

  18. Appropriate Criteria for Calcium Scan and Coronary CTA • Calcium scan • Intermediate risk for CAD • Low risk for CAD with family history of premature coronary heart disease • Coronary CTA • Symptomatic patient with low or intermediate risk • Reduced LVEF with low or intermediate risk • Pre-op evaluation for non-cardiac surgery • Post revascularization JACC 2010;56(22):1864-1894

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