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Transcript
Choosing Wisely: Cardiology Jeffrey Ziffra D.O. Mercy Medical Center – North Iowa 10/14/2016 Financial Disclosures • I have no active relevant financial disclosures Objectives • By the end of the session, participants will be able to: • Risk stratify patients with or for development of coronary artery disease • Be familiar with indications for cardiac testing • Managing stable asymptomatic patients and discussing need or lack of need for cardiac testing Objectives • • • • • • Characterize Types of Chest Pain Risk Stratify, Develop pre-test probability Indications for Cardiac Testing Stress Test Modalities Annual Monitoring Coronary CT Scans / Calcium Scoring From: 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, J Am Coll Cardiol. 2012;60(24):e44-e164. doi:10.1016/j.jacc.2012.07.013 Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons Figure Legend: Spectrum of IHD Guidelines relevant to the spectrum of IHD are in parentheses. CABG indicates coronary artery bypass graft; CV, cardiovascular; ECG, electrocardiogram; IHD, ischemic heart disease; PCI, percutaneous coronary intervention; SCD, sudden cardiac death; SIHD, stable ischemic heart disease; STEMI, ST-elevation myocardial infarction; UA, unstable angina; UA/NSTEMI, unstable angina/non– ST-elevation myocardial infarction; and VA, ventricular arrhythmia. Date of download: 7/25/2016 Copyright © The American College of Cardiology. All rights reserved. http://annals.org/article.aspx?articleid=1392193 http://bestpractice.bmj.com/best-practice/verify-user-north-american-access.html http://phoenixskeptics.org/2013/07/14/false-positives-and-the-base-rate-fallacy/ http://wiki.galenhealthcare.com/index.php/Galen_eCalcs__Calculator:_Framingham_Risk_for_General_CVD http://eurheartj.oxfordjournals.org/content/24/9/789 Stable vs Unstable Diagnosis • Resting EKG reasonable for the complaint of chest pain (1B) Stable CAD – Follow-up • Yearly follow-up at minimum Assessment of symptoms, monitoring risk factors, assess adequacy and adherance to lifestyle changes and medical therapy (1C). • Periodic screening for important comorbidities (DM, CKD, Depression) might be reasonable. (Iib, C) Stable CAD – Follow-up • A resting 12-lead ECG at 1-year or longer intervals between studies in patients with stable symptoms might be reasonable. (Iib, C) Stable CAD – EKGs Conclusion • Don’t order annual EKGs or any other cardiac screening for low-risk patients without symptoms. • With stable disease, there is no strong recommendation in regards to EKG Echocardiogram Echocardiogram • ECHO recommended to evaluate LV function and valvular function in known or suspected CAD and a prior MI, signs of heart failure, ventricular arrhythmia or murmur (IB) Echocardiogram • ECHO, MRI, Cardiac CT not recommended for routine monitoring of patients without signs of heart failure, MI or arrhythmia (III). Echocardiogram • Routine LV function assessment (<1 year)not recommended if low risk and unless there is a change in clinical status or if it will change treatment plan (III). Echo - Conclusions • Don’t perform echocardiography as routine follow-up for mild, asymptomatic native valve disease in adult patients with no change in signs or symptoms. • ECHO reasonable if change in clinical status, chest pain, suspicion of worsening valvular pathology with symptoms Transesophageal Echocardiogram http://ispub.com/IJA/23/2/3141 Pre-Operative Clearance http://www.jcomjournal.com/preoperative-cardiac-evaluation-for-noncardiacsurgery-a-critical-review/v Perioperative Evaluation http://www.aafp.org/afp/2012/0201/p239.html Perioperative - Conclusion • Don’t obtain baseline diagnostic cardiac testing (TTE, TEE, Cardiac stress test) in asymptomatic stable patients with known cardiac disease (e.g., CAD, valvular disease) undergoing low or moderate risk non-cardiac surgery. Stress Testing Stress Testing Stress Testing Stress Testing Stress Testing Stress Testing http://www.revespcardiol.org/en/rational-use-of-noninvasivecardiac/articulo/13052415/ Stress Testing • Nuclear MRI, ECHO or MRI stress or CTA not recommended for stable patients specifically not within 5 years of CABG or 2 years of PCI without symptoms (III). Stress Testing • In patients who have no new or worsening symptoms or no prior evidence of silent ischemia and not at high risk, the utility of annual surveillance exercise EKG testing is not well established (Iib,C) Stress Testing • Standard exercise ECG testing performed at 1year or longer intervals might be considered in high risk patients who can walk and have interpretable ECG. (Iib, C) • In patients who have no new symptoms, the usefulness of annual surveillance exercise ECG testing is not well established. (Iib, C) Stress Testing • Exercise stress with nuclear MPI is not recommended as an initial test in low-risk patients who have an interpretable ECG (IIIC) Stress Tests - Conclusion • Don’t perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients. • Don’t obtain screening exercise electrocardiogram testing in individuals who are asymptomatic and at low risk for coronary heart disease. Stress Tests - Conclusion • Don’t perform cardiac imaging for patients who are at low risk. • Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present. Coronary CT Calcium http://www.myvmc.com/investigations/ct-calcium-scoring/ Coronary CT Calcium • Role is to change risk stratification from intermediate risk to either low/high risk • Not as beneficial in those who already are low or high risk CT Angiogram • Inappropriate for : • Post-Revascularization (PCI, CABG) to evaluate grafts or instent restenosis • Uncertain benefit for: • Intermediate risk patients undergoing intermediate or high risk surgery • http://content.onlinejacc.org/article.aspx?articleid=1137956&_ga=1.185815593.1 895109799.1474037446 CT Angiogram https://www.google.com/search?q=coronary+ct+calcium&biw=1696&bih=869&source=lnms&tb m=isch&sa=X&ved=0ahUKEwiltfKswJTPAhVNySYKHTHMA64Q_AUIBigB#tbm=isch&q=coronary+c t+stent&imgrc=jxSCcAQ4_ln2BM%3A Cardiac CT - Conclusion • Don’t use coronary artery calcium scoring for patients with known coronary artery disease (including stents and bypass grafts). • Don’t order coronary artery calcium scoring for preoperative evaluation for any surgery, irrespective of patient risk. Let’s Simplify • Chest Pain – Stable or Unstable • Risk stratification • Initial EKG Let’s Simplify • Stable Chest pain, low probability – no testing • High probability – likely angiography • Intermediate probability – Stress Testing Let’s Simplify • Stress Test – Exercise preferred • EKG preferred if no baseline changes • Imaging (ECHO and Nuc) if intermediate to high risk Let’s Simplify • Stable Ischemic Heart Disease • No benefit in routine stress tests or ECHO imaging unless change in clinical status • Coronary Artery Calcium is for risk stratifying intermediate risk patients to low or high risk • No annual EKG if low risk and asymptomatic Let’s Simplify • Perioperatively, no survival benefit for revascularization for procedure. No basic testing needed unless high risk patient Questions? Thank You