Chụp chọn lọc động mạch vành có nên là lựa chọn đầu tiên ở người đau thắt ngực

Selective coronary angiography: should be first choice for angina patients? Hoàng Văn Sỹ MD, PhD University of Medicine & Pharmacy, Ho Chi Minh City All roads lead to Rome ! Appropriateness of diagnostic catheterization for suspected coronary artery disease in New York State 80 Operator Rate, % 70 60 50 40 30 20 10 Appropriate Uncertain Inappropriate Hannan E L et al Circ Cardiovasc Interv 2014;7:19-27 Appropriateness of diagnostic catheterization for suspected coronary artery disease in New York State 90% 64% 24,9% N=8986 N=2240 Hannan E L et al Circ Cardiovasc Interv 2014;7:19-27 N=1434 2012 AUC for diagnostic catheterization no prior noninvasive stress testing Risk Assessment Low Intermediate High Asymtomatic Global CAD Risk I I U Symptomatic Pretest Probability I U A Appropriate Use Criteria = AUC Anatomy-based risk stratification is the clinical gold standard in high-probability patients ! Patel MR et al J Am Coll Cardiol 2012;59(22):1-33 Determination of Appropriateness Score Appropriateness Designation score Appropriate AHA/ACC Rec Levele of Evid Additional Published Characteristics of Appropriate Imaging Tests I IIa IIb No patient selection bias (consecutive) IIb All patient image results verified (“gold standard” or prognosis) A–B C Wide spectrum of patients studied Uncertain B–C Inappropriate Blinded interpretation III C A-B Reproducible accquisition and interpretation Parikh MA TCT 2014 Risk vs Benefit BENEFIT RISK No Clear Benefit To Guide Therapeutic Decision Making Exposure Risk Is Not Warranted Given No Clear Benefit ACCF/ASNC Appropriate Use of MPS Criteria RISK Exposure Risk Is Farless Than Potential CV Risk Reduction Following Targeted Treatment St Michel’s inspired Care, Inspiring Science BENEFIT Added Benefit To Guide Therapeutic Decision Making Remember…… All medical therapy vs revascularization patients in highly cited RCTs were triaged (pre-randomization) on the basis of Angiography But how many “inappropriate PCI’s” were really getting done ? Wall Street Journal, July 6, 2011 Data from P Chan et al, JAMA 2011 Revascularization appropriateness in stable CAD and 3-year death/recurrent ACS 1,625 pts from the VRPO Cohort Study Pts with stable CAD and a significant stenosis (50% angio) % Adj HR 0.99 (0.48-2.02) 19% of cohort Adj HR 0.57 (0.28-1.16) Adj HR 0.61 (0.42-0.88) 20% of cohort 61% of cohort Ko et al ACC 2012 Approach to diagnosis of suspected IHD Suspected Ischemic Heart Disease (or change in clinical status in a patient with known IHD) yes Intermediate or high risk UA ? Comprehensive clinical assessment of risk, including personal characteristics, coexisting cardiac and medical condition and health status no Exercise or cardiac imaging study Test results suggest high risk coronary lesions ? Initiate guideline directed medical therapy; Consider coronary revascularization to improve survival yes no ACCF/AHA UA/NSTEMI Guideline Symptoms or finding suggest high risk lesions OR Prior sudden death or serious ventricular arrhythmia OR Prior stent in unprotected lef main coronary artery Initiate guideline directed medical therapy no Successful treatment ? Consider coronary revascu to improve symptoms Fihn SD et al JACC 2012;24:2564–603 11 Invasive coronary angiography • Plays a very limited role in the diagnosis of CAD • Diagnosis in patients with suspected SIHD who: Have survived sudden death or serious ventricular arrhythmias or Have symptoms or findings that suggest high-risk coronary lesions Fihn SD et al JACC 2012;24:2564–603 12 Invasive coronary angiography • Non-invasive testing can establish the likelihood of the presence of obstructive coronary disease with an acceptable degree of certainty • ICA will only rarely be necessary in stable patients with suspected CAD, for the sole purpose of establishing or excluding the diagnosis: Patients who cannot undergo stress imaging techniques, Patients with reduced LVEF < 50% and typical angina Patients with special professions, such as pilots (however, be indicated following non-invasive risk stratification for determination of options for revascularization Patients have a high PTP and severe symptoms, or a clinical constellation suggesting high event risk, early ICA without previous non-invasive risk stratification maybe a good strategy to identify lesions potentially amenable to revascularization European Heart Journal (2013) 34, 2949–3003 13 Noninvasive Risk Stratification *Although the published data are limited; patients with these findings will probably not be at low risk in the presence of either a high-risk treadmill score or severe resting LV dysfunction (LVEF 50%) and low-risk criteria on noninvasive testing Fihn SD et al JACC 2012;24:2564–603 Coronary Angiography to Assess Risk After Initial Workup With Noninvasive Testing (cont.) I IIa IIb III No Benefit I IIa IIb III No Benefit Coronary angiography is not recommended to assess risk in patients who are at low risk according to clinical criteria and who have not undergone noninvasive risk testing Coronary angiography is not recommended to assess risk in asymptomatic patients with no evidence of ischemia on noninvasive testing Fihn SD et al JACC 2012;24:2564–603 SPARC Registry: Therapeutic changes after non-invasive testing 1,703 int/high risk pts with CCTA, SPECT or PET Among pts referred for cath, 63% had obstractive CAD 1% Hachamovitch et al JACC 2012;59:462-474 Adverse outcomes related to underutilization of coronary angiography 9356 UK pts with recent onset chest pain in whom angina was suspected panels rated appropriateness using RAND methodology 57% (Panel A), 71% (Panel B) underuse of angiography for appropriate pts Adjusted HR of death/ACS if angiography was NOT performed Panel A Panel B Inappropriate 0.69 (0.47-1.01) 0.52 (0.26-1.03) Uncertain 1.98 (1.17-3.36) 1.16 (0.79-1.72) Appropriate 2.67 (1.77-4.01) 2.47 (1.72-3.55) Hemingway et al Annals if Int Med 2008 Cornerstone of management of stable CAD First make the diagnosis: is this really CAD ??? Risk-stratify the patient and institute therapeutic maesures that:  Improve prognosis  Improve symtoms European Heart Journal (2013) 34, 2949–3003 23 Approach to diagnosis of suspected IHD Clinical assessment of the probability that SCAD is present in a particular patient (determination of PTP) Non-invasive testing to establish the diagnosis of SCAD or non-obstructive atheroslerosis Stratification for risk of subsequent events - usually on the basis of available non-invasive tests - in order to select pts who may benefit from invasive investigation European Heart Journal (2013) 34, 2949–3003 24 Recent implementation of the AUC Newsweek 8/1/11