foley ct acute chest pain - advanced body imaging
TRANSCRIPT
Acute Chest PainAcute Chest Pain
DENNIS FOLEYDENNIS FOLEY
MEDICAL COLLEGE MEDICAL COLLEGE WISCONSINWISCONSIN
Acute Coronary SyndromeAcute Coronary Syndrome
UNSTABLE ANGINAUNSTABLE ANGINA
NON ST ELEVATION MI ( NSTEMI )NON ST ELEVATION MI ( NSTEMI )
ST ELEVATION MI ( STEMI )ST ELEVATION MI ( STEMI )
Coronary ThrombosisCoronary Thrombosis
VULNERABLE PLAQUEVULNERABLE PLAQUEPATHOPHYSIOLOGYPATHOPHYSIOLOGY
PLAQUE RUPTUREPLAQUE RUPTURE
THROMBOGENIC SURFACETHROMBOGENIC SURFACE
PLATELET AGGREGATIONPLATELET AGGREGATION
THROMBUS FORMATIONTHROMBUS FORMATION
TIMI Risk ProfileTIMI Risk Profile
AGE > 65AGE > 65
3 OR > CARDIAC RISK FACTORS3 OR > CARDIAC RISK FACTORS
ST DEVIATIONST DEVIATION
ASPIRIN USE WITHIN 7 DAYSASPIRIN USE WITHIN 7 DAYS
HISTORY OF CORONARY STENOSISHISTORY OF CORONARY STENOSIS
ELEVATED TROPONIN LEVELSELEVATED TROPONIN LEVELS
Coronary OcclusionCoronary Occlusion
ETIOLOGYETIOLOGY
VULNERABLE PLAQUE RUPTUREVULNERABLE PLAQUE RUPTURE
CORONARY ARTERY DISSECTIONCORONARY ARTERY DISSECTION
TRAUMATRAUMA
IN STENT THROMBOSISIN STENT THROMBOSIS
CORONARY ARTERY ANOMALIESCORONARY ARTERY ANOMALIES
Cardiac Risk ProfileCardiac Risk Profile
TIMI RISK SCORE ( US/ NSTEMI )TIMI RISK SCORE ( US/ NSTEMI )SCORESCORE MACE MACE RISK CATEGORYRISK CATEGORY0/10/1 5%5% LOWLOW22 8%8% LOWLOW33 13%13% MODERATEMODERATE44 20%20% MODERATEMODERATE55 26%26% HIGHHIGH6/76/7 41%41% HIGHHIGH
Coronary ThrombosisCoronary Thrombosis
OUTCOMEOUTCOME
STEMI STEMI -- 90% 90%
NSTEMI NSTEMI -- 35 35 –– 75 %75 %
STABLE ANGINA STABLE ANGINA –– 1 %1 %
Acute Coronary SyndromeAcute Coronary Syndrome
OUTCOMEOUTCOME
PRIOR TO MID 80PRIOR TO MID 80’’ssMYOCARDIAL INFARCT 40%MYOCARDIAL INFARCT 40%
MORTALITY RATE 17%MORTALITY RATE 17%
MID 80MID 80’’s TO CURRENT s TO CURRENT 49% DECREASE IN MORTALITY RATE49% DECREASE IN MORTALITY RATE
Imaging Studies in ACSImaging Studies in ACS
RADIONUCLEIDE PERFUSION STUDYRADIONUCLEIDE PERFUSION STUDY
NORMAL RESTING PERFUSION NORMAL RESTING PERFUSION STUDY HAS NPV > 90%STUDY HAS NPV > 90%
Laboratory Studies in ACSLaboratory Studies in ACS
TROPONIN 1 TROPONIN 1
CK MBCK MB
BASIC METABOLIC PROFILE BASIC METABOLIC PROFILE
C REACIVE PROTEINC REACIVE PROTEIN
ESRESR
Treatment ( 1 )Treatment ( 1 )
PRE HOSPITAL CAREPRE HOSPITAL CARE
EKGEKG
NGT, OXYGEN, ASPIRINNGT, OXYGEN, ASPIRIN
THROMBOLYSISTHROMBOLYSIS
Treatment ( 2 )Treatment ( 2 )
ED CAREED CARE
STEMISTEMIREPERFUSION THERAPYREPERFUSION THERAPY
PHARMACOLOGICAL PHARMACOLOGICAL
CATHETER BASEDCATHETER BASED
NSTEMINSTEMIANTI ISCHEMIC THERAPYANTI ISCHEMIC THERAPY
PCI WHEN APPROPRIATEPCI WHEN APPROPRIATE
ED CareED Care
GOALSGOALS
IDENTIFICATION OF PATIENTS IDENTIFICATION OF PATIENTS WITH STEMIWITH STEMI
EXCLUSION OF OTHER CAUSES OF EXCLUSION OF OTHER CAUSES OF NON ISCHEMIC CHEST PAINNON ISCHEMIC CHEST PAIN
STRATIFICATION OF PATIENTS STRATIFICATION OF PATIENTS WITH ACS INTO LOW AND HIGH WITH ACS INTO LOW AND HIGH RISK GROUPSRISK GROUPS
Acute Coronary SyndromeAcute Coronary Syndrome
EKG GATED CT EXCLUDEDEKG GATED CT EXCLUDED
SHOCK, TACHYCARDIA, SHOCK, TACHYCARDIA,
ARRYTHMIAARRYTHMIA
HIGH TIMI RISK SCOREHIGH TIMI RISK SCORE
? KNOWN CAD , PRIOR CABG? KNOWN CAD , PRIOR CABG
Coronary Angiography Gated Coronary Angiography Gated Freeze FrameFreeze Frame
10 20 30
Contrast
Saline
6 ML/ SEC 12 SECS
6 ML/ SEC 8 SECS
64 X 0.625 MM, 1.0, 0.35 SECS , 2 CM/ SECS
186 +/- 98
222 +/- 102
270 +/- 85
335+/- 78375+/-95
337+/-77
LAD CPR
LCX CPR
RCA LMCA CIRCCPR
CPR
LAD
MIP
LAD CPR
LIMA
LIMA CPR
LIMA LAD ANAST SLAB MIP
RCA STENT SLAB MIP
RCA CPR
LAD STENT FOLLOW UP
Diagnostic Accuracy Diagnostic Accuracy 64 MDCT64 MDCT
SensSens SpecSpec PPVPPV NPVNPV PrevPrev
CORECORE 8585 9090 9191 8383 56%56%
ACCURACY ACCURACY 9595 8383 6464 9999 25%25%
Miller JM et al NEJM 2008: 359; 232Miller JM et al NEJM 2008: 359; 232--23362336
BudoffBudoff MJ et al. JACC . 2008: 52MJ et al. JACC . 2008: 52
Diagnostic AccuracyDiagnostic Accuracy64 MDCT 64 MDCT
( Meta Analysis )( Meta Analysis )
28 STUDIES, STRICT CRITERIA,28 STUDIES, STRICT CRITERIA,
1,286 PATIENTS1,286 PATIENTS
SensSens SpecSpec PPVPPV NPVNPV
PtPt 9999 8989 9393 100100
SegSeg 9090 9797 7676 9999
MowatMowat G et al. Heart 2008: 94; 1386G et al. Heart 2008: 94; 1386--13931393
RomicatRomicat TrialTrial
368 PATIENTS368 PATIENTS
CHEST PAIN > 5 MINCHEST PAIN > 5 MIN
NEG TROPONINS, EKGNEG TROPONINS, EKG
EVALUATION FOR STENOSIS > 50%EVALUATION FOR STENOSIS > 50%
END POINT: MI, UAS, MACEEND POINT: MI, UAS, MACE
RomicatRomicat TrialTrial
RESULTSRESULTS
NO PLAQUE, 50%NO PLAQUE, 50%
PLAQUE < 50%, 31%PLAQUE < 50%, 31%
PLAQUE > 50%, 19%PLAQUE > 50%, 19%
NO CAD, NO CAD, SensSens 100%, NPV 100%100%, NPV 100%
CAD, CAD, SensSens 77%, NPV 98%77%, NPV 98%
Triple Rule OutTriple Rule Out
TECHNIQUETECHNIQUE
NON GATED PULMONARY / AORTANON GATED PULMONARY / AORTA
GATED PULMONARY/ LEFT GATED PULMONARY/ LEFT HEART/ AORTAHEART/ AORTA
GATED LEFT HEART/ AORTA, NON GATED LEFT HEART/ AORTA, NON GATED PULMONARYGATED PULMONARY
Non Gated Pulmonary/ AortaNon Gated Pulmonary/ Aorta
Gated Left Heart / AortaGated Left Heart / Aorta
Gated Left Heart / AortaGated Left Heart / Aorta
Non Gated Right Heart/ PulmonaryNon Gated Right Heart/ Pulmonary
Gated MDCT in ACSGated MDCT in ACS
APPLICATION APPLICATION LOW TO MODERATE RISK LOW TO MODERATE RISK PATIENTS WITH ACUTE CHEST PATIENTS WITH ACUTE CHEST PAIN, NEGATIVE TROPONINS AND PAIN, NEGATIVE TROPONINS AND EKGEKGHIGH NPV IN EXCLUDING ACSHIGH NPV IN EXCLUDING ACSCOST EFFECTIVE WITH EARLY COST EFFECTIVE WITH EARLY DISCHARGE OF PATIENTS WITH DISCHARGE OF PATIENTS WITH NEGATIVE STUDIESNEGATIVE STUDIES