Thorax cardio coeur heart evaluation asymptomatic smoker p douek

Cardiac Imaging of 50 Years old Asymptomatic Smoker Toward a better CV Risk Predcition

Philippe DOUEK

Cardiovascular Imaging Department

Hôpital Louis Pradel Lyon

Prevalence of CV Diseases

Les maladies cardiaques coronaires sont la cause la plus fréquente de décès dans notre société

⇒  Recherche de techniques non invasives pour un diagnostic précoce et un suivi fiable

CV Risk Assessment

– Risk Score in asymptomatic patients: •  Framingham •  Euroscore

– Useful when selecting the most appropriate candidates for drug therapies intended to reduce risk

CV Risk Assessment Major risk factors include:

•  cigarette smoking •  hypertension (BP greater than or equal to 140/90 mm Hg or on

antihypertensive medication) •  low HDL cholesterol (less than 40 mg/dL), •  family history of premature CHD (CHD in male first-degree relative

less than 55 years; CHD in female first-degree relative less than 65 years)

•  age (men greater than or equal to 45 years; women greater than or equal to 55 years).

CV Risk Assessment •  CHD Risk—Low

–  Defined by the age-specific risk level that is below average. –  low risk will correlate with a 10-year absolute CHD risk 10%.

• CHD Risk—Intermediate –  moderate risk will correlate with a 10-year absolute CHD risk between

10% to 20%. •  CHD Risk—moderately high risk:

–  2+risk factors plus a 10-years risk for hard CHD less than 10%

• CHD Risk—High –  Defined as the presence of diabetes mellitus in a patient 40 years of

age, peripheral arterial disease or other coronary risk equivalents (2+risk factors),

–  or the 10-year absolute CHD risk of 20%.

Heart Evaluation 50 Years old Asymptomatic Smoker

• CHD Risk—Intermediate –  2+risk factors –  moderate risk will correlate with a 10-year absolute CHD risk between 10% to 20%.

HCL/UCBL

Predicitive Value of Risk Score

Spécificity: 80 % Sensitivity; 50 %

Sensitivity: 75 % Spécificity: 50 %

CV Risk Assessment:

•  CV Risk score failure in 25 à 50% of patients –  CHD Risk—Intermediate

•  Conventional risk factors do not explain high or lower risk in subgroup of patients –  Intensity and duration of smoking –  Age and Duration of Diabetes –  Genomic factors

Recommendations (HAS)

Screening for Ischemic heart disease:

•  Stress Echo •  Spect Imaging

•  Limitations –  Cost efficicacy? –  Operator dependent

10

Atherosclerosis: Plaque rupture -----AMI

11 Coronary remodeling and calcifications

Introduction to CAC Measurement

Introduction to CAC Measurement

•  Calcium because of its high density can be easily detected, segmented, and quantified:

•  Coronary calcifications more frequently found in advanced lesions or in ederly population

•  Positive correlation between localisation and amount of Ca and % of sténosis, but non linear relationship with large confidence interval

•  Coronary calcifications could be founded on segment without stenosis

•  Relationship between calcified plaque and rupture is unknown

•  Statines can decrease or increase coronary calcification burden

•  Greenland et al ACCF AHA expert consensus document on CAC Circulation 2007

ü  20 3 mm axiales slices covering the heart ü  Ca ++ Structures < 1 mm2 exclued (noise) ü  Surface above threshold (ROI i, coronaire j): Aij ü pondération factor fonction maximal density ü  wij = 1 if 130 HU < CTij Max < 200 HU

2 if 200 HU < CTij Max < 300 HU 3 if 300 HU < CTij Max < 400 HU 4 if 400 HU < CTij Max

ü  Lesion Score = wij x Aij ü  Total Score = scores sommation Mesure HU Maxi = CTij Max

SAG = Σij wij Aij

Surface Aij

Agatston Score * Definition:

•  Agatston AS, et al. Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol1990;15:827

Ca Score : Validation

•  MDCT: Technique validation and software plateformes **:

–  Dose < 1mSv 2 –  New algorithms** :

•  Calcium masse score •  Calcium volume score

**Kopp AF, Ohnesorge B, Becker C, et al. Reproducibility and accuracy of coronary calcium

measurements with multi-detector row versus electron-beam CT. Radiology 2002; 225:113-119 **Weiniger M, et al Radiology, 2012; 265, 70-77.

Calcium scoring

Agatston Score: Exemple

ARCA,1= 53,9 mm2

CTmax= 536 HU wRCA,1 = 4

ARCA,2= 70,1 mm2


ARCA,3= 72,0 mm2


ARCA,4= 28,6 mm2


SRCA = 869,8 AG

Avantages

•  No injection •  Low dose •  Fast Acquisition •  Fast and simple post processing

Calcium Score Diagnosis 0 Very low CVD risk 1 - 10 Low CVD risk 11 - 100 Moderate CVD risk

101 - 400 High CVD risk over 400 Very high CVD risk

Calcium Scoring Risk table: SAG by (EB)CT

Ca Score : Cohorte Follow up

HCL/UCBL/INSERM U870 Detrano R NEJM 2008

22% at 10 Y

RR Ratios According to Level of Risk for CACS From Average Risk to very high risk

Greenland et al ACCF AHA expert consensus document on CAC Circulation 2007

HCL/UCBL/INSERM/CNRS

During a median of 5.8 years of follow-up among a final cohort of 5878, 209 CHD events occurred, of which 122 were myocardial infarction, death from CHD, or resuscitated cardiac arrest. •  In model 1 (conv FRCV): 69% of the cohort was classified in the highest

or lowest risk categories compared with 77% in model 2 (CACS) •  CACS resulted in a net reclassification improvement = 0.25; 95%

confidence interval, 0.16-0.34; P < .001). •  Using CACS An additional 23% of those who experienced events were

reclassified as high risk, and an additional 13% without events were reclassified as low risk

Polonsky TS et al JAMA 2010

NRI: (%) of reclassification in population with intermediary risk (Framingham Score)

Kavousis M et al Ann Int Med 2012

Calcium Score: CV Mortality rate 6,8 years follow-up n= 14 759

HCL/UCBL/INSERM / CNRS Williams M et al JACC imaging 2008

Critiques: Quelle valeur prédictive additive quid des calcifications diffuses

atherome diffus distal médiacalcose

Calcium score: LM Lesions

HCL/UCBL/INSERM CNRS Williams M et al JACC imaging 2008

n = 14 759 pts x 6,8 Y

>6 calcified LM lesions mortality rate 13,6 % / Y

CAC score: Pronostic Value

*J Am Coll Cardiol 2004; 43:1663–9

Patients score 0

Patients score > 400

>10 000 patients refered for Ca Score, 10% diabetes*

Ca Score: Additionnal value for CV Risk

•  Lyon, december 212011 PON Gab / - Scanner Philips Cardio

•  Indication : 63 year old smoking, •  Stress ECG 2008 – •  EIMc 0,92 mm plq+ns

•  Ca Score


•  Result :304


•  consequences :

•  revérification new stress ecg : - •  Risk information: High •  Therapy :adjonction ezetrol for goal

LDL decreased from 1,2 g/l to 0,9 g/l •  Aspirine Introduction primary

prevention


•  Indication : Patiente de 65 years old patient smoker HFh never treated statines intolerance , LDL between 3,5 3,8 g/l HDLc 0,45 g/l.

. •  EIMc 0,80 mm plq+ns

•  Ca score : 2 •  No LDL aphéreses •  No aspirine

A range of noninvasive test options is available for

patients…

Exercise ECG Stress

Echo Excercice SPECT

PET

MRI

Ca Scoring

IMT

Comparison With Other Tests for CHD Diagnosis

HCL/UCBL/INSERM /CNRS

Adams et al Circulation 2005 Kablack Ziebinska et al Heart 2004

Diagnostic Accuracy Exercise ECG Test

meta-analysis for CAD obstructive disease: One hundred forty-seven consecutively published reports involving 24 074 patients who underwent both coronary angiography and exercise testing were summarized. •  Wide variability in sensitivity and specificity was found (mean sensitivity

was 68%, with a range of 23% to 100% and a standard deviation of 16%; •  mean specificity was 77%, with a range of 17% to 100% anda standard

deviation of 17%). •  seven consecutively published reports involving 24 074 patients •  Who

Gianrossi et al

Diagnostic Accuracy: Bayesienne Approch

Probability pré-test of coronaropathy, %

Prob

abili

ty P

OST

-test

of c

oron

ar.,

%

100

100

54

50

0

Ca ++ Score

Stress ECG

Adapted from Diamond GA, Forrester JS. N Engl J Med. 1979;300:1350-1358.

20

85

Comparison With Other Tests for CHD Diagnosis

HCL/UCBL/INSERM CNRS

Adams et al.Fleischmann KE, Hunink MG, Kuntz KM, Douglas PS. Exercise echocardiography or exercise SPECT imaging? A meta-analysis of diagnostic test performance. JAMA 1998;280

Myocardial Perfusion Imaging and Stress Echocardiography.

24 reported exercise echocardiography results in 2637 patients 27 reported exercise SPECT in 3237 patients •  24 reported •  exercise echocardiography results in 2637 patients •  Exercise echocardiography had a sensitivity of 85% (95% CI 83% to 87%) with a

specificity of 77% (95% CI 74% to 80%) •  Exercise perfusion yielded a similar sensitivity of 87% (95% CI 86% to 88%) but a

lower specificity of 64% (95% CI 60% to 68%)

IMT Limitations

HCL/UCBL/INSERM U870

Adams et al Circulation 2005 Kablack Ziebinska et al Heart 2004

Comparaison of l’IMTc vs Ca Score for identication of lesions > 50 %

HCL/UCBL/INSERM CNRS

ROC adjusted pour age and sex Terry JG et al ATVB 2005

Comparaison Ca Score IMT Ca score IMT

morphology morphology

Coronary Localisation + -

LM LAD Carotid stenosis

Prédiction ++/ quantitative +/quantitative

Validity IIa IIb

duration 10 secs 15-20 mn

reproductibility +++ +? Inter obs dep +++

cost ++ radio + radio ou cardio ou angeiologue

100,51 +40,38 +1,5 = 142,39 € 75,6€

Limitations •  whether to include any newer test in a risk prediction algorithm requires full

consideration of the financial costs (health system). •  clinical cost (individual people) exposing potentially healthy populations to

radiation in a screening program requires careful considerations of the balance of risks and benefits.

HCL/UCBL/INSERM /CNRS

The EISNER Study

Early Impact of Coronary Artery Calcium Scanning on Coronary Risk Factors and Downstream Testing

Impact of Coronary Artery Calcium Scanning on Coronary Risk Factors and Downstream Testing

The EISNER (Early Impact of Coronary Artery Calcium Scanning onCoronary Risk Factors and Downstream Testing

•  Méthods: –  Randomisation of 2137 < 80 ans - before risk facor consulattion: –  Primary criteria: : risk factor change

The EISNER Study

HCL/UCBL/INSERM U870 Rozanski et all JACC 2011

Cedar mount sinai LA population!!!

HCL/UCBL/INSERM CNRS Rozanski et all JACC 2011

Impact of Coronary Artery Calcium Scanning on Coronary Risk Factors and Downstream Testing

The EISNER (Early Impact of Coronary Artery Calcium Scanning onCoronary Risk Factors and Downstream Testing

•  Results summary: at 4 years

•  With CA score: •  TA systolique LDL cholestérol, abddominal perimeter and weight decrease •  Proportional response to ca sore

–  Without Ca score Framingham score increase

–  No significative impact on other medical test, medication and cost in mean •  More d’exams and medications if Ca score> 400 •  Less si Ca score= 0

Recommendations: Asymptomatic Patient

•  Calcium scoring – Appropriate if intermediate risk A(7)

•  If high CAC –  Reclassification to a higher risk status –  Subsequent patient management modified

Greenland P et al. Circulation 2007 Oudkerk et al. Int J Cardiovasc Imaging 2008

Recommendations: Asymptomatic Patient

•  Calcium scoring – Appropriate if intermediate risk A(7) – Appropriate if low risk and Family history of

premature CHD A(7) •  CTA

–  Inapropriate •  but, U(4) in high risk patient

Greenland P et al. Circulation 2007 Oudkerk et al. Int J Cardiovasc Imaging 2008

CTA Indications §  Coronary artery diseases

ü  Detection of CAD in ü  (A) symptomatic patients ü With(out) known CAD ü Preoperative Coronary Assessment Prior to Noncoronary Cardiac

Surgery ü Use of CTA in the Setting of Prior Test Results

ü  By pass graft control ü  Stents control ü  Assessment of anomalies of coronary arterial and other thoracic

arteriovenous vessels

§  Cardiac diseases; evaluation of cardiac sructures and function ü  Heart failure ü  Electrophysiological procedure ü  Cardiac anatomy:

ü Congénital heart diseases ü Tumor

Detection of CAD in Symptomatic Patients Without Known Heart Disease

•  ECG non diagnostic/ impossible stress – Low risk A(7) –  intermédiate risk A(8) – High Risk U(4)

Asymptomatic Patient •  Seoul National University study

–  1000 volunteers patients, mean age of 50 year old , 63% men

•  215 patients +, 40 (4%) with lésions non Ca •  52 patients (5%) st >50% •  21 patients (2%) st>70%

–  Mean follow up 17 month •  15 MACE (all CT +) dont 14 revascularizations

–  Non négligeable prevalence

Choi EK et al. JACC 2008;52:366

Axial cardiac CT images in 63-year-old man.

Kim T J et al. Radiology 2010;255:369-376

©2010 by Radiological Society of North America

Axial cardiac CT images in 63-year-old man with solitary pulmonary nodule that is visible in full FOV only.



Axial full-FOV thoracic CT image in 57-year-old woman shows right upper lobe nonsolid nodule (arrow), which was not visible on full-FOV cardiac image (not shown).



Axial full-FOV thoracic CT image in 64-year-old man with left-side chest pain shows left upper lobe spiculated mass (arrow) with pleural retraction.



Lung Cancer Detected at Cardiac CT: Prevalence, Clinicoradiologic Features, and Importance of Full–FOV Images

•  Materials and Methods:

–  retrospective study between January 2004 and December 2007. –  Patients known to have lung cancer at the time of cardiac CT were excluded. –  The rates of lung cancer detection at three FOVs—limited and full FOV at cardiac scanning

and full FOV at thoracic scanning—were compared by using McNemar testing. •  Results:

–  The prevalence of lung cancer detected at CT was 0.31% (36 of 11654 patients, 16 [44%] never smokers) and was higher in patients suspected or known to have coronary artery disease (0.43% [24 of 5615 patients]) than in asymptomatic screening-examined patients (0.20% [12 of 5924 patients]) (P = .0457).

–  Adenocarcinoma was the most common (in 31 [86%] of 36 patients) histologic subtype. –  Of 34 non–small cell lung cancers, 23 (68%)—including 16 stage IA cancers—were resectable. –  Four (11%) and 19 (53%) of the 36 CT-depicted cancers were visible in limited and full FOV

at cardiac scanning, respectively, and 17 (47%) were visible in full FOV at thoracic scanning only.

•  •  Conclusion:

–  The prevalence of lung cancer at cardiac CT was 0.31%; and 68% of these malignancies were at a resectable stage.

–  Use of a limited FOV at cardiac scanning led to a large majority (89% [32 of 36 cancers]) of the lung cancers detected at full thoracic scanning being missed; thus, inclusion of the entire chest at cardiac CT is advisable.

• 

=

Take Home message Stratification of indermediary risk +++++ Ca Score

Thank you…

Thorax cardio coeur heart evaluation asymptomatic smoker p douek

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