investigations in perspective search for ebm do all if all can be done ? choices and sharing in care...

Investigations in perspective

Search for EBM

Do all if all can be done ?

Choices and Sharing in Care

18-04-23 1© Eduard van den Berg, cardio.nl

Question to start with

What does the department Cardiology Atrium Medical Center

endorse as guidelines ?

18-04-23 Eduard van den Berg, cardio.nl 2

De Orde Definition Guideline



De Orde Legal status Guideline

3-th Definition MI 250812


Does Cardiology Atrium agree with GL hierarchy ?


1. Dutch GL2. Endorsed ESC GL3. Non-endorsed ESC GL4. US GL

YES

NSTE ACS GL 2011


NSTE ACS endorsed by ?


NO complaints


Primairy Prevention

18-04-23 © Eduard van den Berg, cardio.nl 14

• No complaints but in the foodlight

• The general physician participates in CVRM

CVRM ESC 2012


CVRM – CVD Prevention


Not (yet) endorsed by NVVC (luckily ?)


Decrease † in about 10 yrs


NICE report


According to the report of NICE, implementation of the population approach may bring numerous benefits and savings:

† Narrowing the gap in health inequalities.† Cost savings from the number of CVD events avoided.† Preventing other conditions such as cancer, pulmonary diseases,and type 2 diabetes.† Cost savings associated with CVD such as medications, primarycare visits, and outpatient attendances.† Cost savings to the wider economy as a result of reduced loss ofproduction due of illness in those of working age, reducedbenefit payments, and reduced pension costs from peopleretiring early from ill health.† Improving the quality and length of people’s lives.

Remarks vdB I


• Patiënt Awareness only postpones disease but increases both whished and unwished consumption

• Assumed is that disease could be extended to the ‘inproductive’ period in life but retirement age will tan also increase with survival until 18.5 yrs life-expectancy remains

• So we live longer but is it with good overall (mental) health ? Qualies ?

• At the end interference always costs money (FFR + FU)

Remarks vdB• After the civilization stage of obvious welfare (thick,

smoking, alcohol, cars, Russia ?) comes the stage of prevention (no smoking, sport, nutritial habits, Netherlands)

• Doctors Awareness of patients whishes if informed consent is there could reduce costs with 25 % ?

• The survival of Elderly due to interference can transcend that of younger pts but may be the younger will never become old primary because of the genetics, look at years to be gained and Qualies


CVRM recommendations 2012



CONCEPT

OF

RiSk

Age

Risk categories, 15 % / 10 yr = highest


Differences with Framingham score

• In SCORE 10 year fatal event

• In Framingham 10 year incidence of coronary deaths and recognised non-fatal myocardial infarction

• Great difference in conception of Risk


Categories Framingham


Combination of Risk Factors SCORE ®


Risk and Survival


Heartscore ®, now the Netherlands are at high risk


Risk age is also automatically calculated as part of the latest revision of the SCORE system the HeartScore (260811). Upgraded with HDL, BMI and Risk Age

http://www.HeartScore.org

Europe high risk (English)Albania, Algeria, Armenia, Austria, Belarus, Bulgaria, Croatia, Czech Republic, Denmark, Egypt, Estonia, Finland, Georgia, Hungary, Iceland, Ireland, Israel, Latvia, Libanon, Libya, Lithuania, Former Yugoslav Republic of Macedonia, Moldova, Morocco, Norway, Romania, San Marino, Serbia and Montenegro, Slovakia, Slovenia, The Netherlands, Tunisia, Turkey, Ukraine, United Kingdom

http://www.HeartScore.org/


https://escol.escardio.org/Heartscore/pmsCenter.aspx?model=EuropeHigh

All your patients can be registered online

And patiënt Tailored advice is given, also for the pt self

https://escol.escardio.org/Heartscore/pmsCenter.aspx?model=EuropeHigh


Does Cardiology Atrium agree with Score hierarchy ?

1. Heartscore®2. Score®3. Framingham Score4. UKPDS5. PROCAM

So the heartscore® will be used for initial risk calculation ?

YES

Heartscore ® Risk categories, Remarks


• no threshold is universally applicable, the intensity of advice should increase with increasing risk

• In persons older than 60, these thresholds should be interpretedmore leniently, because their age-specific risk is normally around these levels, even when other cardiovascular risk factor levels are ‘normal’.

• The higher the risk the greater the benefit from preventive efforts

• compatible with the joint European Atherosclerosis Society/ESC lipid guidelines

1 Very High Risk


Subjects with any of the following:

† Documented CVD by invasive or non-invasive testing (such as coronary angiography, nuclear imaging, stress echocardiography, carotid plaque on ultrasound), previous myocardial infarction, ACS, coronary revascularization (PCI, CABG), and other arterial revascularization procedures, ischaemic stroke, peripheral artery disease (PAD).

† Diabetes mellitus (type 1 or type 2) with one or more CV risk factors and/or target organ damage (such as microalbuminuria: 30–300 mg/24 h).

† Severe chronic kidney disease (CKD) (GFR ,30 mL/min/1.73 m2).

† A calculated SCORE ≥10%.

2 High Risk


Subjects with any of the following:

† Markedly elevated single risk factors such as familial dyslipidaemiasand severe hypertension.

† Diabetes mellitus (type 1 or type 2) but without CV risk factorsor target organ damage.

† Moderate chronic kidney disease (GFR 30–59 mL/min/1.73 m2).

† A calculated SCORE of ≥5% and ,10% for 10-year risk of fatalCVD.

3 Moderate Risk


Subjects are considered to be at moderate risk when their

SCORE is ≥1 and ,5% at 10 years.

Many middle-aged subjects belong to this category. This risk is further modulated by factors mentioned above.

4 Low Risk


The low-risk category applies to individuals with a

SCORE ,1%

and free of qualifiers that would put them at moderate risk.

Recommendations, Imaging Remarks, MR


Non-invasive tests such as carotid artery scanning, electron-beam computed tomography, multislice computed tomography, ankle–brachial BP ratios, and magnetic resonance imaging (MRI) techniques offer the potential for directly or indirectly measuring and monitoring atherosclerosis in asymptomatic persons,

Recommendations, Imaging I, MR


Recommendations, Imaging II, MR


Asymptomatic pts, MRI 2012


At present, MRI is a promising research tool, but its routine use remains limited and it is not yet appropriate for identifying patients at high risk for CVD.

Early detection by magnetic resonance imaging of cardiovascular disease in asymptomatic subjects

Asymptomatic pts Agatston score 2012


In contrast, coronary calcium scanning shows a very high negativepredictive value: the Agatston score of 0 has a negative predictivevalue of nearly 100% for ruling out a significant coronary narrowing.

However, recent studies have questioned the negativepredictive value of the calcium score: the presence of significantstenosis in the absence of coronary calcium is possible.

Although calcium scanning is widely applied today, it is especiallysuited for patients at moderate risk.

The presence of coronary calcium proves a ‘coronary disease’ (coronaryatherosclerosis)—it does not necessarily reflect ‘CHD’ defined as ≥50% narrowing.

Asymptomatic pts, CTA

18-04-23 ©Eduard van den Berg, cardio.nl 50

Recent studies have also shown that multislice computed tomography coronary angiography with decreased radiation levels is highly effective in re-stratifying patients into either a low or high post-test risk group

Asymptomatic pts, Carotid ultrasound


• Carotid ultrasound can add information beyond assessment of traditional risk factors that may help to make decisions about the necessity to institute medical treatment for primary prevention.

• Arterial stiffness has been shown to provide added value in stratification of patients. An increase in arterial stiffness is usually related to damage in the arterial wall, as has been suggested in hypertensive patients.

Asymtomatic pts, Ankle–brachial index


The ABI predicts further development of angina, myocardial infarction, congestive heart failure, CABG surgery, stroke, or carotid surgery.

ABI is inversely related to CVD risk

Asymptomatic pts, Ophthalmoscopy


Most important new information

† Vascular ultrasound screening is reasonable for risk assessmentin asymptomatic individuals at moderate risk.

† Measurement of coronary artery calcifications may be reasonablefor cardiovascular risk assessment in asymptomatic adultsat moderate risk.

RI, OSAS and

Viagra


Smoking


UseWHOAlgorithm

Diet


Physical

Activity


Other factors, stress, Weight, RR, DM, Chol


• Specific interventions to reduce depression, anxiety, and distress

• Systematic reviews of patients with coronary artery disease or undergoing PCI have suggested an ‘obesity paradox’ whereby obesity appears protectiveagainst an adverse prognosis

• DM is a cardiovascular disease

• BP is a major factor

MEDICATION


Lifestyle ans Lipid intervention


ATT


Whom CVRM, Take home I


• In apparently healthy persons, CVD risk is most frequently the result of multiple interacting risk factors.

• A risk estimation system such as HEARTSCORE can assist in making logical management decisions, and may help to avoid both under- and over-treatment.

• Total risk estimation using multiple risk factors (such as HEARTSCORE) is recommended for asymptomatic adults without evidence of CVD.

• High-risk individuals can be detected on the basis of established CVD, diabetes mellitus, moderate to severe renal disease, very high levels of individual risk factors or a high HEARTSCORE risk.

Whom CVRM, Take home II


• Low socio-economic status, lack of social support, stress at work and in family life, depression, anxiety, hostility and the type D personality, contribute both to the risk of developing CVD and the worsening of clinical course and prognosis of CVD.

• Novel biomarkers have only limited additional value when added to CVD risk assessment with the HEARTSCORE algorithm.

• High-sensitive CRP and homocysteine may be used in persons at moderate CVD risk.

Whom CVRM, Take home III


• Measurement of carotid intima-media thickness and/or screening for atherosclerotic plaques by carotid artery scanning should be considered for cardiovascular risk assessment in asymptomatic adults at moderate risk. Measurement of ankle-brachial index and computed tomography for coronary calcium may also be considered.

• All persons with obstructive sleep apnoea and all men with erectile dysfunction should undergomedical assessment, including risk stratification and risk management.

complaints

Investigations in the foodlight


Complaints sec

Type of chest pain, chest disconfort


ANGINA PECTORIS


• We talk about:• 1) Chest discomfort • 2) provoked by exertion or emotional stress and is • 3) relieved by rest or NTG

• Typical anginaMeets all three of the above characteristics

• Atypical anginaMeets two of the above characteristics

• Non-cardiac chest painMeets one or none of the typical anginal features

Chest Pain


• Type of chest pain • Severity (Canadian Cardiovascular Society, CCS)• cardiac functional status (New York Heart Association,

NYHA)

complaints

STABLE18-04-23 Eduard van den Berg, cardio.nl 72

Stable AP, 2006 (newest !!)


AP classes and related P(CAD)


ECG

Who, when


Who should get when an ECG


X-ECG


X-ECG, SENS, SPEC


What is a pos X-ECG test


Changing the treshold, Harmless ?


Quantitative, prevalence CAD


Typical angina Atypical angina Non anginal chest pain

AGE Men Women Men Women Men Women

30-39 69.7 25.8 21.8 4.2 5.2 0.8

40-49 87.3 55.2 46.1 13.3 14.1 2.8

50-59 92.0 79.4 58.9 32.4 21.5 8.4

60-69 94.3 90.6 90.6 54.6 28.1 18.6

3 of 3 criteria 2 of 3 criteria 1 of 3 criteria

1) Retrosternal discomfort.2) Provoked by exercise or stress.3) Relieved by rest or NTG

Post X-ECG P(CAD), Age and AP related


Routine X-ECG every yr ?


Remember Classes of recommendation


And levels of evidence


X-ECG, Tl-201, X-Echo I



X-ECG, Tl-201, X-Echo II

Pharmalogical stress tests


Adenosine MRI


SENS and SPEC of CAD tests


Sensitivity and Specificity NI tests for CAD


Diagnostic Test

Sensitivity

% (range)

Specificity% (range)

# Studies # Patients

TMT 68 77 132 24,027

Planar MPI 79

(70-94)

73

(43-97)

6 510

SPECT 88

(73-98)

77

(53-96)

8 628

Stress echo 76

(40-100)

88

(80-95)

10 1174

Echocardiography at rest


Ambulatory ECG


CTA


Coronary MRA


Coronary angiography I



Coronary angiography II

Risk assessment I



Risk assessment II


Risk assessment III

Summary of recommendations

Routine non invasive Investigations


Non Invasive Investigations in stable AP I



Non Invasive Investigations in stable AP II


Non Invasive Investigations in stable AP III

Be able to establish Risk quantitatively


In mortality % / year

Prognostic Angina Score


Treatment, low Risk, Mort<1 % /yr


Treatment intermediate Risk 1-2%/yr


Treatment, High Risk >2 % / yr


First Medical therapy, but if…….


If CAG done, then if……


Risk Stratification I


Risk Stratification II


Risk Stratification III


Risk Stratification IV



Risk Stratification V


Risk Stratification VI

Stable AP 2006 needs revision

For instance Ca-score is not included


complaints

ER, Unstable ?


GL NSTE-ACS, nov 2011


Summary ESC GL NSTE-ACS, ER


• Establish the working diagnosis NSTE-ACS < 10 min from entrance from complaints, CAD Likelihood, Physical Examination and ECG

• Validate the working diagnosis from the moment of establishing• As long as the WD is not rejected treat the pt as such• Repeatedly establish the risk assessment

ER 1



ER 2


ER 3


ER 4


ROC curves of four models for predicting the composite MACE measure. Model I incorporated traditional risk factors, including age, sex, hypertension, diabetes, and dyslipidemia; model II, CAC scoring; model III, coronary CT angiographymodel IV, the combination of CAC scoring and coronary CT angiography. P = .031 for model II versus model I, P < .001 for model III versus model II, and P = .198 for model IV versus model III. SE = standard error of the estimate. IV = BEST

Incremental value of X-ECG for classes of Angina depending on

ST-depression

Most of the findings of the early days are still valid at this moment

Also the starting points !!!!18-04-23 Eduard van den Berg, cardio.nl 134

X-ECG Legend and Steps


Young Women 30-39


Young men 30-39


Women 40-49


Men 40-49


Women 50-59


Men 50-59


Women 60-69


Men 60-69


To present it another way


Posttestprob, women, age, ST related


Posttestprob, men, age, ST related


X-ECG what do we learn from Forrester

• At higher age the a priori probability for sign CAD is very high even with a negative bicycle test

• With a high pre-test probability an X-ECG can be done for best estimation of the max wait for intervention if applicable


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