carotid imt: a practical how-to primer - lipidcarotid imt: a practical how-to primer allen j. taylor...

Carotid IMT: A Practical How-to Primer

Allen J. Taylor MDChief, Cardiology Division

Medstar Georgetown University HospitalMedstar Washington Hospital Center

Professor of Medicine

Disclosure: No conflicts

Carotid Ultrasound Principles

•Straightforward procedure

•Instrumentation for office-based assessment

•Highly accurate/reproducible

•Technology assisted

•Predictive of outcomes

•Incremental, integrates with CV risk

Questions

In which patients? How to perform?

– Equipment– Procedure– Training/experience

How to integrate in clinical decisions? How to get reimbursed?

ACC CV Risk Guideline•Methods such as noncontrast CT for the assessment of coronary artery calcium, or carotid ultrasound for the assessment of intima media thickness and plaques improve the coronary heart disease risk assessment.

•In 2010, the American College of Cardiology:

•CAC and CIMT granted a level 2A recommendation indicating these tests as reasonable to perform in the initial assessment of cardiovascular risk in order to refine the risk assessment.

•“Measurement of carotid artery IMT is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk”.

ASE/SVM Consensus StatementPatient Selection

“Intermediate” risk– 10-year Framingham risk of 6-20% – Not already at high risk

Family history of premature CVD in a first-degree relative (men <55, women <65 yo)

Younger people with severe abnormalities in a single risk factor who are not being treated with medications (e.g., genetic dyslipidemia, heavy smoker)

Women <60 years old with ≥2 CVD risk factorsStein JH, et al. J Am Soc Echocardiogr 2008;21:93

PROG-IMT Only meta-analysis that pooled

individual, patient level data (versus study-level pooling) from 16 prospective cohort studies

– 36,984 patients encompassing – 71% of the worldwide data

2028 events (MI, stroke, death). Baseline CIMT predicted each of

these outcomes with hazard ratios from 10-22% for each 0.1mm increase in CIMT. – These data were after full

adjustment for patient data on all cardiovascular risk factors, demographics, and socioeconomic adjusters.

Lancet 2012;379:2053-62.

CIMT: Net reclassification of CHD Risk

Nambi and Ballantyne; JACC , 2010

•Net reclassification based upon CIMT findings in ARIC:•1 in 8 reclassified to a lower risk group•1 in 9 reclassified to a higher risk group

7.2

13.2 12.215.6

18.2

24.7

4.6

97.6

11 11.717

2.96.1 4.4

8.1 7.111.4

0

5

10

15

20

25

C-IMT<25thpercentile, no

plaque

C-IMT<25thpercentile, yes

plaque

C-IMT25-75percentile, no

plaque

C-IMT25-75percentile, yes

plaque

C-IMT>75percentile,no

plaque

C-IMT>75, percentile yes

plaque

Women

Overall

Men

Figure 1: Adjusted coronary heart disease incidence rate per 1,000 person year adjusted by C-IMT categories (<25th percentile, 25th-75th percentile and >75th percentile) with and

without plaque

Women

Overall

Men

2013 Lipid Guideline•Downgraded ALL methods of detection of residual risk

•Class 2B recommendation

•Imaging- CAC scoring

•ABI

•Family history

•Class 3 recommendation- CIMT

•Why?

•Wrong procedure- CIMT alone, not CIMT and plaque

•Methodology- IOM methods (RCT, Meta-analysis only)

•Narrow focus- statin selection only

•New, proposed pooled risk estimator- ?more accurate

USE IMT

Study-level pooling of 14 population-based cohort studies

– 45 828 individuals.– The net reclassification improvement

was 3.2% in men, 3.9% in women, a finding that the authors assessed as not clinically meaningful.

Weaknesses– CIMT, not inclusive of plaque– Less selective approach than the

PROG IMT authors, pooling studies in this analysis that were heterogeneous, including those that used very different technical methods for CIMT over the past 2 decades

– They also included many short studies that used different methods of adjudicating events.

– The authors included studies that used CIMT as a method of pharmacologic evaluation (e.g., statin trials) leading to a source of bias in event rates.

JAMA. 2012;308(8):788-795

August, 2012:“The addition of common

CIMT measurements to the Framingham Risk

Score was associated with small improvement in 10-year

risk prediction of first-time myocardial

infarction or stroke, but this improvement is unlikely to be

of clinical importance.”

June 2012:“….a positive, robust, and statistically

significantassociation exists between mean cIMT

and subsequentclinical endpoints.”

Patient Selection

Typical patient vignette 62 year old woman without symptoms of heart disease presents

for evaluation of cardiovascular risk factors. The patient’s father died from a myocardial infarction at age 50. She no longer smokes, adheres to a healthy diet and exercises infrequently. Body mass index is 32 kg/m2. Blood pressure is 133/82 mm Hg on an anti-hypertensive medication. Lipid profile shows a total cholesterol of 226 mg/dL, triglycerides 179 mg/dL, HDL-C 42 mg/dL, and LDL-C 148 mg/dL. Fasting glucose is 96 mg/dL. High-sensitivity C-reactive Protein is 1.8 gm/dL. The calculated 10-yr Framingham Risk Score is 6%. A CIMT/plaque survey is requested to refine the patient’s cardiovascular risk assessment, and thereby assist the physician with decision making on the selection and intensity of risk reducing therapies.

Questions




B-Mode Image of theCarotid Artery Wall

5 mm carotid artery wall

plaque

Courtesy of W. Riley

media

adventitia

intima

plaque

CIMT Ultrasound•Frequency: broadband

•Newest device 13 MHz•Device cost: $40K +

•Specific advantages•Clinical

•Noninvasive•No radiation exposure•No incidental findings

•Research•Scalable•Low entry costs for multicenter investigations•Understood by clinicians

CIMT: Progressive improvement in image quality

5 MHz: 19958 MHz: 199910 MHz: 1999

“Intermediate” Risk

CIMT and

Plaque Survey

Normal study

Increased CIMT

and/or Plaque Present

Standard RF approach

• Intensify treatment

Traditional Risk

Assessment

Optimal Scanning Protocol

CIMT Ultrasound: Simple

•Far wall•Acoustic shadowing in near wall

•Which site? •CCA most reproducible•ICA/Bulb: more difficult

•Plaque more common•Greater magnitude of change

•Measurement•ABD or manual, 1cm length•Easy- takes minutes•Accurate- .0x mm

Mean CIMT 1.174 mm

Bulb Lumen

Far wall IMT

Selection of end-diastolic imagesSystolic expansion/IMT thinning

Stein JH, et al. J Am Soc Echocardiogr 2008;21:93

CIMT Instrumentation and Views

Gain Persistence

Alignment

Angulated

Interpretation Steps

Questions




http://www.aricnews.net/CIMTCHD/RiskCalc2.html

Questions




Criteria for development and evaluation of CPT Category I and Category III Codes

•Current codes•0126T- Level 3 code•93880 Duplex scan of extracranial arteries; complete bilateral study•93882 unilateral or limited study

•According to the latest CPT code book, 93880 and 93882 should not be used for a carotid IMT study (currently code 0126T), which is “for evaluation of atherosclerosis burden or CHD risk assessment.”

•Parity with calcium scoring:•75771 Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium

Current Usage of Limited Carotid Ultrasound

Site of Care: 93882 2009 2010 2011Outpatient Facilities 15,760 15,448 15,283Freestanding 0 0 0Physician Office 157,192 163,984 163,863Emergency 664 660 905Total Outpatient Episodes 173,616 180,092 180,051

Source: Thomson-Reuters (Aileron)

IMT Scans As Per AAPP (0126T, 93882)Site of Care 2009 2010 2011 2012** 2017**Concierge Cash Pay Practices (40 scans a month) 140,000 160,000 200,000 220,000 480,000

Criteria for development and evaluation of CPT Category I and Category III Codes

In developing new and revised Category I codes the CPT Advisory Committee and the CPT Editorial Panel require:

•that the service/procedure has received approval from the Food and Drug Administration (FDA) for the specific use of devices or drugs;

•that the suggested procedure/service is a distinct service performed by many physicians/practitioners across the United States;

•that the clinical efficacy of the service/procedure is well established and documented in U.S. peer review literature;

•that the suggested service/procedure is neither a fragmentation of an existing procedure/service nor currently reportable by one or more existing codes; and

•that the suggested service/procedure is not requested as a means to report extraordinary circumstances related to the performance of a procedure/service already having a specific CPT code.

CPT proposal:Carotid wall quantitative thickness by ultrasound (intima-media; IMT) with detection of atheroma, bilateral

Status:February 2014: Category I code recommended by AMA CPT Editorial Panel April 2014: Procedure presented for RVU assignment to RUC panelOngoing 2014: CMS to publish final 2015 rule in November 2014

Atherosclerosis: Clinical Perspectives Through ImagingEditors: Taylor and Villines

Publisher: Springer

Carotid Ultrasonography for CIMT/Atheroma Detection

Who?– Office or facility technique to identify residual risk,

primarily in intermediate risk persons

How?– Standardized protocol, specific devices– Training and experience

Clinical management?– Integrate with CV risk factors for adjusted risk

assessment- management follows. Reimbursement?

– CPT code offers promise for 2015

carotid imt: a practical how-to primer - lipidcarotid imt: a practical how-to primer allen j. taylor...

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