Transcript Supplemental Content - Annals of Internal Medicine

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© 2016 American College of Physicians
The information contained herein should never be
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BEYOND THE GUIDELINES:
Screening for Coronary Artery Disease in
Asymptomatic Persons
Medicine Grand Rounds
October 22, 2015
Discussants
Donald E. Cutlip,
M.D.
Duane S. Pinto,
M.D.
BIDMC Assistant
Series Editor
Gerald W.
Smetana, M.D.
The Series Editors have no conflicts of interest to disclose.
Moderator
Deborah Cotton,
M.D., MPH
Conflict of Interest Disclosure
The speakers have no financial
relationships with a commercial entity
producing healthcare-related products
and/or services.
Gerald W. Smetana, M.D.
Donald E. Cutlip, MD
Deborah Cotton, M.D., MPH
Dr. Pinto discloses the following relationships
with commercial entities producing healthcare related products and/or services:
Medicines Company
Medtronic
Abbott Vascular
Covidien
OUR PATIENT
Mr. F: Medical History
• Mr. F is a 72 year old man who is generally fit
• Walks for exercise
• No exertional chest pain, dyspnea, or other exercise
limitation
• Acknowledges generalized worry about health
• Has wondered if he should be screened for coronary
artery disease to reduce risk of heart attack
• Not sure what he would do with a positive test
OUR PATIENT
Past Medical and Surgical History
•
•
•
•
•
•
Hypertension
Elevated cholesterol
Hypothyroidism
Allergic rhinitis
Anxiety
Fatigue
• Insomnia
• Irritable bowel
syndrome
• Low back pain
• H/o palpitations
• GERD
OUR PATIENT
Cardiac History
•
•
•
•
1991 palpitations
Briefly on propranolol to alleviate symptoms
Holter showed few symptomatic PACs
Exercise tolerance test to a rate pressure
product of 31,000 was negative for ischemia
• No cardiac testing since
• Palpitations since resolved
OUR PATIENT
Social and Family History
•
•
•
•
•
•
Former smoker, < ½ ppd, last 25 years ago
Worked in marketing and product branding
Mostly retired now
No family history of heart disease
Tries to follow a heart healthy diet
Framingham 10-year risk CHD estimate: 16%
OUR PATIENT
Medications
•
•
•
•
•
•
Lisinopril 40 mg qd
Levothyroxine 100 mcg qd
Simvastatin 40 mg qd
Aspirin 81 mg qd
Loratadine prn
Nasacort
OUR PATIENT
Periodic Health Examination
•
•
•
•
•
Well appearing
BP 150/82 (white coat component), HR 66
Chest – clear
Cardiac – S4, S1, S2 normal. No S3 or murmur
Extremities – no edema. DP pulses full and
symmetric
• Labs: Cholesterol 205, HDL 74, LDL 112
OUR PATIENT
Resting ECG 7/19/05
1st Audience Vote
Will Go Here
CONTEXT, EVIDENCE, & GUIDELINES
March 17, 2015
CONTEXT, EVIDENCE, & GUIDELINES
Potential rationale for screening
• Coronary heart disease (CHD) causes 1/3 of deaths
among those > 35 years old in the U.S.
• High prevalence: by middle age, 50% of men and
33% of women have evidence of CHD
• The first presentation of CHD can be catastrophic
– Sudden cardiac death
– Acute MI
• Sudden cardiac death preceded by cardiac
symptoms in less than one half of patients
CONTEXT, EVIDENCE, & GUIDELINES
Methodology – Information Sources
• Systematic review (2011) and recommendations
(2012) from USPSTF
• Guidelines from the American College of Cardiology
(2010)
• Appropriateness criteria from consensus
committees (2008)
• Target patient population is asymptomatic low risk
patients (10 year CHD risk < 10%)
CONTEXT, EVIDENCE, & GUIDELINES
What does the guideline not cover?
•
•
•
•
Pediatric screening
Preoperative cardiac evaluation
ECG for drug safety monitoring
Diagnostic cardiac testing for evaluation of
chest pain, dyspnea, or effort intolerance
Recommendations of Others: USPSTF 2012
• Resting and exercise abnormalities are associated with
increased risk of CHD events
• Inadequate evidence that screening adds to risk
assessment based on clinical evaluation alone
• Recommends against screening with resting or exercise
ECG for predicting CHD events in asymptomatic low
risk patient (level D)
• Evidence insufficient to recommend for or against
screening in adults at intermediate to high risk (level I)
*Moyer VA, U.S. Preventive Services Task Force. Screening for Coronary Heart Disease With Electrocardiography:
U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2012;157:512-518.
USPSTF: Potential Harms and Benefits
Potential Harms
Potential Benefits
• Overtreatment
• Unnecessary invasive
procedures
• Abnormalities on exercise
ECG confer increased rates
of CHD events (RR 1.4-2.12
range)
• Unknown if results change
risk stratification beyond
clinical assessment
• Unlikely to prompt new or
different interventions to
reduce CHD risk
– Bleeding, radiation exposure,
MI, contrast reactions
• Labeling
• 3% of asymptomatic
patients with abnormal
exercise ECG subjected to
cath
• Downstream costs
*Moyer VA, U.S. Preventive Services Task Force. Screening for Coronary Heart
Disease With Electrocardiography: U.S. Preventive Services Task Force
Recommendation Statement. Ann Intern Med. 2012;157:512-518.
American College of Cardiology
2010
• Exercise echocardiography and exercise MPI not indicated in
asymptomatic low and intermediate risk adults (Class III)
• Consider exercise ECG for intermediate risk asymptomatic
patient including those planning to begin a vigorous exercise
program (Class IIb)
– Exercise time, ST segment changes, chronotropic response,
and heart rate recovery each predict CHD events
• Consider exercise MPI in asymptomatic adults with diabetes,
strong family history, or high coronary calcium score (Class IIb)
*Greenland P, Alpert JS, Beller GA, Benjamin EJ, Budoff MJ, Fayad ZA, et al. 2010
ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults: a
Report of the American College of Cardiology Foundation/American Heart Association
Task Force on Practice Guidelines. J Am Coll Cardiol. 2010;56:e50-103.
QUESTIONS TO DISCUSSANTS
1. Do findings on resting ECG, stress echocardiography, or
myocardial perfusion imaging accurately estimate 10-year
risk of coronary events in asymptomatic patients?
2. Do medical therapies or percutaneous coronary
interventions improve outcomes in asymptomatic patients
who “screen positive” for coronary artery disease?
3. Do existing cardiovascular risk calculators identify
asymptomatic patients who would benefit from screening
for CAD?
OUR MODERATOR & DISCUSSANTS
Deborah Cotton, M.D., MPH (Moderator)
Deputy Editor, Annals of Internal Medicine
Professor of Medicine, Boston Univ School of Medicine
Donald E. Cutlip, M.D.
Professor of Medicine, Harvard Medical School
Division of Cardiology, BIDMC
Duane S. Pinto, M.D.
Associate Professor of Medicine, Harvard Medical
School, Division of Cardiology, BIDMC
Donald E. Cutlip, M.D.
Argument in Favor of Screening
Question 1.
Do screening tests detect patients at
higher risk of MI or sudden cardiac death?
Coronary Events and Asymptomatic Patients
• Symptoms are important predictor of outcomes
– Among 5,558 who were administered the Seattle Angina
Questionnaire, increasing frequency of symptoms and physical
limitation were strongly associated with one year mortality.1
• Asymptomatic status provides limited reassurance
– Over ½ of patients presenting with sudden cardiac death are
previously asymptomatic.2
– Among patients presenting with first acute MI, only ½ have had
preceding angina.3
– Silent MI may represent up to 1/3 of MI with increasing prevalence
over age 60 and with CAD risk factors.4
1.
2.
Spertus JA, Jones P, McDonell M, Fan V, Fihn SD. Health Status Predicts Long-Term Outcome
in Outpatients With Coronary Disease. Circulation. 2002;106:43-49.
Lerner DJ, Kannel WB. Patterns of Coronary Heart Disease Morbidity and Mortality in the
Sexes: a 26-year Follow-Up of the Framingham Population. 1986;111:383-390.
3.
4.
Pierard LA, Dubois C, Smeets JP, Boland J, Carlier J, Kulbertus HE. Prognostic Significance of Angina
Pectoris Before First Acute Myocardial Infarction. Am J Cardiol. 1988;61:984-987.
Sigurdsson E, Thorgeirsson G, Sigvaldason H, Sigfusson N. Unrecognized Myocardial Infarction:
Epidemiology, Clinical Characteristics, and the Prognostic Role of Angina Pectoris: The Reykjavik Study.
Ann Intern Med. 1995;122:96-102.
Screening tests and coronary outcome risk
Detection of ischemia and risk of death or MI
• 1126 asymptomatic pts, >10% ischemic myocardium by SPECT
MPI associated with death or MI (HR 2.7, 95% CI 1.3-5.4). 1
• 10,627 pts (60% w/o angina), death or MI ↑ linearly with
ischemia by SPECT MPI (0.7% for 0% ischemia to 6.7% for >20%
ischemia).2
• 14, 140 pts (~50% w/o prior CAD or med Rx), ischemia on stress
echo was an independent predictor of mortality for DM (HR
1.7) and non DM (HR 1.5). 3
1.
2.
3.
Chang SM, Nabi F, Xu J, Peterson LE, Achari A, Pratt CM, et al. The Coronary Artery Calcium Score and Stress Myocardial Perfusion Imaging
Provide Independent and Complementary Prediction of Cardiac Risk. J Am Coll Cardiol. 2009;54:1872-1882.
Hachamovitch R, Hayes SW, Friedman JD, Cohen I, Berman DS. Comparison of the Short-Term Survival Benefit Associated With
Revascularization Compared With Medical Therapy in Patients With No Prior Coronary Artery Disease Undergoing Stress Myocardial Perfusion
Single Photon Emission Computed Tomography. Circulation 2003;107:2900-2907.
Cortigiani L, Borelli L, Raciti M, Bovenzi F, Picano E, Molinaro S, et al. Prediction of Mortality by Stress Echocardiography in 2835 Diabetic and
11 305 Nondiabetic Patients. Circ Cardiovasc Imaging. 2015;8:e002757.
Do screening tests detect patients at higher risk
of MI or sudden cardiac death?
Yes. Despite the absence of symptoms, a positive screening test
for ischemia in our patient would indicate a higher risk for
subsequent cardiac death or MI.
Question 2.
Do medical therapies or percutaneous coronary
interventions improve outcomes in asymptomatic
patients who “screen positive” for coronary
artery disease?
Detection of Silent Ischemia and Medical Therapy
Guideline Directed Medical Therapy
• Lifestyle modification for smoking cessation, diet and exercise.1
• Add moderate- or high-intensity statin based on baseline LDL,
presence of DM, and estimated 10-year ASCVD risk. 2
• Treatment of BP and HbA1C to goal if applicable.
GDMT reduces coronary events and improves survival
1.
2.
Eckel RH, Jakicic JM, Ard JD, de Jesus JM, Houston Miller N, Hubbard VS, et al. 2013 AHA/ACC Guideline on Lifestyle Management
to Reduce Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice
Guidelines. Circulation. 2014;129:S76-99.
Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, et al. 2013 ACC/AHA Guideline on the Treatment of
Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:S1-45.
Treating Asymptomatic Ischemia
Medical Therapy
• Beta blockers and calcium channel blockers have been shown
to reduce silent ischemia.
• In the ASIST RCT of 306 pts. with silent ischemia, atenolol vs.
placebo associated with longer event-free survival and trends
for lower mortality and non-fatal MI.1
• In the ACIP RCT of 618 pts., combination anti-ischemic medical
Rx or revascularization associated with reduction in silent
ischemia. The degree of improvement with med Rx was
associated with better prognosis.2
1.
2.
Pepine CJ, Cohen PF, Deedwania PC, Gibson RS, Handberg E, Hill JA, et al. Effects of Treatment on Outcome in Mildly
Symptomatic Patients with Ischemia During Daily Life. The Atenolol Silent Ischemia Study (ASIST). Circulation. 1994;90:762768.
Knatterud GL, Bourassa MG, Pepine CJ, Geller NL, Sopko G, Chaitman BR, et al. Effects of Treatment Strategies to Suppress
Ischemia in Patients with Coronary Artery Disease: 12-Week Results of the Asymptomatic Cardiac Ischemia Pilot (ACIP)
study. J Am Coll Cardiol. 1994;24:11-20.
Benefit of Optimal Medical Therapy
Courage Trial
N = 2287; OMT vs. Coronary Stenting; 12% Class 0 Angina.
1 endpoint – Death or MI
Meds at 5 Years
Statin
93%
ACE I or ARB
77%
Aspirin
95%
Beta Blocker
86%
Ca++ Blocker
52%
Residual ischemia at 6-18 months was a
significant predictor of future death or MI
regardless of strategy.
*From New England Journal of Medicine, Boden WE, O'Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk
WJ, et al, Optimal Medical Therapy with or without PCI for Stable Coronary Disease, Vol. 356, pp. 15031516, Copyright © 2007, Massachusetts Medical Society. Reprinted with permission from Massachusetts
Medical Society.
*Shaw LJ, Berman DS, Maron DJ, Mancini GB, Hayes SW, Hartigan PM, et al. Optimal Medical
Therapy With or Without Percutaneous Coronary Intervention to Reduce Ischemic Burden:
Results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug
Evaluation (COURAGE) Trial Nuclear Substudy. Circulation. 2008;117:1283-1291.
Do medical therapies or percutaneous coronary
interventions improve outcomes in asymptomatic
patients who “screen positive” for coronary
artery disease?
Yes. Anti-ischemia therapies reduce risk for death or MI in
patients with stable ischemic heart disease, including those with
silent ischemia.
Revascularization and Asymptomatic Ischemia
Role of the Interventional Cardiologist
• Appropriate use criteria specify revascularization as appropriate
for asymptomatic patients only if very high-risk anatomy or
high-risk non-invasive testing despite medical therapy. 1
Asymptomati
c
Positive ETT
(? False +)
1.
Diagnostic
Angiography
PCI
(Inappropriate)
Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA, American College of Cardiology Foundation Appropriateness Criteria Task Force, et al.
ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization: a Report by the American College of Cardiology
Foundation Appropriateness Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American
Association for Thoracic Surgery, American Heart Association, and the American Society of Nuclear Cardiology Endorsed by the American Society of
Echocardiography, the Heart Failure Society of America, and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol. 2009;53:530-553.
Question 3.
Do existing cardiovascular risk calculators identify
asymptomatic patients who would benefit from
screening for CAD?
Value and Limitations of Risk Calculators
• Risk calculators are based on multivariable statistical models
that perform moderately well at a population level.
• Limited ability to discriminate individuals who will
experience a coronary event.
– >75% of asymptomatic patients in low or intermediate risk categories
– 60-75% of first coronary events occur in low or intermediate risk
groups 1
• Framingham risk score does not incorporate diabetes or
family history.
1.
Akosah KO, Schaper A, Cogbill C, Schoenfeld P. Preventing Myocardial Infarction in the Young Adult in the
First Place: How do the National Cholesterol Education Panel III Guidelines Perform? J Am Coll Cardiol.
2003;41:1475-1479.
Risk Calculators and Asymptomatic Patients
Identifying patients for additional screening
Asymptomatic Population aged 40-79 (NHANES Overall)
Proportion of Population
Appropriate Use
Category
10-year risk
Men
Women
Criteria for ETT
Low
<10%
65.8%
82.5%
Rarely Appropriate
Intermediate
10-20%
20.9%
10.0%
May Be Appropriate
High
>20%
13.3%
7.5%
Appropriate*
* May be appropriate for ETT with imaging
•
•
Goff DC Jr, Lloyd-Jones DM, Bennett G, Coady S, D'Agostino RB, Gibbons R, et al. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: a Report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:S49-73.
Wolk MJ, Bailey SR, Doherty JU, Douglas PS, Hendel RC, Kramer CM, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 Multimodality Appropriate Use Criteria for the
Detection and Risk Assessment of Stable Ischemic Heart Disease: a Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart
Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography
and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2014;63:380-406.
Risk Calculators and Asymptomatic Patients
Assessing Individual Risk
• Assessing sub-clinical coronary artery disease
– Silent ischemia: Important but less frequent in low and intermediate
risk patients
– Vulnerable plaque (most <50% stenosis) and subsequent acute
coronary syndrome as initial manifestation of disease
• ACC/AHA guideline advises consideration of newer markers
(hsCRP, Coronary CT Calcium score [CCS], ABI). (Class IIb)
• CCS as a surrogate of plaque burden is a strong prognostic
indicator and adds individual risk stratification.
*Goff DC Jr, Lloyd-Jones DM, Bennett G, Coady S, D'Agostino RB, Gibbons R, et al. 2013 ACC/AHA
Guideline on the Assessment of Cardiovascular Risk: a Report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:S4973.
Reclassification of Individual Risk by CCS
Population/N
MESA1
6814
10-Year Low
Risk Threshold
CCS
Threshold Impact on Risk Stratification
<7.5%
300
Neg. CCS: 10y event rate = 3%
Pos. CCS: 10y event rate = 13%
Framingham*2
3529
10%
100
If Intermediate Risk by FRS:
Neg. CCS = 25% > low risk
Pos. CCS = 39% > high risk
South Bay3
1461
10%
300
Pos. CCS predicted individual
risk if FRS >10% (p>0.05 if ≤10%)
FRS 10-15%: HR 17.6 (3.7-83.0)
FRS 16-20%: HR 8.9 (1.9-41.8)
1.
* Offspring and
3rd
gen. cohort
2.
3.
Yeboah J, Polonsky TS, Young R, McClelland RL, Delaney JC, Dawood F, et al. Utility of Nontraditional Risk Markers
in Individuals Ineligible for Statin Therapy According to the 2013 American College of Cardiology/American Heart
Association Cholesterol Guidelines. Circulation. 2015;132:916-922.
Preis SR, Hwang SJ, Fox CS, Massaro JM, Levy D, Hoffmann U, et al. Eligibility of Individuals with Subclinical
Coronary Artery Calcium and Intermediate Coronary Heart Disease Risk for Reclassification (from the Framingham
Heart Study). Am J Cardiol. 2009;103:1710-1715.
Greenland P, LaBree L, Azen SP, Doherty TM, Detrano RC. Coronary Artery Calcium Score Combined with
Framingham Score for Risk Prediction in Asymptomatic Individuals. JAMA. 2004;291:210-215.
Screening for CAD in Asymptomatic Patients
Proposed Algorithm
Careful History
Atypical Symptoms
Functional Status
Risk Calculator
(Our patient ~19-20%)
Low Risk
Intermediate Risk
High Risk
 Low yield for screening
 Consider ETT or CCS
if clinical uncertainty
• Consider CCS
• If high risk after CCS
• Maximize GDMT
• ± ETT*
• Maximize GDMT
• ± ETT*
* ETT if uncertain symptoms
or functional status
Duane S. Pinto, M.D.
Argument Against Screening
Common Misconceptions
Myth: An asymptomatic patient with an abnormal ETT is at high
risk for short term complications
“Thankfully, doc ordered that screening stress test when I turned
50 and that other nice doctor did an angioplasty the next day. I
could have had a heart attack!”
Facts
• The benefit of revascularization in asymptomatic patients (even our high-risk
diabetic patients) is likely restricted only to those with high risk stress test
findings.
• Risk of periprocedural MI approximates annual risk in some cases
*Sorajja P, Chareonthaitawee P, Rajagopalan N, Miller TD, Frye RL, Hodge DO, et al. Improved survival in asymptomatic
diabetic patients with high-risk SPECT imaging treated with coronary artery bypass grafting. Circulation. 2005;112:I311-1316.
Everybody’s Happy After the Screening Test!
• Patient’s Happy-”My blockage is now fixed! Doc Found It!”
• Referring MD Happy -”Whew! Heart attack averted!”
• Interventional Cardiologist Happy-”Another successful
(billable?) procedure!”
• Hospital’s Happy-”I like that DRG!”
• Dr. Zeidel’s Happy-”RVUs increasing in Cardiology”
What were the goals of care?
Did we practice evidence based medicine?
Assessing Quality in Medical Care
• Current paradigm of quality improvement generally focuses on
identifying of specific processes of care (e.g., guidelines) and
assessing how frequently they are achieved in an “ideal patient
population”
• Much less attention has traditionally been paid to the frequency
of overuse of treatments in patients for whom there is little or
no evidence of benefit
• As compliance with standard performance measures increases,
however, much of the real opportunity to improve quality of
care may lie in identifying inappropriate care/overuse
WHO “Wilson’s Criteria” for a Screening Test”
1.
2.
3.
4.
5.
The condition should be an
important health problem.
There should be a treatment
for the condition.
Facilities for diagnosis and
treatment should be available.
There should be a latent stage
of the disease.
There should be a test or
examination for the condition.
*Wilson JMG, Jungner G. Principles and Practice of Screening for Disease. WHO Chronicle Geneva:
World Health Organization, Public Health Pap. 1968;34:22-473.
5.
6.
7.
8.
9.
The test should be acceptable to the
population.
The natural history of the disease
should be adequately understood.
There should be an agreed policy on
whom to treat.
The total cost of finding a case should
be economically balanced in relation
to medical expenditure as a whole.
Case-finding should be a continuous
process, not just a "once and for all"
project.
WHO “Wilson’s Criteria” for a Screening Test”
 The condition should be an
important health problem.
 There should be a treatment for
the condition.
 Facilities for diagnosis and
treatment should be available.
 There should be a latent stage of
the disease.
 There should be a test or
examination for the condition.
*Wilson JMG, Jungner G. Principles and Practice of Screening for Disease. WHO Chronicle
Geneva: World Health Organization, Public Health Pap. 1968;34:22-473.

6.
7.
8.
9.
The test should be acceptable to the
population.
The natural history of the disease
should be adequately understood.
There should be an agreed policy on
whom to treat.
The total cost of finding a case should
be economically balanced in relation
to medical expenditure as a whole.
Case-finding should be a continuous
process, not just a "once and for all"
project.
The Argument Against Screening for CAD
in Asymptomatic Patients
• It doesn’t work.
1. The inaccuracy of the screening tests simply
engenders more testing in healthy people
2. The chances of finding coronary disease where
revascularization alters prognosis is <1%
3. Any results reemphasize the need for medical
therapy that the patients should have been getting
anyway regardless of risk prediction scores
Pretest Likelihood of CAD in Symptomatic Patients:
Percent with significant CAD on Catheterization
Age, yrs
Nonanginal
Chest Pain
Atypical
Angina
Men Women
Men Women
Typical
Angina
Men
Women
30-39
4
2
34
12
76
26
40-49
13
3
51
22
87
55
50-59
20
7
65
31
93
73
60-69
27
14
72
51
94
86
*Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM, et al. ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary
and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with
Chronic Stable Angina). Circulation. 1999;99:2829-2848.
Six Blind Monks and the Elephant:
We all “see” different aspects of CAD
*From Charles Maurice Stebbins & Mary H. Coolidge, Golden Treasury Readers: Primer,
American Book Co. (New York), 1909, p. 89.
5,000 Asymptomatic Men Aged 30-65 Years
Undergoing Screening Exercise ECG Testing
Normal (96.8%)
N=4,838
N=79
N=70
No Further
Work-up
Coronary
Angiography
Significant*
Coronary
Disease (78%)
N=67/86
CABG Surgery
(38.8%)
N=26/86
PTCA
(10.4%)
N=7/86
Abnormal (3.2%)
N=162
N=13
Thallium
Imaging
N=7
*>=75% stenosis in
at last 1 vessel
Medical
Therapy
(50.7%)
N=34/67
*Davies B, Ashton WD, Rowlands DJ, el-Sayed M, Wallace PC,
Duckett K, et al. Association of conventional and exertional
coronary heart disease risk factors in 5,000 apparently
healthy men. Clin Cardiol. 1996;19:303-308.
Does Screening Make a Difference?
•
>20% asymptomatic diabetic patients have an abnormal nuclear
study
•
Abnormalities found at the same rate regardless of #of risk factors
•
Selecting only patients who meet ADA guidelines for testing would
have failed to identify 41 % of patients with ischemia
•
The majority demonstrated resolution of ischemia upon repeat
stress imaging after 3 years.
•
This resolution was associated with more intensive treatment of
cardiovascular risk factors.
*Wackers FJ, Young LH, Inzucchi SE, Chyun DA, Davey JA, Barrett EJ, et al. Detection of silent myocardial ischemia in
asymptomatic diabetic subjects: the DIAD study. Diabetes Care. 2004;27:1954-1961.
*Wackers FJ, Chyun DA, Young LH, Heller GV, Iskandrian AE, Davey JA, et al. Resolution of asymptomatic myocardial i
schemia in patients with type 2 diabetes in the Detection of Ischemia in Asymptomatic Diabetics (DIAD) study.
Diabetes Care. 2007;30:2892-2898.
*Bansal S, Wackers FJ, Inzucchi SE, Chyun DA, Davey JA, Staib LH, et al. Five-year outcomes in high-risk participants in the
Detection of Ischemia in Asymptomatic Diabetics (DIAD) study: a post hoc analysis. Diabetes Care. 2011;34:204-209. Copyright
and all rights reserved. Material from this publication has been used with the permission of American Diabetes Association.
Appropriate Use: Screening for CAD
*Reprinted from the Journal of the American College of Cardiology, Vol 63/No. 4, Wolk MJ, Bailey SR, Doherty JU, Douglas PS, Hendel RC, Kramer CM, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS
2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force,
American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and
Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons, pp. 380-406, Copyright 2014, with permission from Elsevier.
Anatomic Disease Predicts Outcomes
Extent of CAD
•
5-Year
Survival Rate
(%)*
1 VD, 75%
93
>1VD, 50%-74%
93
1VD, >=95%
91
2VD
88
2VD, both >=95%
86
1VD, >=95% pLAD
83
2VD, >=95% LAD
83
2VD, >=95% pLAD
79
3VD
79
3VD with at least another 95%
73
3VD, 75% pLAD
67
3VD, >=95% pLAD
59
Fuster V, Gotto AM, Libby P, Loscalzo J, McGill HC. 27th Bethesda Conference: matching the intensity of risk factor management with the hazard for coronary disease events. Task Force 1. Pathogenesis of
coronary disease: the biologic role of risk factors. J Am Coll Cardiol. 1996;27:964-976.
Appropriate Use for PCI
*Reprinted from the Journal of the American College of Cardiology, Vol 59/No. 9, Patel
MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA.
ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 Appropriate use criteria for
coronary revascularization focused update: a report of the American College of
Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular
Angiography and Interventions, Society of Thoracic Surgeons, American Association for
Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology,
and the Society of Cardiovascular Computed Tomography, pp. 857-881, Copyright
2012, with permission from Elsevier.
What are The Chances?
• The chances of finding the left main or three vessel disease,
(where revascularization actually alters prognosis) is
approximately 0.5% across an asymptomatic population
• Is this worth the radiation exposure, procedural complications,
and cost to the healthcare system?¯
*Davies B, Ashton WD, Rowlands DJ, el-Sayed M, Wallace PC, Duckett K, et al. Association of
conventional and exertional coronary heart disease risk factors in 5,000 apparently healthy men.
Clin Cardiol. 1996;19:303-308.
We Already Knew What (and What Not)
To Do Before the Tests
• Most medical interventions
for smoking, hypertension,
diabetes, and inactivity are
generally indicated regardless
of cardiac screening test
findings
• In Mr. F, it is anticipated
control of his hypertension
would predict a 6% lower
mortality over 10-years1
1.
Framingham Risk Calculator: http://cvdrisk.nhlbi.nih.gov/
For the vast majority PCI doesn’t even
have an advantage over medical
therapy, so why are we looking?
*From New England Journal of Medicine, Boden WE, O'Rourke RA, Teo KK, Hartigan PM, Maron DJ,
Kostuk WJ, et al, Optimal Medical Therapy with or without PCI for Stable Coronary Disease, Vol.
356, pp. 1503-1516, Copyright © 2007, Massachusetts Medical Society. Reprinted with permission
from Massachusetts Medical Society.
But We Have Room for Improvement in Medical Therapy
Even in clinical trials of CAD patients <1/3 all three of the
following (BARI 2D):
• Target levels of LDL (<100 mg/dl)
• HgA1c <7.0%)
• Blood pressure <130/80 mm Hg
In USA
• 82% are aware of their HTN
• 75% are using antihypertensive medication
• 53% of those have it controlled to target levels.
*Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Blaha MJ, et al. Executive
summary: heart disease and stroke statistics--2014 update: a report from the American
Heart Association. Circulation. 2014;129:399-410.
The
Framingham
Score for Risk
Prediction
Risk:
Low
Intermediate
High
<10%
10-20%
>20%
*From the New England Journal of Medicine, Greenland P, Gaziano JM, Clinical practice.
Selecting asymptomatic patients for coronary computed tomography or electrocardiographic
exercise testing, Vol. 349, pp. 465-473. Copyright © 2003, Massachusetts Medical Society.
Reprinted with permission from Massachusetts Medical Society.
Framingham-based risk scores overestimated
cardiovascular events by 37% to 154% in men and 8% to
67% in women.
• DeFillippis AP, Young R, Carrubba CJ, McEvoy JW, Budoff MJ, Blumenthal RS, et al. An analysis of calibration and discrimination among
multiple cardiovascular risk scores in a modern multiethnic cohort. Ann Intern Med. 2015;162:266-275.
We don’t need a risk calculator for Mr. F to know his risk is
“not low”. We took a history!
•
Wald NJ, Simmonds M, Morris JK. Screening for future cardiovascular
disease using age alone compared with multiple risk factors and age.
PLoS One. 2011;6:e18742.
Good
Preventive
Medicine?
SUMMARY
The best way to keep Mr F out of the clutches of the
interventional cardiologist is:
To keep exercising, get his blood pressure under control and take his
meds.
He should not get unnecessary screening tests that provide no useful
information
Energy Expenditure 1000 kcal/week reduces all cause mortality by 30%
It’s Cost Saving to Treat Hypertension
*Lee IM, Paffenbarger RS Jr. Associations of light, moderate, and vigorous
intensity physical activity with longevity. The Harvard Alumni Health Study.
Am J Epidemiol. 2000;151:239-299.
*From New England Journal of Medicine, Moran AE, Odden MC, Thanataveerat A, Tzong KY, Rasmussen PW, Guzman D, et
al, Cost-effectiveness of hypertension therapy according to 2014 guidelines, Vol. 372, pp. 447-455. Copyright © 2015,
Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society.
Drs. Cutlip and Pinto
A Discussion
2nd Audience Vote
Will Go Here
We would like to thank…
Our Patient, Mr. F
Donald Cutlip, MD & Duane Pinto, MD
Risa Burns, MD, MPH
Deborah Cotton, MD, MPH
Howard Libman, MD
Eileen Reynolds, MD
Gerald Smetana, MD
Last Minute Productions
BIDMC Media Services
Lizzie Williamson
© 2016 American College of Physicians
The information contained herein should never be
used as a substitute for clinical judgment.