Download ZiffraChoosingwiselyinCardiology

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