SPRING 2011

Eye on Imaging | Spring 2011 For a consult or to refer a patient, please call (310) 423-8000

EISNER Trial Results Published: Coronary Artery Calcium Scans Help Patients Lower

Heart Disease Risk Without Increasing Tests and CostsA new study of coronary artery calcium scanning (CCS) has shown that the scan helps patients make heart-healthy lifestyle changes and lower their heart disease risk factors.

The study, the EISNER trial (Early Identification of Subclinical Atherosclerosis by Noninvasive Imaging Research) was headed by researchers at Cedars-Sinai’s Heart Institute and Cedars-Sinai’s S. Mark Taper Foun-dation Imaging Department. The study results were published in the April 12, 2011 issue of the Journal of the American College of Cardiology.

The EISNER trial, the largest randomized trial of CCS, studied 2,137 volunteers with coronary risk factors but no known heart disease, randomizing them to either have or not have CCS, then followed the subjects for their risk-factor changes over four years. The final trial results demonstrated that early screening does not in-crease subsequent tests and their associated costs.

“For patients who may be at risk for heart disease, coro-nary artery calcium scanning gives patients and their doctors definitive anatomic evidence of plaques in the coronary arteries and takes much of the guesswork out of lifestyle management and medical procedure deci-sion-making,” said Daniel S. Berman, MD, the study’s principal investigator and chief of Cardiac Imaging and Nuclear Cardiology at the Cedars-Sinai Heart Institute and the S. Mark Taper Foundation Imaging Center. “In our study, patients who knew their coronary calcium scores were low were able to avoid unnecessary testing

and major lifestyle modification, while those with high scores were motivated to take more aggressive steps to reduce their risk.”

CCS shows plaques in coronary arteries long before symptoms develop and has been consistently shown to effectively identify patients with silent heart disease at risk for a heart attack or sudden death. The test is rarely covered by insurance although a large number of studies have consistently shown that CCS detects these patients more accurately than standard blood tests.

The current study found that patients who were screened had better long-term risk profiles than those who were not. All 2,137 study volunteers in the EISNER trial had an initial, private risk factor counseling session and assessment of seven modifiable risk factors: blood pres-

Single Slice Diagram of Heart

Abnormal Coronary Calcium Scans show bright deposits of calcium in the coronary arteries, as shown in the

yellow circle in above image.

Eye on Imaging | Spring 2011 For a consult or to refer a patient, please call (310) 423-8000

Cardiac Imaging Innovator, Daniel S. Berman, MD Receives Pioneer in Medicine Award

Left to right: Steven S. Galen, MD, Vice Chief of Staff, and Chair of the Pioneer in Medicine selection panel, John D. Friedman, MD, Chief of Outpatient Cardiac Imaging, Scott Karlan, MD, FACS, Chief of Staff, Daniel S. Berman, MD, Chief of Cardiac Imaging

Patients around the world who undergo advanced heart imaging studies benefit from the research and innova-tion of Daniel S. Berman, MD, chief of Cardiac Imag-ing and Nuclear Cardiology at the Cedars-Sinai Heart Institute and Cedars-Sinai’s S. Mark Taper Founda-tion Imaging Center. Recently, Cedars-Sinai’s medical staff recognized Berman’s achievements and influence, awarding him its highest honor, the Pioneer in Medi-cine Award.

Dr. Berman is one of the world’s preeminent clini-cal investigators in non-invasive cardiac imaging and one of the founding fathers of nuclear cardiology. He established the largest and most extensively studied patient database in the field of cardiac imaging. He also co-directed a program to create software that enables computers to analyze 3D images produced by advanced imaging technologies. The automated software in nu-clear cardiology is considered the gold standard.

sure, cholesterol and triglyceride profiles, blood sugar, weight, waist circumference, exercise, and smoking.

Of the total study participants, 1,424 were selected at random to have CCS. The remaining 713 were assigned to a no-scan group. Four years later, all available par-ticipants were reevaluated and both groups had CCS.

Compared to the no-scan group, subjects who under-went initial scanning had significant improvement in several risk factors after four years: systolic blood pres-sure; LDL levels; waist size among those with large ab-dominal circumference; and weight among those who were overweight.

An important outcome was that the Framingham Risk Score, the widely used assessment tool that calcu-lates a person’s overall risk of having a heart attack or dying within 10 years, increased in the no-scan group, but remained unchanged in those who had initial scans. Individual risk factor profiles, based on the seven mod-ifiable risk factors, improved in both groups, but the degree of improvement was greater in the scan group.

There was no difference between the groups in the cost or use of invasive or noninvasive diagnostic and treat-ment procedures. Patients who had normal baseline scans had fewer tests and procedures in the subsequent four years compared to patients who did not have scans. Drug costs were seven percent higher in the scan group because more of these patients started taking blood pressure and cholesterol medications.

Berman noted, “By showing improved patient out-comes with scanning – without increasing the need for subsequent tests – the EISNER trial will be very helpful in our quest to prevent heart attacks. The test isn’t for everyone, but should be considered in patients with risk factors for coronary artery disease who are in the right age group.”

The EISNER trial was supported by a grant from the Eisner Foundation. Dr. Berman has research grants from Siemens and GE/Amersham.

Daniel S. Berman, MD(310) 423-4223bermand@cshs.org

New ACC/AHA Guidelines Support Coronary Calcium Scanning in Asymptomatic Patients

New Reduced Cash PriceThe CCS cash price has been reduced to $185 (without consult).

Imaging’s White Glove Service

“As Imaging’s Patient Care Advocate, my goal is to assist your patients with their unique needs.”

- Paula Rubin

Our White Glove Service applies to all modalities and is offered to those patients with specialized needs. The service includes:

• Personalized scheduling• Flexible appointment hours• Expedited registration• Private entrance with escort• Private waiting area• Patient accompanied throughout the visit• Special attention to privacy needs• Additional security when necessary

If you feel any of your patients require this service, please contact Paula Rubin directly at (310) 423-3268 or rubinp@cshs.org.

SUPER STAT Coronary CTAIn the emergency room, ruling out an acute coro-nary syndrome (ACS) in patients with chest pain is of crucial importance for avoiding unnecessary hospitalization of patients who do not have ACS and for getting patients to the cath lab who need such care. Coronary CTA provides an extremely accurate method for these purposes and is most applicable in patients presenting to the emergency department with a low to intermediate likelihood of ACS.

A new rapid coronary CTA process is now be-ing implemented by the Ruth and Harry Roman Emergency Department and the Department of Imaging at Cedars-Sinai.

Time from ED order to reporting: 2 hours

Availability of study: 6 am to 5:30 pm Monday through Friday

New ACC/AHA Guidelines Support Coronary Calcium Scanning in Asymptomatic Patients

The American College of Cardiology (ACC) Founda-tion/American Heart Association (AHA) Task Force on Practice Guidelines recently released new guidelines for assessment of cardiovascular risk in asymptomatic adults. For the first time, the new guidelines, which are characteristically conservative, contain two Class IIa indications, defined as “the weight of evidence or opinion is in favor of the procedure or treatment,” for Coronary Calcium Scanning (CCS):

• Asymptomatic patients with an intermediate (10-20%) 10-year risk of cardiac events based on the Framingham Risk Score (FRS) or other global risk algorithms

• Asymptomatic patients >40 years old with diabetes mellitus

The guidelines are based on a large number of studies in-volving more than 100,000 asymptomatic subjects which consistently reported that CCS provides strong prognos-tic information for coronary artery disease (CAD). The guidelines also considered recent multicenter studies that have reported how standard clinical assessments such as the FRS—based on coronary risk factors alone—are in-ferior to CCS in predicting cardiac events.

“The recommendation by major professional organiza-tions in cardiology that coronary calcium be measured is likely to have as great an impact on saving lives as the recommendation that cholesterol be measured and controlled,” says Daniel S. Berman, chief of Cardiac Imaging and Nuclear Cardiology at the Cedars-Sinai Heart Institute and Cedar-Sinai’s S. Mark Taper Foun-dation Imaging Center.

An abnormal CCS establishes the presence of underly-ing CAD and signals the need for aggressive risk-factor management, which has been shown to prevent cardiac events. The risk for future events increases in direct proportion to CCS score elevation. Subjects with high CCS scores may be candidates for cardiac stress testing to rule out the presence of silent myocardial ischemia. Application of these newly published guidelines may represent a true breakthrough in our nation’s attempt to eliminate unnecessary myocardial infarction and coro-nary deaths due to unrecognized heart disease.

Case of the MonthA 78-year-old female presented with severe acute non-pleuritic, substernal chest pain. ECG and cardiac enzymes were normal. A coronary CT angiogram was performed.

Selected patient images are shown on the left.

What’s your diagnosis?

A) Superior vena cava thrombosis

B) Pulmonary embolism

C) Aortic dissection and rupture

D) Acute myocardial infarction

For the answer, please visit www.csmc.edu/caseofthemonth

To refer a patient, please call (310) 423-8000www.csmc.edu/imaging

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