silent MI coronary revascularization prevention guideline computed tomography, CT myocardial perfusion scintigraphy, MPS risk stratification

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1 1-2 prevention guideline 3 4 risk stratification intermediate risk Rose' paradox biomarker silent MI coronary revascularization computed tomography, CT myocardial perfusion scintigraphy, MPS CT MPS European Heart Journal 2010 July 14 Working Group on Nuclear Cardiology and Cardiac CT of the European Society of Cardiology CT MPS hard cardiac events 3

2 non-hemodynamically significant plaques hemodynamically significant stenosis CT MPS CT / microcirculation 5 MPS revascularization 1-2 CT medial calcification, non-atherosclerotic vascular biological age coronary artery calcium, CAC CAC CT Agatston Score calcium coverage score cross-sectional Agatston Score Agatston Score Agatston Score 6 CAC Multi-Ethnic Study of Atherosclerosis MESA CAC calcium percentiles Coronary artery calcium

3 CAC percentile CAC Prognostic value of coronary artery calcium in asymptomatic subjects CAC 3-5 <1% Agatston Score> MESA CAC 70% 52% CAC Agatston Score> Framingham risk score CAC Agatston score >300 Coronary calcium in type 2 diabetic patients silent ischemia CAC silent ischemia revascularization silent ischemia CAC Coronary calcium in the elderly and in renal disease CAC CAC CAC 5

4 CAC Measurement of coronary artery calcium progression CAC CAC 15~25% CAC statin CAC meta-analysis CAC 9 Coronary computed tomography angiography positive remodeling CT 10 retrospective ~ % coronary atherosclerosis 5% revascularization 26~36% 12 primary prevention risk stratification

5 Myocardial perfusion scintigraphy, MPS MPS MPS in asymptomatic subjects MPS 2~3 <1% MPS silent myocardial ischemia silent ischemia 50~60 2% 90 15% 7.5% intermediate risk stress MPS 4% 1.6% 13 MPS MPS in asymptomatic type 2 diabetic patients meta-analysis MPS 0.85% MPS 5.9% MPS MPS DIAD 15 Detection of Silent Myocardial Ischemia in Asymptomatic Diabetics MPS MPS MPS 21% MPS autonomic cardiac neuropathy 4.8 MPS 2.4% MPS 0.4% MPS 6% 33/561 MPS 1% MPS MPS Combination of coronary calcium or coronary computed tomography angiography with myocardial perfusion scintigraphy 7

6 MPS 400 Agatston Scores MPS MPS MPS 18% Agatston Score % Agatston Score % Agatston Score Agatston Score 100 MPS MPS Agatston Score 100 Risk assessment in subjects with familial hypercholesterolemia and with familial history of premature coronary artery disease FH 24% MPS 26% % 64% 78% P< MPS 18 MPS MPS 4.7 MPS 14.5 MPS Agatston score> % MPS Agatston score 0~10 21% MPS negative predictive power MPS level of evidence C

7 CAC intermediate-risk Recommendation IIa MPS recommendation III MPS revascularization recommendation IIa premature CAD MPS recommendation IIb coronary CT angiography recommendation III CAC recommendation III Reference 01. Muller-Nordhorn J, Binting S, Roll S, Willich SN. An update on regional variation in cardiovascular mortality within Europe. Eur Heart J 2008;29: Yach D, Hawkes C, Gould CL, Hofman KJ. The global burden of chronic diseases: overcoming impediments to prevention and control. JAMA 2004;291: Graham I, Atar D, Borch-Johnsen K, et al. European guidelines on cardiovascular disease prevention in clinical practice: executive summary. Eur Heart J 2007; 28: Unal B, Critchley JA, Capewell S. Modelling the decline in coronary heart disease deaths in England and Wales, : comparing contributions from primary prevention and secondary prevention. BMJ 2005;331: Schuijf JD, Wijns W, Jukema JW, et al. Relationship between noninvasive coronary angiography with multi-slice computed tomography and myocardial perfusion imaging. J Am Coll Cardiol 2006;48: Greenland P, Bonow RO, Brundage BH, et al. ACCF/ AHA 2007 clinical expert consensus document on coronary artery calcium scoring by computed tomography in global cardiovascular risk assessment and in evaluation of patients with chest pain: a report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force ACCF/AHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography developed in collaboration with the Society of Atherosclerosis Imaging and Prevention and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol 2007;49: Detrano R, Guerci AD, Carr JJ, et al. Coronary calcium as a predictor of coronary events in four racial or ethnic groups. N Engl J Med 2008;358: Greenland P, LaBree L, Azen SP, Doherty TM, Detrano RC. Coronary artery calcium score combined with Framingham score for risk prediction in asymptomatic individuals. JAMA 2004;291: McCullough PA, Chinnaiyan KM. Annual progression of coronary calcification in trials of preventive therapies: a systematic review. Arch Intern Med 2009; 169: Motoyama S, Sarai M, Harigaya H, et al. Computed tomographic angiography characteristics of atherosclerotic plaques subsequently resulting in acute 9

8 coronary syndrome. J Am Coll Cardiol 2009;54: Choi EK, Choi SI, Rivera JJ, et al. Coronary computed tomography angiography as a screening tool for the detection of occult coronary artery disease in asymptomatic individuals. J Am Coll Cardiol 2008;52: Romeo F, Leo R, Clementi F, et al. Multislice computed tomography in an asymptomatic high-risk population. Am J Cardiol 2007;99: Khandaker MH, Miller TD, Chareonthaitawee P, Askew JW, Hodge DO, Gibbons RJ. Stress single photon emission computed tomography for detection of coronary artery disease and risk stratification of asymptomatic patients at moderate risk. J Nucl Cardiol 2009;16: Shaw LJ, Iskandrian AE. Prognostic value of gated myocardial perfusion SPECT. J Nucl Cardiol 2004; 11: Young LH, Wackers FJ, Chyun DA, et al. Cardiac outcomes after screening for asymptomatic coronary artery disease in patients with type 2 diabetes: the DIAD study: a randomized controlled trial. JAMA 2009;301: Anand DV, Lim E, Hopkins D, et al. Risk stratification in uncomplicated type 2 diabetes: prospective evaluation of the combined use of coronary artery calcium imaging and selective myocardial perfusion scintigraphy. Eur Heart J 2006;27: Nasir K, Michos ED, Rumberger JA, et al. Coronary artery calcification and family history of premature coronary heart disease: sibling history is more strongly associated than parental history. Circulation 2004; 110: Blumenthal RS, Becker DM, Moy TF, Coresh J, Wilder LB, Becker LC. Exercise thallium tomography predicts future clinically manifest coronary heart disease in a high-risk asymptomatic population. Circulation 1996;93: Blumenthal RS, Becker DM, Yanek LR, et al. Comparison of coronary calcium and stress myocardial perfusion imaging in apparently healthy siblings of individuals with premature coronary artery disease. Am J Cardiol 2006;97:

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