C o ntro : A. Erlicher (Bolzano)

La d iagno si ap p artie ne all’im ag ing : o gg i la co ro -TAC

p o ne in m o d o incrue nto d iagno si d i p ato lo g ia

co ro narica e va co nsid e rata un e sam e d i ro utine ne lla

ge stio ne clinica

Devo far qualcosa per la mia salute

• Un 52enne mi chiede di fargli eseguire una TC per calcio coronarico (CC) per valutare il suo rischio di eventi dopo aver letto un articolo su un a rivista. Non ha sintomi cardiaci non ha mai fumato, non è sovrappeso ma non fa alcuna attività fisica. Suo padre, forte fumatore, è morto di infarto a 45 anni. La pressione è 130/85, il colesterolo è 220 mg per decilitro LDL e HDL 160 mg e 38 mg per decilitro rispettivamente, il glucosio 92 mg. Cosa gli consiglio?

Should Coronary Calcium Screening Be Usedin Cardiovascular Prevention Strategies?

The goal of CAC scanning in asymptomatic persons is to refine the risk assessment in order to determine whether preventive strategies should be intensified, not to identify persons with asymptomatic coronary artery stenoses.

The 7-Year Rate of Major Coronary Events Predicted on the Bas isof the Framingham Risk S core and the Coronary-Artery Calcium

S core.

• Rate s are base d on a C ox

re gre ss ion analys is of d ata from

1 029 in itially asym ptom atic

ad ults who we re followe d for a

m e d ian of 7.0 ye ars .

• A coronary- arte ry calcium

(C AC ) score of 0 ind icate s no

d e te ctable calcium ; h ighe r C AC

score s ind icate m ore se ve re

d e gre e s of coronary

calcification, with the e xte nt of

s e ve rity influe nce d by age ,

e thnicity, and se x.

• A m ajor coronary e ve nt was

d e fine d as d e ath or nonfatal

m yocard ial infarction.

• the studies of the CS as a predictor of CAD or cardiac events have not analyzed the incremental risk prediction over clinical assessment.

• Until then, a CS of 0 cannot be interpreted as a reassurance of the absence of CAD.

Appropriateness

• CAC screening is inappropriate in asymptomatic patients who are at low risk for coronary events according to the ATP III criteria;

• uncertain about the appropriateness of screening for those at intermediate or high risk.

Should Coronary Calcium Screening Be Usedin Cardiovascular Prevention Strategies?

No

• In the absence of data on outcomes, the CAC score does not meet the criterion for population screening

• Widespread CAC screening runs the risk of increasing the number of unnecessary tests and procedures downstream — and of escalating health care costs

Getting the Bes t Bang for

the Rad

In 1980, medical imaging was responsible for only about 15% of the total radiation exposure to the U.S. population from all sources; now the proportion is about 50%

Up to 30% of the radiation exposure to the U.S. population that is associated with medical diagnostic imaging now comes from cardiac imaging

Currently, approximately 9 million myocardial-perfusion-scintigraphic imaging studies are performed each year in the United States, and this test represents one of the single largest man-made contributors to radiation exposure in the U.S. population.

..e il nostro 52enne

• Il nostro 52enne ha un basso rischio CV (meno del 10% di rischio di eventi CV nei prossimi 10 anni).

• Sconsiglio una TC lo informo dell’assenza di evidenza che l’uso di quel test migliori l’outcome e delle possibili conseguenze svantaggiose del test quali il rischio radiologico e un possibile catena di ulteriori accertamenti inutili

• Consiglio l’assunzione di aspirina a basse dosi, probabilmente una statina e sicuramente un programma di regolare esercizio fisico.

D IR E C T -T O -C O N S U M E R M A R K E T IN G O F

H IG H -T E C H N O L O G Y S C R E E N IN G T E S T S

• We recommend aspirin, a statin, and exercise, but we advise against a CAC scan

• What if the patient responds, “Thanks, Doc, but I’m not worried about radiation and I really don’t want to take those drugs or exercise if my coronaries are clean”?

• However, since even “clean coronaries” on a calcium scan would not change the recommendations, the test would not be cost-effective at any level of cost.

•CT angiography is accurate in identifying coronary stenoses and characterizing disease severity in symptomatic patients•However, multidetector CT angiography cannot be used as a simple replacement for conventional coronary angiography, given its negative predictive value of 83% and positive predictive value of 91% in this population of patients

• To date, the explosive growth of imaging has not been associated with any improvement in patients’ outcomes, and it is difficult to justify imaging scans without knowing how the additional information they provide will improve the care patients receive.

• Obstacles to implementing an evidence-based approach include our faith in technology, the mistaken belief that tests can prevent heart attacks, the influence of lobbying

• The continued unrestrained use of new technology, in the absence of evidence-based criteria, portends a bleak future for our health care system.

Continua…………..