Coronary assessment for non CABG CVTthaists.org/news_files/news_file_535.pdf · •Coronary...
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Coronary assessment for non CABG CVT Dr. Khate Sripratak ,MD. BSCI/SCCT/SCMR Chest disease institute
Transcript of Coronary assessment for non CABG CVTthaists.org/news_files/news_file_535.pdf · •Coronary...
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
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
FUNCTIONAL STATUS
FUNCTIONAL STATUS
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
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.
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III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
Thank you for your attention
