Coronary assessment for non CABG CVT

Dr. Khate Sripratak ,MD.

BSCI/SCCT/SCMR

Chest disease institute

European Heart Journal (2009) 30, 2769–2812 , online on August 27, 2009

www.escardio.org

Inflammatory

State

Hypercoagulable

State Stress

State

Hypoxic

State

Trigger

s •Surgical Trauma

•Anesthesia/analgesia

•Surgical Trauma

•Anesthesia/analgesia

•Surgical Trauma

•Anesthesia/analgesia

•Intubation/extubation

•Pain

•Hypothermia

•Bleeding/anemia

•Fasting

•Anesthesia/analgesia

•Hypothermia

•Bleeding/anemia

↑TNF-α

↑IL-1

↑IL-6

↑CRP

↑ PAI-1

↑ Factor VII

↑ Platelet reactivity

↓ antithrombin III

↑ catecholamine and

cortisol levels ↓oxygen delivery

↑ BP

↑ HR

↑ FFAs

↑ relative insulin

deficiency

Coronary artery shear

stress

Plaque fissuring

↑ Oxygen demand

Myocardial

Ischemia

Acute Coronary

Thrombus

Perioperative Myocardial Infarction

Plaque fissuring

www.escardio.org

www.escardio.org

www.escardio.org

www.escardio.org

www.escardio.org

FUNCTIONAL STATUS

FUNCTIONAL STATUS

www.escardio.org

www.escardio.org

www.escardio.org

www.escardio.org

www.escardio.org

www.escardio.org

What test

Balance flow

MIBI 11mSv

CXR 0.02 mSv

500 CXR

High Risk features

High Risk features

Indications for CMR

• Cardiac structure and function

• Viability – fibrosis, stress testing

• Valve disease

• Pericardial disease

• Coronary angiography and plaque imaging

• Aortic pathology – aneurysms, coarctation, dissection

• Cardiomyopathy – sarcoid, amyloid, ARVD, viral

• Paediatric & adult congenital heart disease

• Cardiac tumours

Indications for CMR

according to the

EuroCMR Registry

n=11040

n=92 patients

(%)

Bruder. JACC 2009; 54:1457

Ischemic cascade

Where are we now?

EST Stress imaging

Transmural infarct

Cardiac CT

Appropriate criteria for CT detection of CAD (A 7-9) :

Symptomatic + • CPC Intermediate probability and equivocal stress test/ abnormal baseline ECG

• ACS with intermediate probability no ECG changes and negative enzymes – rapid discharge Coronary anomaly Heart failure: IHD aetiology

NOT ASYMPTOMATIC SCREENING

Radiation exposure

• 120 kV, Spiral Scan, no pulsing 15 - 30 mSv *

• 120 kV, Spiral Scan, ECG pulsing 8 - 15 mSv *

• 100 kV, Spiral Scan, ECG pulsing 4 - 6 mSv *

• 100 kV, Prospective Trigger 2 mSv *

• 40 slice CAC 0.5 - 0.9 mSv

• Single CXR 0.2 mSv

* Rough estimates

Average annual exposure from natural background radiation in UK is 2.5 mSv

Einstein JAMA 2007

CORE 64 14 msv men 15 msv women

MDCT CMR

Temporal Resolution

83-165 ms 20 ms

Spatial Resolution 0.4 mm 0.7 mm

Flow data No Yes

Coronary angiography

Yes +/-

Left Ventriculography

Yes Yes

Right Ventriculography

+/- Yes

Calcium Assessment

Yes No

Fibrosis / Scar +/- Yes

INVASIVE TESTING

• Coronary angiography is rarely indicated to assess the

risk of non cardiac surgery.

• There is a lack of information derived from RCT on its

usefulness in patients scheduled for non cardiac surgery.

ESC

Guideline

2009

Conclusion

ESC

Guideline

2009

NON INVASIVE TESTING OF IHD

• Physiological exercise using a treadmill or bicycle

ergometer

• Myocardial perfusion imaging

• Stress echocardiography using exercise or

pharmacological

• *Cardiac MRI (No data in pre op. setting)

• *Coronary CT scan (No data in pre op. setting)

ESC

Guideline

2009

ESC

Guideline

2009

RECOMMENDATIONS FOR NONINVASIVE

STRESS TESTING

Green bars indicate no recommendation of noninvasive stress testing

and that patients can go directly to surgery

Orange bars indicate patients for whom testing maybe considered if it

will change management (class IIb)

Red bar indicates a class IIa recommendation for noninvasive stress

testing.

PERIOPERATIVE THERAPY

• Beta-blockers

• Statins

• Nitrate

• ACEI

• Alpha-2 agonists

• Calcium channel blockers

• Diuretics

• Aspirin

• Revascularization

B-BLOCKER

ESC Guideline 2009

www.escardio.org

www.escardio.org

Recommendations for Statin Therapy

For patients currently taking statins and scheduled

for noncardiac surgery, statins should be continued.

For patients undergoing vascular surgery with or

without clinical risk factors, statin use is reasonable.

For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures,

statins may be considered.

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

www.escardio.org ESC Guideline 2009

www.escardio.org ESC Guideline 2009

www.escardio.org

Thank you for your attention