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Women - In - Cardiology Session - Stable CAD - Ischemia Evaluation

Feb 19 | 2:00 PM

Dr. Sonali Inamdar: Pharmacological stress Echocardiography would be the best choice Dr. Purvi Parwani: Stress CVMRI would be the best strategy Dr. Andrew Choi: CT angiography is a safe and reliable option Dr. Renne Bullock Palmer:Stress Radio nuclear imaging (PET/SPECT) is the most appropriate option

[Music] thank you very much uh dr kamal sharma it's always a pleasure to be at cardio con and also at this very special session uh it is my pleasure to introduce our first speaker as you know this is a debate and the debate will be on a 52 year old woman who was hyper defensive and dislipidemic with atypical angina with non-specific std changes in inferior leads and an ejection fraction of 58 with no evident regional wall motion abnormalities she also has bilateral osteoarthritis in the knee the debate is on which is the best strategy for coronary artery disease evaluation other than invasive korean geography so that's off the table it's an imaging debate and it is my pleasure to introduce our first speaker who is dr sonali she's a consultant interventional cardiologist at the inunda heart clinic at pune in india and also an associate consultative cardiology at the ancient reliance foundation hospital and research center she has numerous prizes and publications to her credit and um she will be speaking first but i would also like to very briefly introduce our next other two other three speakers we have a stellar panel of international uh speakers we also have dr puri parani who is also a very good friend she is of indian origin i believe from ah but she is now doing very well in the united states she is an assistant professor of medicine at the loma linda university in uh california and also the director of women's cardiovascular clinic at that institute so something to watch out for in terms of debate because this is home tour i suppose and uh she also has numerous complications to her credit we also to debate on the role of city and geography we have dr andrew choi who is the co-director of cardiac ct and mri an associate professor of medicine and radiology at the george washington university of medicine he is a national and international thought leader in cardiovascular imaging and he's an author of over 100 abstracts so very prolifically published in the arena as well and uh last but not least is dr renee bloch palmer she is a cardiologist as well as board-certified cardiovascular and nuclear as well as imaging specialists and she comes from jamaica but she is also now i have the pleasure of knowing her off uh this as well as one of the winners of the women as one escalator awards and she's also known to be a phenomenal mentor so a stellar panel today and we're really looking forward to the debates i will hand it over to dr sonali number to kick off the debate today happens to be dr kamal sharma's wife that is a special introduction i wanted to give thank you please go ahead thank you for introducing hi everybody so just a second i just want to say that uh i've been uh in last year also i was in session with dr aisha and dr puri parwani last year and dr puri is like a family member to me so hello everybody please continue the session and then uh are you able to view me and the slides you are visible as well as audible okay thanks uh so i'd like to extend my uh warm uh gratitude to dr kamal sharma and to dr niha sharma man it's a second in innings for me in this conference we had met last year and it's so wonderful to meet all my colleagues and friends again this year around so i'll be speaking on uh the approach to this patient in terms of ischemia evaluation of stable coronary artery disease and i'll be talking on pharmacological stress echo right okay so let's begin i just want to introduce a little concept known as the paradox of choice because now we've been inundated with so many choices in our lives and in in our day-to-day world um just as a start this is a menu or menu card of a restaurant in a ordinary restaurant in pune and you can see the immense number of choices that you've got to face and the problem with having so many choices is that when you have so many items to choose from you are confused there's a lot of stress and this is known as the paradox of choice in which the more number of choices you have your happiness quotient goes down so less is in fact more and too much choice adds to a lot of conflict what we suffer from in today's world as physicians as cardiologists is something known as the opportunity cost which means that the attractive features of the choices that you're not making add up to make the choice that you actually do make seem less appealing so similarly when it comes to the immense number of choices that we have in terms of pd evaluation of a stable coronary patient we have anatomical tests like a coronary cpa we have a host of stress tests like the exercise ecgx stress echo stress mri and stress nuclear scans i've not mentioned the prices here unlike a restaurant menu because the cost of course differs from region to region country to country so that's up for that's up for debate so let's let's see how do we uh deal with this paradox of choice in such people who come with uh evaluation for coronary artery disease and who have stable angina so as uh dr ayesha has mentioned that we are talking about a 52 years old female who has some uh non-specific changes in her ecg who's unable to exercise and who has certain risk factors like hypertension and dyslipidemia now what would be the best strategy now if we go by the old guidelines we typically risk stratify these patients by going by talking about the pretest probability of such patients so considering that she has had atypical angina and she's in her mid-50s her risk before undergoing any further tests is at a six percent pre-test probability however in 2021 that is last year new guidelines have come up which have lowered the pre-test probability of these patients even further if you notice the numbers here as compared to the numbers in the prior guidelines we see that most of the patients irrespective of gender and uh considering both chest pain or dyspnea as a feature as a presenting feature most of their pre-test probability numbers is quite low that is because the overall incidence of an obstructive coronary artery disease in the in the general community in patients who have stable coronary artery disease is less than 10 so if we look at our patient she falls under this particular category in which her risk is in fact less than 15 and she would in fact fall in the low risk category however we cannot just treat patients as numbers we cannot just go by the pre-test probability in its entirety we have to consider certain other considerations we can add a calcium score and improve the pre-test probability or add on to the pre-test probability and get a further understanding of her risk status additionally in these new guidelines atypical engineer is no longer a term what we have now is either it's a cardiac angina which is very typical with the central pressure squeezing gripping chest pain or it could be possibly cardiac which lies in the center or it could be a non-cardiac chest pain so going by her symptoms we could probably say that she falls in the possibly cardiac category and let's just assume that she falls into this intermediate to high risk group now how do we approach these patients if you notice this very wonderfully colored uh pyramid which has been proposed by the latest guidelines it shows that in stable chest pain evaluation the intermediate risk and the high risk patients are clubbed together and then we approach them in a similar manner so the approach to these patients is either by going down the anatomical pathway that is by doing a coronary ct or going down the stress testing pathway now there have been certain factors which favor the use of coronary cp versus stress testing for example if you have younger patients and who are not on optimal preventive therapy we can go for a ct coronary angel but the rule the use of ct is more for ruling out an obstructive cad that is more than 50 percent coronary artery disease however if you look at a patient clinically and decide that she's likely to have a higher likelihood of ischemia you look at which region she comes from if this is an indian patient we know that south asian patients have higher propensity towards multivessel disease and you want to rule out discovery in such a patient then you go down this ischemic pathway and consider a stress testing pathway the esc guidelines also tell something similar where they say that the choice of the test is based on clinical likelihood the patient characteristics and preferences and of course the availability and local expertise so you either go down the coronary coronary ct way or you go down the stress testing pathway so as we all know about the ischemia cascade when there is a coronary blockage as the just before the chest pain occurs a lot of abnormalities take place in the myocardium it begins with perfusion and metabolic alterations which are detected by nuclear imaging whereas other changes like diastolic dysfunction regional motion abnormalities and ecg changes happen much later and these are the ones which are picked up by pharmacological stress echocardiography and also by mri as we go down the tests become more specific so what are the various methods that are used for stress echocardiography more commonly of course we use an inotropic agent which is dobutamine with the help of atropine it has beta 1 beta2 and alpha 1 agonist action and at a lower dose it has a balanced effect on the peripheral vasculature and at a higher dose there is a greater beta2 response which leads to peripheral vasodilatation and hypotension on the other hand there are some vasodilators like dipyridamole and adenosine which cause mild distribution of blood flow this is a less sensitive test for regional one motion abnormality and it is better for relative perfusion changes detection now when it comes to a pharmacological stress echo more specifically a debutant stress echo we can have a whole a big scope of uh various diagnostics which we can pick up in in a particular patient in addition to the basic parameters like the ecg and the heart rate and blood pressure we are able to see the regional wall motion abnormality and wall thickening we can see ejection fraction changes we can get very nice pictures of transient lv dilatation which points towards multivessel disease so measuring the end systolic volume on an echo in a dynamic way you can see the lv cavity dilating in front of you is something which is which is very useful and it gives you a prognostic indication and tells you that there is something wrong we can calculate the ischemic threshold of of that patient an ischemic threshold is the heart rate at which the first ischemic changes are detected on stress echocardiography divided by the maximum heart rate as per the age of that patient if it is less than 60 we can prognosticate the patient and tell that the patient has a higher risk we can use strain and speckle tracking and also use contrast technical cardiography to see the segments in a better way and to delineate perfusion abnormalities as i mentioned risk stratification and prognostication is very useful when it comes to the use of dobutamine stress echo when you have regional one motion abnormality the event rates rise up to more than six percent when there's a transient ischemic dilatation the rates rise up to nineteen percent annually we use the between stress echo when when when you want to assess a pre-operative risk as i mentioned the ischemic threshold also helps in telling you the prognosis and contrast use helps to improve the prognostic value now this is a very interesting graph which shows that even if you get a false positive dobutamine stress echo it does not mean that you just stopped there because it has been shown in this study that even with a false positive dobutamine stress echo which was shown on coronary angiogram to have a non-obstructive cad or a normal coronary artery the survival still decreased over follow-up which means that this points to the presence of something microscopic that could be microvascular dysfunction or the patient could have a subclinical cardiomyopathy which was unmasked by the dobutamine stress echo test this particular pattern is not seen with a false positive exercise stress echo when an exercise stress echo is positive and it is proven to be normal on a coronary angiogram the survival is similar it does not dip other very important uses of using a dobutamine stress echo is we can find out other causes of chest pain or dyspnea in a patient like hcm cardiomyopathy pericarditis embolism valvular diseases one important issue is when patients have dyspnea you can do a lung lung scan immediately dynamically and you can find that there are bee lines there are comets which which point to the presence of fluid in the lungs which have happened there and then because of the exercise that was induced also the butamine stress echo is useful to detect viability if there is a baseline regional wall motion abnormality this is an example of dobutamine stress echo in which various heart rates have been denoted here this is a four chamber view in which the lv is on this left side here you can see at higher heart rates there is a dilatation of the lv cavity the end systolic volume has increased and here you can see that the lateral wall has become a kinetic in this particular group of cine images this is a two chamber view in which initially the lv cavity is nice and triangular it becomes dilated at higher heart rates and the inferior basal and mid wall has become a kinetic so how do you talk about the performance of various non-invasive stress tests to detect an anatomically significant coronary artery disease everything is about sensitivity and specificity when you talk about a coronary ct it has a very high sensitivity but its specificity is quite low similarly when you talk about nuclear imaging tests they have very high sensitivity but again their specificity varies the butamine stress echo also has a good amount of sensitivity and it maintains a good amount of specificity as well when you look at something known as the likelihood ratio of a test that is when a particular test is positive does it really mean that the patient does have that disease you can see that with the dobutamine stress echo its likelihood ratio is quite high so it has a very powerful uh index to rule in a particular disease my apologies uh doctor inaudible yeah yeah this is my life so let's keep it simple let us avoid this decision fatigue let us avoid uh paradox of choice let us just choose a test which will help us assess a patient in terms of morphology physiology as well as prognosis the latest guidelines have mentioned that when it comes to stress tests the test choice should be guided by local availability and expertise they have not put one test about the other and when it comes to butane stress echo you have to consider the patient characteristics the accessibility and simplicity simplicity of the test the local expertise the costs and also to be a bit flexible and to not hesitate in adding or sequentially adding other tests in case you feel you want more information thank you thank you dr chanali for uh very informative uh talk now we will be moving to our next talk and from the right corner we have dr purvi parwani and i'll again take this opportunity to introduce dr purvi parwani who is my mbbs senior and we are both from the same city and from the same college and her contribution in the field of cardiology and has made us all proud she is an amazing teacher and a wonderful person and she would be debating on stress cv mri would be the best strategy in this case dr bowie thank you pooja for that lovely introduction it's always homecoming for me uh and really happy to see um all of you here so i'll be speaking about stress cmr today um and uh you know my my disclosure is that i'm a multimodality imager so quite frankly in any of these categories you put me i can debate and i can tell you why the modality is good because um you know i know my toolbox i have many tools in my toolbox and according to the patient i see i use those tools very effectively and uh um you know that's but right here i am um here to present my favorite modality um and that is uh cmr no doubt so what i'm going to do is i'm going to let the science speak um for each modality and tell you why stress cmr is a good strategy so we have this 53 year old woman she has hypertension hyperlipidemia severe arthritis we haven't been told why she has severe arthritis maybe some rheumatic condition we don't know she has atypical angina and as dr imam that very nicely pointed out that's not the term we use anymore um with new guidelines but nonetheless she has chest pain that has been thought to be anginal uh maybe not maybe and she does have some non-specific st changes she hasn't had any previous cardiovascular evaluation so the question here is best stress modality and rather than the cardiac cath which i see happens more often in india than not so i think the best thing is why this patient has the questions i want to answer is what's the cause of this chest pain um is it truly cardiac or not cardiac why does this patient has st changes um how can i get this information all these question answered if possible in one modality because as we know cost is a big issue back home and what does this patient need next do they really need the test or do do they not and how what am i going to tell this patient about their overall prognosis um particularly given the risk factors they have maybe they have rheumatoid arthritis maybe they are menopausal um and and they do have this non-specific st changes so when it comes to the best stress modality i want to go for a test that's accurate safe appropriate has management and prognostic implication and also is cost effective um so you know for the consideration of my this debate uh these are the points that i'm gonna touch upon um whether um you know getting an anatomy in a patient like this um is it is it going to help us with her st changes or her chest pain are we gonna be able to tell her what exactly is causing her chest pain um are we gonna be able to tell her that she affords all the radiation that a ct or a nuclear stress test brings or if her dobutamine stress ago is negative she should go home and rest and forget about having um cardiac chest pain so that's what i'm gonna debunk here and i'm also gonna tell you the sensitivity and specificity of um each test so as dr imam that very nicely pointed out yes this patient if you take the you know criteria by pretest probability she kind of falls into the low risk category but then she also forgot why she has the increased likelihood of having cad she already has the risk factors for cad she has hypertension she has hyperlipidemia we have already been told she has some sort of arthritis rheumatic conditions as we know are responsible for premature coronary artery disease and maybe she is menopausal that information wasn't given to us she's 52 she's in that age group so again for women this pretest likelihood in my opinion doesn't matter because i'm gonna take that individualized approach and for this particular patient i think she has increased likelihood of having coronary disease now i'm not using the word microvascular disease or microvascular disease because that's what we are going to figure out as we know 30 of the women that present with chest pain they have microvascular disease and none of the modalities that my opponents are going to pose um do give any information on um a microvascular disease except pet which unfortunately is not available in india so um also as we have already pointed out that this patient has resting ekg changes um and these resting ekg changes again put her in a different category so although we thought that this patient may be in low to intermediate risk in my opinion this patient has clinical likelihood of cad all the present models kind of underestimate the women having cad particular the microvascular cad so these all things need to be considered very carefully and as dr imam they're very nicely pointed out um the guidelines suggest that in this case you can go for anatomical testing or you can go for trust testing and i will tell you why stress testing is a better approach but compared to anatomical testing and within the stress testing why stress cmr is the best approach so of course we have already looked at the sensitivity and specificity all the modalities kind of um you know particularly if we talk about the between stress echo unfortunately the problem with the dovetail mean stress echo is when it is negative it does not tell me much it doesn't tell me much about the microvascular disease when it comes to stress the mpi we all know that if there is no attenuation correction half of stress mpi that we read are um um you know are wrong um and of course um we um you know i'm going to talk about why ct coronary cta is not a good modality so let's talk about the accuracy so um this is ce mark trial where they took uh patients um with intermediate uh probability um cad and they compared them head to head spec and cmr was able to perform better than spec in this study this was the first study this is the real world patient that we see so we already have established in the literature that stress emr is better strategy than spect uh when we look at stress cmr um because of this black blood sequence that we use not only we are able to tell you about the ischemia but also we can tell you enough about the anatomy so um it's not just a ischemia test but if you use one more sequence you are also able to see coronary artery arteries um very well now when we look at the safety look at the radiation on the right side when i googled nuclear stress tests in india all that came up was thallium thallium is a criminal activity in my opinion no one should be using pallium in 2022. look at the radiation them thallium um uh you know and technetium these isotopes use um if it was my family member or my patient i would never want them to that get that kind of radiation and also same applies to uh cardiac ct yes retrospective uh you know cardiac ct perhaps here has way more radiation um then um you know the cts that we utilize these days and your cts definitely have less radiation but it's still radiation um and one can argue that if you want to go for an anatomical test perhaps cardiac cath is not a bad idea um because it's probably if you use the contrast and the radiation wisely you can give the lot of information um in in the same amount of radiation so into to my mind uh particularly in indian subcontinent um anatomical testing when we look at the cost and the radiation perhaps cath is a better idea but when it comes to ischemia again the cat won't tell you why this patient has chest pain it would just tell you that there is no atherosclerosis and there is no obstructive cad so in my opinion um you know safety device other modalities um except w to me nekko here um you know kind of take a hit uh when we look at the management and prognosis um this was an ejm article and um this this article um uh nagel's group from germany they compared in a multi-center trial uh role of stress cmr compared to ffr and again compared to the ffr strategy in patients with uh risk factors this strategy um you know were similar um also compared to ffr uh strategy stress cmr performed very well when it came to downstream testing we all know with ct scan with a coronary ct downstream testing is um you know way more likely particularly in real world experience because we all get scared of atherosclerosis we all get scared when there is an intermediate atherosclerotic lesion and we want to give that patient benefit of the doubt and make sure there is no obstructive cad so in this paper particularly stress cmr showed not only it was cost effective because it led to less downstream cat which a lot of indian cardiologists perhaps don't like but it's a cost-effective strategy even when it comes to um you know ffr and this again was proven in the real world experience so this is the registry data again multi-centers um you know across the united states and it showed that not only uh cmr reduced the need for coronary revascularization but also this less revascularization was associated with better outcomes so it wasn't that um you know it was a false uh negative uh negative study it actually a negative study meant that those patients had excellent prognosis um so i think that um i have uh you know rested my case here with the management and prognosis and then let's come to cost effectiveness so i wanted to talk to this audience about the cost effectiveness in india granted i looked up the prices on google yesterday but the ctca in uh india causes around cost around a fifteen thousand and nuclear is forty two thousand rupees uh dope you mean stress echo is the cheapest five thousand because it has been uh you know it has been there uh long and a stress cmr cause it costs uh probably between um eight to ten thousand rupees according to the google estimate now i know that i can be wrong but when we look at the cost effective analysis that is already done for cmr what it showed is the no no imaging strategy was associated with a low um you know um quality uh life years but when they applied and the worst uh cost was associated with uh angiogram but when they applied both the cost as well as the better quality of life it was the stress cmr that um you know that was able to shine in um in comparison to any other stress modality um so again um it's a one-stop shop um you get one test and you're gonna get all your answers and that's that's one of the biggest uh uh you know um uh arguments for using cmr now microvascular disease again we know for women particularly for women that we presented here microvascular disease 30 percent of the women have it and none of the other stress modality include expect mpi is able to you know tell you if a woman comes with microvascular disease now this concept may be new but we all know that women do present with microvascular disease and unfortunately anatomical tests like ct are not able to figure this out so if we just pay attention to this slide um you know by using what we call quantitative stress cmr we are able to tell you if that patient has the myocardial blood flow that is optimal or not if the myocardial blood flow right here on the right side if you pay attention if the global stress myocardial blood flow is optimum more than 2.25 that patient has normal coronaries both metro as well as micro you can tell that patient that go home this pain that you are experiencing is not cardiac because you have um told them both about macro and microvascular disease versus if you have less myocardial uh blood blood flow then you can figure out what exactly is the cause for that that patient's inuka also known as ischemia without any um coronary obstructive coronary disease um so again these are just some more uh you know um slides so this is the normal microvascular reactivity so you can see this is the rest uh cmr on the right side below this is the stress cmr and look at this abnormal microvascular activity at rest you have nice perfusion but at stress you have this rim of darkness in the endocardium which is classic um you know for microvascular um ischemia similarly here um you know a globally normal will shine up uh on the left side and on the right side are the blood flow is low and it is globally low and that can be responsible for microvascular uh disease now why is you know coronary ct is not a good modality and i will debunk some of the ischemia trial um beliefs that people have um is this is this test gonna tell you um um you know what is the cause of chest pain for this patient the answer is no am i interested in knowing what's the cause of the patient's chest pain or am i interested in knowing how much amount of atherosclerosis does a patient have i'm not interested in knowing what kind of atherosclerosis this patient has i'm more interested in knowing why does this patient have chest pain my ct colleagues often use the argument that ct um using the promise trial that ct and you know promise and the scott hart trial the ct led to better outcome but we must keep in mind that ct led to better outcome because every patient got a and aspirin and my argument is why can't we just tell all our patients with mixed hyperlipidemia to take a torah statin and aspirin whenever um you know it is appropriate so why do do a test and tell them that you have atherosclerosis why not just directly apply that preventive strategy tell our patients to apply dietary and lifestyle modification now um you know the positive predictive value because of this reason for ct is not very robust is ct a gatekeeper for cath i would argue not there are a lot of real-world er studies which have shown cp leads to more downstream cath which is not the point and that's what does not make it cost effective particularly in indian subcontinent and the argument all my colleagues make um i love coronary ct but they'd like to make the argument of left main disease now let me remind you in community the left main disease is only present in one to two percent patients it is not very common and stress cmr would be a great strategy because it does not have balanced ischemia as you can see with stress mpi or any of the nuclear modalities so if a patient has left me um you know it stress emr is going to show you so in my opinion um the ionizing radiation also um makes the quest uh ct uh a safety point uh questionable so for all that reason a coronary ct for this patient in my opinion would not be ideal choice um so i have rested my case yeah i'm sure you're fine yes i've shown you why cmr is safe efficacious appropriate has management and prognostic implications um and uh and you know it would be the best strategy for this patient so i was going to show you some examples of the stress cmr um this is an example of a completely normal stress cmr on the on the bottom you have the resting images on the top you have stress images as you can see when the contrast agent comes in there is nice um uh you know perfusion of the entire myocardium um this patient also did not have any sort of we could tell her yes and she did not have any sort of previous myocardial infarction so once that one test that gave us a lot of answers and then i will show you real quick what a abnormal um stress test a look abnormal cmr looks like this is a smoker a male substernal chest pain and look at this patient's stress cmr so pay attention to those arrows as you can see in the endocardium there is less perfusion particularly the apex has less perfusion all over and i will in real uh quick i will show you the cat this patient also did not have any previous previous in fact and on cath he was found to have multivessel disease including significant led circumflex as well as rca disease um so um again this patient had multiversal ischemia no myocardial scar viability was present and surgeons were able to take him so if you are interested check out the stress perfusion series on youtube by scmr that we were able to put out there are six sessions and would give you a lot of information about stress cmr so in my opinion dobutamine stress echo is not a good choice because it does not tell you about microvascular disease it also has poor sensitivity stress mpi is not a good choice because it has a lot of radiation it does not tell you anything about the ef accurately and it does not tell you why does this patient have sd changes accuracy can be debated for stress mpi ct coronary is not a good choice because of the radiation it doesn't tell you the cause of the chest pain it does not tell you the ef and it leads to more downstream testing in addition to not giving you any information about the microvasculature in this woman who is at higher risk of microvascular disease and of course stress cmr because of all the reasons i told you is safe appropriate cost-effective and evidence-based strategies thank you very much for inviting me and i'll be happy to take question at the end thank you so much dr poovey and everybody would agree that it was a wonderful talk with a lot of information and insights thank you okay now i would like to tell you that dr andrew choi has a pre-recorded session so we'll be playing it now right here dr andrew has actually poetically made it an all woman session as a mark of respect sessions hi i'm andrew choi from george washington university in washington dc uh and i'm honored to participate in cardio con this year i want to thank dr sharma the organizers dr parwani and others for the opportunity to participate in this debate i apologize that i can't join you this year and i hope to be able to come back next year and hopefully even come to india and so what we want to do over the next 10 minutes is to discuss in this debate now why is cta geography not only a safe and reliable option but the best option for our patient presented these are my disclosures and so it's presented as a 52 year old woman with a couple of risk factors atypical angina normal heart ejection fraction and severe bilateral osteoarthritis and i think to understand why uh why ct angiography would be the best test we should think about our general goals of cad imaging we want a test that's safe that's simple that meets appropriate use criteria allows for diagnosis of symptoms enhances prevention is supported by the highest quality randomized controlled trial evidence aligns with guidelines and allows for the best downstream uh decision making and so as we know and this audience knows very well there's a high cad prevalence in india particularly in the north and in the south and when we look across multiple data sets cad is a particular issue in young adults even aged 20 to 40 that over 50 of coronary disease mortality occurs in individuals under the age of 50 and a quarter of acute miss are reported in patients under 40 in the south asian population and in the united states we can look to these examples of younger individuals president bill clinton in his 50s who had a heart attack even after a normal stress test rosie o'donnell an actress who suffered a heart attack at the young age of 50 and carl ruiz was a celebrity chef on the food network who died of a heart attack at age 44. where does ct allow us to do it's a comprehensive assessment multiple studies have shown very high accuracy and high negative predictive value for obstructive cad of over 95 percent in both stable and acute chest pain ct allows for the evaluation of non-obstructive cad for cardiac function of protocol appropriately myocardial assessment mass aorta and lvad multiple studies and the protection six registry and jack imaging have shown that it is it can be done at low radiation dose around the world and at low cost about 180 is the reimbursement in medicare in the united states so it's at low uh low cost and so i liken a ct to a tesla it gives you all of the modern things that you want in a cad testing test now when we look at the spectrum of cad cardiac ctoli allow for identification of both non-obstructive and obstructive cad across the spectrum of cad and that we should point out that a normal stress test does not equate to the absence of cad because a stress test will miss the early or non-obstructive cad we know this is important because most acs occurs in non-obstructive plaques this is from a trial called iconic that did case control from the larger much larger confirmed registry and on the left when you look on a per patient basis two-thirds of the patients in the iconic trial presented that had stable cad with a later mi had initially 50 or less than 50 stenosis and that when you look at the culprit lesions from those patients it was three quarters had non-obstructive or less than 50 percent stenosis ct uniquely allows for evaluation of a sex-specific plaque signature in women uh and this is from a review article on the left that we had put together and women have smaller vessels they have while lower plaque volume and lower tax score and maybe non-obstructive which ct uniquely allows you to identify non-obstructive cad women are still at at risk for major adverse events and it has to do with the plaque type that's present and from the sect we've been able to really identify uh higher risk plaque features that include a non-calcified plaque a low attenuation plaque that even with non-obstructive ced have similar prognostic significance to obstructive cad now when we look at the evidence there's been tremendous evidence generation in ct over the last 15 years and this is from an editorial that we put together summarizing this including a number of major trials including the ischemia trial the promise trial we have a number of guideline statements and education milestones and so in 10 minutes i can't go through all of this but i do want to go through the scott hart trial and as you recall this was 4 000 patients with suspected angina that were randomized to standard care including stress testing exercise stress testing versus stress testing plus ct angiography while there were and there was no difference in revascularization there was an increased use of preventative therapies particularly the ct arm and impressively there was a 40 reduction in death or myocardial infarction those patients that underwent ct angiography and this is attributed to the identification of early plaque the ability to start preventative therapies as well as identify those patients that would be best suited for revascularization and so why is this the case again as we point out these factors including increased clinician attention to patients with cad when we look at a cost analysis of using a cta based approach for to guide treatment versus recent drug therapies based on the treatment effect the cost would be about 400 dollars per year if you account for the medicare cost of the ct angiography plus the cost of aspirin and statin generic drugs if you compare that to a pcsk9 inhibitor 5800 us dollars per year can echidna map for inflammation 16 000 a year and aspirin while very inexpensive has not been shown to have benefit in a primary prevention in primary prevention cohorts now when we look at guidelines the european society of cardia of cardiology guidelines in 2019 reminded us to assess symptoms look at comorbidities and attest pre-test probability including the presence of lv dysfunction or other factors like an abnormal ttt or coronary calcium and using the pretest probability for the low to intermediate risk patients ct angiography is preferred such as the patient shown here the 51 year old at lower uh loaded intermediate probability and risk and so it is a class one indication in the esc guidelines for cta being recommended as the initial test for diagnosing coronary disease in symptomatic patients if the cad cannot be excluded by clinical assessment alone this is also based on your local availability and patient specific factors we can now point to the new 2021 acc aha multi-society chest pain guideline and i was an official reviewer one of the official societal reviewers for this guideline and my congratulations again to dr golotti who is the chair of this guideline and others that were a critical role in bringing the evidence to the national guideline like dr blankstein shaw bullock palmer who's in this session today and many others and so one important point from dr golotti was what's new in the guideline is that the redefinition of coronary disease that goes beyond just not being just obstructive cad but also being non-obstructive cad so that those with lesser degrees of stenosis would benefit from optimized preventative medical therapy when we take a look at intermediate risk patients with no known cad how do we now choose among the best imaging tests importantly cta has a class one indication for the diagnosis of cad which is new compared to the old uh 2012 u.s guidelines as well as stress testing and so what are the factors that favor cta versus stress imaging well if your goal is to identify both obstructive and non-obstructive cad you have high quality imaging a favor towards younger patients now the older age is not a cutoff for cta but it favors younger patients if you're looking for other things like aorta or permanent artery evaluation but uniquely we can look at plaque composition high-risk plaque features lesion-specific ischemia through ffrct and we can guide decisions for goal-directed medical therapy and prevention for these patients in an acute chest pain population cta has been shown to contribute to reduced time to diagnosis and prompt and safe discharge when we think of the right diagnostic tests you might think about potential contraindications and the guideline lays this out and we you can look at each society's guidelines for more specific details on contraindications and certainly you might want to avoid cta and somebody that is unstable that has chronic uh kidney impairment or as an allergy to iodinated contrast and so the ideal patient by the acc aha guideline is a younger age patient to be able to evaluate your plaque as well as obstructive cad that has intermediate pre-test probability that might have a prior functional study that's inconclusive that doesn't have contraindications and if you want to have rapid diagnosis safe discharge and you have high quality imaging available to you and so when we go back to the patient and why cta is the best test it's safe can be done at low dose simple to do is appropriate allows for diagnosis of symptoms with high accuracy to roll out obstructive cad supported by high quality randomized controlled trial evidence it aligns with both european and u.s guidelines it allows for downstream decision making including allowing for identification of early atherosclerosis that would allow for prevention so that we can attack this problem that exists in south asia and in india and so in summary cta is now class 1 in 2021 accha chest pain guidelines and it allows for improved outcomes and goal-directed prevention by identifying obstructive and non-obstructive cad and the last point i make is if it was your friend or family what is the test that you would choose and when i talked to many of my colleagues from south asian india their choice would be a ctn geography thank you very much so after that wonderful speak from all three of you it's my pleasure to have dr rene uh dr renee pleasure to have you for the session and over to you great thank you can everyone see my slides right great so just like that thanks so just like to find the organizers of this year's cardio khan meeting this is my first time joining you guys and i'd like to also especially thank dr sharma for inviting me to speak in this session on why nuclear mechanical fusion imaging is the best option for the presented case i'm dr renee pollackhammer the director of the non-invasive cardiac imaging program as well as the director of the women's heart center at the bar heart lung center in new jersey i have no disclosures but like kirby and also also with multiple modality imagers so i could debate on either sides of the of the debate here this morning so for women uh 60 percent of symptomatic women have no flu limiting stenosis and despite this heart disease is the number one killer for women there is emerging data that has significantly contributed to our understanding of the full spectrum of ischemic heart disease in women which includes obstructive avocado disease microvascular disease coronary spasm and spontaneous coronary artery dissection the role of microvascular dysfunction vascular inflammation coronary activity and endothelial function and hormonal influences as well as oxidative stress and coronary sites all have impact on the development of ischemic heart disease in women and is being increasingly recognized i'd also like to remind the audience that women have a higher prevalence of plaque erosion compared to more plaque rupturing men and in older women the frequency of plaque rupture increases with each decade so with regards to the ischemic cascade which shows um it shows here that my catalytic imaging is able to detect its human heart disease much earlier than the other multi um other modalities that were debated here this um this morning in addition to this micro vascular disease can be detected with pets cmr pet cfr with coronary flow and reserve with um and in addition with pets you also have pet ct where you can also detect subclinical coronary disease and of course it does not have the limitations that other animal dialectics have such as mri where patients who may have devices are unable to have an mri or with a ct where patients have renal dysfunction or arrhythmias are not able to undergo ct additionally there are a multitude of other reasons why nuclear stress testing may be useful in addition to arrhythmias patients may be obese with poor acoustic windows for echocardiography um they may also have allergies to contrast and i'll remind you that with the newer software and hardware we are able to do nuclear imaging with a very low radiation dose and in some cases even less than three millisieverts and also as um i will outline later on in the talk that mac had a blood flow reserve is very useful in women and can be detected with pets so there's incremental prognostic value respect and this uh study that was led by dr ramy duke in 2015 has shown that respect in addition to clinical variables ekg variables and mechanical perfusion imaging you're able to adequately assess prognosis in patients in a step-wise fashion moreover with pet imaging you also have the addition of the left ventricular contractile reserve which or with ultra which also helps in prognostication of our patients and in this particular case in our female patient this morning now with regards to coronary macrovascular dysfunction this plays a major role in determining my catalyst in many cardiovascular conditions including angina with and without abstracted coronary disease and also in cases of mac have infraction known ischemic cardiomyopathy such as amyloid hypertrophic cardiomyopathy tachycuba syndrome and heart failure and many of these have a greater prevalence in women compared to men many molecular functional and structural mechanisms are also involved and are related to the underlying disease process now chronomicrovascular dysfunction is more prevalent in women as in our case and our patient presented in hypertensive patients also in our patient that was presented and in patients with disability dyslipidemia again in the case that was presented other populations for patients with valvular heart disease so particularly aortic valve stenosis infiltrative cardiomyopathies all have a greater prevalence of coronary microvascular dysfunction now the role of ischemia may be caused by epicardial and also microvascular structural and functional mechanisms avocado causes determining ischemia includes acute plaque disruption with lumen occlusion and avocado coronary spasm myocardial bridging and progressive obstruction of with vessel narrowing of a previously present plaque coronary microvascular function can result from an abnormal vasodilator ability of the microvasculature and also compressive external forces affecting the intramural micro vessels and of course microvascular spasm now coronary macrovascular function is not benign and has a greater implication for women with regards to adverse outcomes in this uh these diagrams that were published in um the journal of nuclear cardiology led by doctor bibiani taketa in 2017 the diagram on the left shows the distribution of coronary cardiovascular risk by pet npi corner flow reserve and a corner fluorescence of that weight that was greater than or equal to two is associated with a relatively low rate of analyzed cardiac death conversely coronary flow reserve less than two are associated with substantially worse prognosis which may result from base and motor dysfunction arising from a combination of pathophysiologic cd phenotypes and also multivessel absorptive cab as well diffuse atherosclerosis and coronary microvascular dysfunction on the right there's a log adjusted hazard for major adverse cataract events in females versus male patients and it varies as a function of the pet npi corner fluid reserves now looking at um the gender-specific differences you can see that the effect of gender on cardiovascular events was modified um shows significant difference in outcomes for women compared to men where for that particular carnot flow reserve for example a corner floor is of one point one point four or one point two that women have a far higher um prevalence of major adverse cardiac events so bring it back to bringing it back to our patients it's a 52 year old female she has hypertension disease which are cardiac risk factors she also has severe bilateral obstructive arthritis of the knees um which could be due to a multitude of reasons and also for this reason she's not able to do an exercise nuclear stress test so of course the pharmacologic option is the only option for this patient now the possibility etiologies for this patient's angina could include epicardial macrovascular disease or indeed coronary microvascular dysfunction so they as you know the chest pain guidelines that were published last year in october 2021 also helps to tease out the reasons why permanent cataclysm imaging is a choice for this patient and as was mentioned before this was chaired by dr matthew bilati dr philip levy and dr murphy and as fortunate to be a part of the writing group so in this document the clinical decision pathways are very important for patients presenting with chest pain with regards to the choice of testing for patients with an intermediate risk presenting with stable chest pain these patients may be referred for functional stress testing or anatomic testing but i will argue that functional stress testing is the option for this patient now one must also remember that it is important to look at the patient specific features whether or not they've had an unestablished um cad or history of cad this patient has no history um whether or not they've had prior test results available and also test availability and local interpretation expertise at one's own institution with the guidelines there are several clinical scenarios that are online that favor stress imaging such as patients with an intermediate pre-test probability in whom more obstructive cd's suspected and i would argue with this patient 52 years of age he's leaning more towards that um that group and also additionally in clinical situations where an ischemic guided strategy is required especially in cases where there's established cad on cases where you're looking for coronary microvascular dysfunction as i would argue for this patient narcotic pets with mac had a blood flow reserve also has the benefit of being able to detect primary microvascular dysfunction now in this patient who is unable to exercise the options for her with regards to my catalytic confusion imaging expect or pet however because they're looking for coronary macro vascular dysfunction i would argue that pet npi would be the choice for this patient and as and as i had mentioned before that these patients are able to have this test with a very low radiation dose of less than three millisieverts with the nearest software available so with the chest pain guidelines in the evaluation of patients with stable chest pain it's very important that the pre-test probability is assessed and then this patient who is 52 years of age female presenting with chest pain she's lying more in the into intermediate range here more towards the intermediate um range here now a typical is out with regards to the guidelines in this patient presenting with chest pain should either be cardiac maybe cardiac or non-cardiac and in this particular case i would argue that she is in the maybe cardiac range and therefore in our patient i do believe that she's an is as an intermediate pre-test probability for having abstracted cd so what are the options for this patient so with regards to mechanical future imaging pet mpi or spec mpi has a class 2a recommendation in these patients and if pet is available at your institution then pet is a choice for this patient now this is a case in our lab where we had a patient that underwent a nuclear stress test which was a pharmacological nuclear stress test was a 72 year old female and you can see that she has a very large area of anterior septal anterior defect that was moderate um protein reduction and it was reversible when compared to the supine rest images however in our lab we do a stress prone on most of our patients and you can see that in the stress prone images this defect completely resolved indicating that this study was indeed normal now also this patient also had adjunctive use of coronary calcium assessment and her coronary artery custom score was zero so why is this important in the chest pain guidelines they recommended that attenuation correction or two position imaging is reasonable with a class 2b recommendation to decrease false prostate findings and i would argue that many labs doing our spect or mechanical fusion imaging should have a method of attenuation compensation either with acceleration correction software or two position imaging to improve your accuracy of your reading additionally the chest pain guidelines recommended in patients who have a no who have no known history of cd this patient had no history that these patients would benefit from adjunctive use of corner calcium scoring and has a class 2a recommendation to further progno prognosticate the patient now with regards to chest pain guidelines they had also included um assessment of coronary macrobascus functioning in in the guidelines and also ways in which we can assess these patients now it's very important that with regards to the macroconfusion of the heart that we not just look at macrovascular disease with epicardial disease but also looking at microvascular circulation which is the benefit of pets with mac had a blood flow reserve and this is an example this is the last case of a fourteen annual female who presented with recurrent chest pain multitude of tests including cardiac catheters for all normal and she had um was referred for pitch ct with half some scoring and you can see that the scout images and that was used for generation corrections showed no calcium um coronary classification her profusion was indeed normal however with the mackinac blood flow reserve you can see that in all three characters the led the circumflex and the rca the makata blood storage server all less than 1.5 this is 1.3 1.25 1.43 and her global flow reserve is 1.33 indicating that this patient indeed had coronary macrovascular dysfunction and with the guidelines they recommended that pet um mpi with macular blood flow reserve has a class 2a recommendation in these patients to assess for the presence of coronary macrovascular dysfunction so i would argue that nuclear imaging with pet ct but back how the blood flow reserve assesses the entire coronary tree from the subclinical atherosclerosis by the assessment of coronary classification on the non-contrast ct images for the epicardial macrovascular um circulation with mpi microconfusion imaging to the microvascular circulation assessing endothelial function with macular flow reserve and in the indeed in this patient i believe that this is the most comprehensive non-invasive assessment for this patient so in summary pathophysiologist cd is different than women compared to men and the women are more likely to have none of social disease in addition the diagnostic test strategy for chest pain should be determined by the question that's being asked of the test and also whether or not this patient has had established cd or not now one must also remember the availability of testing at one's own institution and the interpretation expertise and not to forget that coronary microvascular disease is for a prevalent woman and should be further diagnosed with pet mpi if available and it's also a prevalence prevented not only women but in hypertensive patients patients with hyperlipidemia cardiomyopathy and also vaginal heart disease such as aortic vapour stenosis and as i had indicated pet ct with mac had a blood flow reserve assesses the full spectrum of the coronary circulation from macrovascular avocado disease to macrovascular disease and i rest my case here thank you very much thank you so much dr rene and uh thank you so much all the speakers for your insightful and uh informative talk uh it's the i think that dr movie has convinced me that that i think now i think that mri gives a lot of information on structure as well as hemodynamics of the heart altogether so if we keep the debt apart i think mri would be the best choice considering its broad diagnostic capacity but we all we cardiologists have our toolbox and uh as doctor we likely say that we need to choose our tools wisely as per our patients thank you pooja i know you may be a bit biased because i i think i think we need to bring out another aspect to this and uh being from indian ethnicity would understand moms are so difficult to convince so our wives you know they would say i don't have a pain i i don't want myself to be going to get a checkup i'm doing fine i don't want the day to be you know lost for my son or my husband uh and usually they refrain from a checkup that's that's a bigger social problem rather than what to choose in our side of the world and the other problem that has now creeped in is the free access to health care when you're hospitalized but outpatient you need to pay from your pocket which means if you're hospitalized your angiogram is free with the various schemes that have come in including the social health care sector including in india where you have pradhan mantri yojana the prime minister scheme where everybody who's at the low poverty line gets a free health care which is one third of in india and if you want to get even ekg done you have to pay out of your pocket so that is another aspect that also needs to be looked into and i believe that's also the case with the reimbursement probably in west as well because you need to justify every imaging that you do on outpatient basis i can have comments from dr puri and dr renee as well on this aspect now is the reimbursement an issue for procedures invest as well for whatever you do on outpatient basis say cardiac mr or ct or even nuclear imaging well if i agree um with that um or hospital we are we actually serve um you know a population very high prevalence of medicaid patients and i do have that challenge sometimes that there are patients that definitely need the test but they're not able to have it covered by the insurance um if it's done as an outpatient and sometimes if it's unstable action i'll just have to admit the patient and get to get the studies done so i do agree with that thanks i would say um the other side of the story that i had seen a lot before i left india is women are not paid attention their chest pain you know often is considered you know the money should not be spent on a woman the money should be spent on the breadwinner so that's the harsh reality of the india that i lived in and i'm i know that still in small villages things have not changed much um so whatever you say i think women are still ignored all around the world but more in our countries than um you know other parts in my opinion um and uh yeah when it comes to stress cmr i think access is a bigger issue than the reimbursement um i think that uh reimbursement in general at least um in in where i am in southern california it's not been an issue with uh we we do all of the imaging we do we do mean stress echo um you know spect mpi pet as well as stress and it's it's not been an issue that much that's all i have our eminent speakers have given very impressive lectures i have a question to all of the speakers uh do we have any uh approach to the diagnostic modality as a comparison between the asian indian women and the caucasian women for this heart disease you know what can be is there a difference or is the same everywhere is there any data about it any trials any studies about it i don't think there are any studies but um i mean the point especially with um you know a lot of um you know east asians and stuff the best the coronary vessels are very small and they're the higher um prevalence of quantum activated dysfunction and i would argue that in those in these women that you know mri i'll turn it to perfect [Music] hopefully one of the indian centers can look up but i think there is something called dr saxena can you please mute yourself sir thank you um there is a there is a cohort called masala study out of ucsf um that has studied uh south asian population particularly the indian population and they have suggested that coronary calcium is vapor in india diverse in indian population and but they i don't think i have seen any gender differences dr walkman is also an expert on women's cardiovascular disease so she wants to comment something feel free annabelle yeah no as you know we wrote the scientific statement paper on cardiovascular disease in south asians in the united states and uh unfortunately the eight south asian men and women have worse coronary artery disease than a lot of other races and ethnicities women definitely have um you know earlier on heart disease than a caucasian woman but the men have really bad disease they have early and severe coronary artery disease and this is something that a lot of south asian doctors know but i don't think a lot of other doctors know and that's why we wrote that scientific statement paper to raise awareness about the um heart disease in south asians whenever um americans talk about asians they lump all of us together with the east asians who do have less coronary artery disease than south asians and filipinos and so we wanted to highlight the the severe coronary artery disease that we're seeing in young men and young women from south asia thank you okay thank you so much thank you so anything else any other comments from the chair or we moved to dr edible's session itself which is another interesting session on atrial fibrillation um in india the af ablation is something that's not very often done and that's why what dr annabelle is going to talk about is going to be very important and that's the debate that we have so thank you everyone thank you for the previous session thank you purvi and dr andrew all the chairs uh dr dr neha and all the moderators dr archana and dr bhumi


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