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Cardiac CT in the Emergency Room PowerPoint Presentation

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Description : Cardiac CT in the Emergency Room

Tags : Chest pain, Cardiac CT, CT coronary angiography

Published on : Mar 16, 2023 | Views : 1320 | Downloads : 4

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CARDIAC CT New Approach to Cardiovascular Disease Stephen Fleet, M.D.
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A picture is worth 1000 words
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MESA Study – 6,814 Patients: 3.5 year follow-up Fully adjusted – Detrano et al– NEJM 2008 Ref Nonfatal MI & CHD Death 4.47 (2.45,8.13) 10.26 (5.62,18.71) 14.13 (7.91,25.22)
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<10% 10-20 >20 % 10-year risk ATPIII Score Risk Assessment CAC Score high Intermediate Zero Reclassification of ATP III Risk Categories Using CAC Scheme according to Wilson PWF et al JACC 41:1889 – 1906, 2003 with HNR data
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MESA – Aspirin Use 2018
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15 Year WarrantyValenti, Min Callister 2015
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CAC Zero as Negative Risk Marker
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ST FRANCIS RANDOMIZED TRIALRandomized Double Blind Placebo Controlled Trial of Atorvastatin in the Prevention of Cardiovascular EventsAmong Individuals With Elevated CAC Score Arad Y et al. J Am Coll Cardiol 2005: 46: 166-172. Atorvastatin 20 mg (N=490) MI Stroke CVD Death CABG/PTCA No Prior CVD Men, Women 50-70 years CAC >80% of age-gender Placebo (N=515) Mean duration of treatment was 4.3 years. Treatment reduced low-density lipoprotein cholesterol by 40%, while reducing clinical endpoints by 30% (6.9% vs. 9.9%), and MI/ Death by 44% (NNT = 30) Event rates were more significantly reduced in participants with baseline calcium score >400 (8.7% vs. 15.0%, p=0.046 [42% reduction]). NNT = 15.8
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Does CAC scanning improve outcomes? Rozanski. Berman. EISNER. JACC 2011;57:1622. CACS 0 = 631. CACS>400 = 109.
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“assessing CAC is likely to be the most useful of the current approaches to improving risk assessment among individuals found to be at intermediate risk after formal risk assessment.” ACC/AHA 2013 PREVENTION GUIDELINES– Goff JACC 2014
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CAC IN 2018 GUIDELINES
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MESA STUDY 10 year outcomes Budoff EHJ 2018
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NNT for CAC >100 12
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Case presentation 41 year old male presented with intermittent chest pain for <1 day with associated nausea/vomiting/back pain. Initially assessed as intermediate risk for ACS History only remarkable for smoking Non-diagnostic ECG; unremarkable exam/labs Initial Troponin was .048 Patient was taken for cardiac CT
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Guidelines SCCT guidelines on the use of coronary computed tomographic angiography for patients presenting with acute chest pain to the emergencydepartment: A Report of the Society of Cardiovascular Computed Tomography Guidelines Committee Raff et al. JCCT June 2014
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Figure 1 Study Algorithm In this diagnostic algorithm, patients in the multi-slice computed tomography (MSCT) group with normal scans were eligible for immediate discharge. Patients with severe stenosis on MSCT (over 70%) were referred for invasive angiog... James A. Goldstein , Michael J. Gallagher , William W. O’Neill , Michael A. Ross , Brian J. O’Neil , Gilbert L. Ra... A Randomized Controlled Trial of Multi-Slice Coronary Computed Tomography for Evaluation of Acute Chest Pain Journal of the American College of Cardiology, Volume 49, Issue 8, 2007, 863 - 871 http://dx.doi.org/10.1016/j.jacc.2006.08.064
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Figure 1 Study Algorithm Coronary computed tomographic angiography (CCTA) arm (orange) : *invasive coronary angiography = 24 patients (18 = abnormal CCTA, 3 = abnormal myocardial perfusion imaging [MPI], 3 = physician discretion). MPI = 37 patients (24 =... James A. Goldstein , Kavitha M. Chinnaiyan , Aiden Abidov , Stephan Achenbach , Daniel S. Berman , Sean W. Hayes ,... The CT-STAT (Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patients to Treatment) Trial Journal of the American College of Cardiology, Volume 58, Issue 14, 2011, 1414 - 1422 http://dx.doi.org/10.1016/j.jacc.2011.03.068
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CT-STAT 2011 No missed ACS
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ROMICAT-II (Hoffman et al, NEJM 2012) - Notable differences to the prior randomized studies: -TIMI scores did not limit entry criteria - SOC included any available management strategy deemed appropriate by the treating physicians. These choices included EKG treadmill testing, stress echo and stress single photon emission CT, as well as no further diagnostic testing
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CT-Compare Hamilton-Craig et al. International Journal of Cardiology 177 (2014) 867–873
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