2010 Asmiha 64mdCTA Slide Final

Curriculum Vitae

IDI (Indonesian Medical Association)

PAPDI (Indonesian Association of Internal Medicine)

PERKI (Indonesian Heart Association)

PUSKI (Indonesian Society of Medical Ultrasonography)

PERKAVI (Indonesian Society of Heart Research)

ASE (American Society of Echocardiography)

ASNC (American Society of Nuclear Cardiology)

AHA (American Heart Association – council on Cardiac Imaging)

SCCT (Society of Cardiac Computerized Tomography)

ASFC (ASEAN Society & Federation of Cardiology)

ISFC (International Society & Federation of Cardiology)

WHL (World Hypertension League)

Membership :

National

International

Curriculum VitaeCurriculum Vitae

Sept-Oct 1992Sept-Oct 1992 Nuclear CardiologyNuclear Cardiology. Royal Adelaide Hospital. University of Adelaide. South . Royal Adelaide Hospital. University of Adelaide. South Australia. Australia. AustraliaAustralia. .

Nov 1992-February 1993Nov 1992-February 1993 Nuclear Cardiology & Other Cardiac ImagingNuclear Cardiology & Other Cardiac Imaging. Academische . Academische Zijkenhuijs Leiden. Zijkenhuijs Leiden. NetherlandNetherland..

Jan 1995Jan 1995 Stress EchocardiographyStress Echocardiography. Hunter-Hill Clinic Cardiology. Sydney. New . Hunter-Hill Clinic Cardiology. Sydney. New South Wales. South Wales. Australia.Australia.

April – June 2000April – June 2000 Research on Antioxidant Effect of Garlic Extract on Copper and Research on Antioxidant Effect of Garlic Extract on Copper and Lypoxygenase-catalyzed oxidation of LDL. Institute of Biochemistry. Lypoxygenase-catalyzed oxidation of LDL. Institute of Biochemistry. University Clinic Charite. Humboldt University. Berlin. University Clinic Charite. Humboldt University. Berlin. GermanyGermany..

Sept – Oct 2003Sept – Oct 2003 Research on the effect of Garlic Extract on Cholesterol Efflux from Research on the effect of Garlic Extract on Cholesterol Efflux from Lipid-loaded J-774 Macrophages. Institute of Biochemistry. University Lipid-loaded J-774 Macrophages. Institute of Biochemistry. University Clinic Charite. Humboldt University. Berlin. Clinic Charite. Humboldt University. Berlin. GermanyGermany..

Jan 2007Jan 2007 Advanced Course on Tissue Doppler ImagingAdvanced Course on Tissue Doppler Imaging. Chinese University. . Chinese University. Hong Hong Kong.Kong.

May 2007 May 2007 Advanced Course Advanced Course (Level 2 Certification) (Level 2 Certification) on on CardiCardiovascularovascular C Computed omputed TomographyTomography, , Albany, New YorkAlbany, New York,, USAUSA

Courses and Training :

Curriculum VitaeCurriculum Vitae

1.1. Effects of Onion on Diabetic patients. Effects of Onion on Diabetic patients. 15th International Congress of 15th International Congress of Internal Medicine. Hamburg, (WEST GERMANY) : 18th - 22nd 1980.Internal Medicine. Hamburg, (WEST GERMANY) : 18th - 22nd 1980.

2.2. Hypertension in the Critical Area of East Java. Singapore: 8th ASEAN Hypertension in the Critical Area of East Java. Singapore: 8th ASEAN Congress of Cardiology. 7-11 December 1990.Congress of Cardiology. 7-11 December 1990.

3.3. Blood glucose and other coronary risk factors in critical areas of East Java. Blood glucose and other coronary risk factors in critical areas of East Java. Jakarta : 6th Congress of ASEAN Federation of Endocrinology, 2-4 July Jakarta : 6th Congress of ASEAN Federation of Endocrinology, 2-4 July 1992.1992.

4.4. The Effect of Garlic extracts (DDS, SAC) on Oxidized-LDL. Measurement The Effect of Garlic extracts (DDS, SAC) on Oxidized-LDL. Measurement of HETE, HODE and its isomeres by HPLC. 1st National,Congress of of HETE, HODE and its isomeres by HPLC. 1st National,Congress of Indonesian Society of Heart Research. Jakarta : July 2002.Indonesian Society of Heart Research. Jakarta : July 2002.

5.5. The Effect of Garlic extracts (DDS, SAC) onThe Effect of Garlic extracts (DDS, SAC) on the Efflux of Cholesterol from Acetylated-LDL-loaded J-774 Macrophages. Asian Pacific Congress of Atherosclerosis. Nusadua, Bali 2004.

6.6. Effects of Garlic & its metabiolites on Atherosclerosis. Focus on Effects of Garlic & its metabiolites on Atherosclerosis. Focus on Atherosclerotic Regression. Keynote Speaker. Atherosclerotic Regression. Keynote Speaker. International International Organization for ChemicalOrganization for Chemical Sciences in Development (IOCD)Sciences in Development (IOCD). . Working Group on Plant Chemistry. Working Group on Plant Chemistry. Surabaya : April 09-11,2007.Surabaya : April 09-11,2007.

7.7. 3 Other International Publications 3 Other International Publications 8.8. > 100 National Publications and Papers> 100 National Publications and Papers

Publications :

Lessons learned from Recent Multicenter Trial on Cardiac mdCTA

Prof. Budi Susetyo Pikir MD PhDDepartment of Cardiology & Vascular Medicine /

Medical Faculty - Dr.Soetomo Hospital Airlangga University

S U R A B A Y A

Predictor & Prognostic Performance of Cardiac CT

In patient with Zero Calcium Score

Cost-Benefit Analysis of mdCTA Diagnostic Performance

Assessment the Absent of Atheroscclerosis

Assessment the Present of Atherosccle

Assessment of Coronary Stenosis

Assessment of In-Stent Restenosis

Asessment of Vulnerable Plaque

Assessment of Myocardial Viabilty

Predictor Performance / Prognostic Performance Predict the Development of CAD

Predict Morbidity & Mortality of CAD

Evaluation of Treatment

Cost-Benefit Analysis of mdCTA Diagnostic Performance

Assessment the Absent of Atheroscclerosis

Assessment the Present of Atheroscclerosis

Assessment of Coronary Stenosis

Assessment of In-Stent Restenosis

Asessment of Vulnerable Plaque

Assessment of Myocardial Viabilty

Predictor Performance / Prognostic Performance Prognostic Performance of patient with Zero Calcium Score

Predict Morbidity & Mortality of CAD

Evaluation of Treatment

The Calcium Scale

The calcium scale is a linear scale with 4 calcium score categories:

0 none

1–99 mild

100–400 moderate

>400 severe

*Calcium score correlates directly with risk of events and likelihood of obstructive CAD*

Patient with ZERO CALCIUM SCORE

• International Multicenter Trial (9 centers) : CORE-64 Trial – Gottlieb et al 2010.

• USA Multicenter Trial (4 centers) : Min et al 2010

Diagnostic Performance of Zero Calcium Score

Core 64 TrialPrevalence of CAD = 56 % ( 50 % stenosis)

291 patients : 73 % male Age 59.3 ± 10.0 years Pre-test Probability of CAD :

Low 5 % Intermediate 75 % High 20 %

Calcium Score

0(n = 72)

1-10(n = 24)

> 10(n = 195)

Pvalue

> 50 % Stenosis 19 % 46 % 71 %

Disease Distribution by CCA• No Disease• 1-vessel disease• 2-vessel disease• 3-vessel disease

78 %

19 %

3 %

0 %

46 %

42 %

13 %

0 %

27 %

25 %

31 %

16 %

Revascularization 13 % 25 % 44 %

Core 64 TrialPrevalence of CAD = 56 % ( 50 % stenosis)

Calcium Score

0(n = 72)

1-10(n = 24)

> 10(n = 195)

PValue

> 50 % Stenosis 19 % 46 % 71 %

Coronary Risk Factor• Hypertension• Diabetes Mellitus• Dyslipidemia• Smoking• Family History of CAD

60 %

17 %

49 %

21 %

22 %

67 %

13 %

58 %

13 %

17 %

68 %

27 %

65 %

19 %

25 %

0.43

0.083

0.059

0.048

0.30

Emergency Department presentation

Chest Pain (within 30 days)

22 %

53 %

17 %

48 %

25 %

62 %

0.035

0.25

Revascularization 13 % 25 % 44 %

Core 64 TrialPrevalence of CAD = 56 % ( 50 % stenosis)

Core 64 Trial (International Multicenter Trial)72 patients with Ca Score = 0Prevalence of CAD = 19 % ( 50 % stenosis)

< 50 % Stenosis

Sensitivity Specificity PPV NPV

Patient Based

45 % 91 % 68 % 81 %

• Revascularization 12.5 % (9 pts)

Prognostic Performance of Zero Calcium Score

Core 64 TrialPrevalence of CAD = 56 % ( 50 % stenosis)

• 383 Vessel without Calcification – 12 % with significant stenosis

• 64 of Total Occluded Vessels – 20 % with No Calcium

•20%20%

•80%80%

• Total Coronary Artery PlaqueTotal Coronary Artery Plaque• and EBCT Coronary Calciumand EBCT Coronary Calcium

•80%80%

•PlaquePlaque•DetectableDetectable•by IVUS,by IVUS,•PathologyPathology

•Lipid RichLipid Rich

•FibroticFibrotic

•CalcifiedCalcified •20%20%

•80%80%

GLOBAL RISK ASSESSMENTSCORING SYSTEMS

•• FRAMINGHAM Scoring System

•• PROCAM Scoring System

•• HEART SCORE Project

•• INDIANA Project

ASSESSMENT OF ABOLUTE RISKMETHODS

• Calculate The Number Of Points For Each Risk Factor

• Estimate Global Risk Score ( Sum Of Points )• Consult Coronary/CV Risk Chart• Assess 10-years Asolute Risk Level For CHD

or CV event

Use of Risk Prediction Models in International Guidelines

• US: Risk factor counting and three levels of the 10-year “hard” CHD risk using a Framingham model (> 20%, 10-20% & < 10%).

• Australia: 5-year CVD risk 10-15% using a Framingham model or risk factor counting.

• Europe: 10-year “total” CHD risk > 20% now or as projected to

age 60 using a Framingham model.

Categories of Risk FactorsMajor, independent risk factors

Life-habit risk factors

Emerging risk factors

Obesity (BMI 30)

Physical inactivity

Atherogenic diet

Lipoprotein (a)

Homocysteine

Prothrombotic factors

Proinflammatory factors

Impaired fasting glucose

Subclinical atherosclerosis

Major Risk Factors (Exclusive of LDL Cholesterol) That Modify LDL Goals

• Cigarette smoking• Hypertension (BP 140/90 mmHg or on

antihypertensive medication)• Low HDL cholesterol ( < 40 mg/dL)† • Family history of premature CHD

– CHD in male first degree relative <55 years– CHD in female first degree relative <65

years• Age (men 45 years; women 55 years)

• † HDL cholesterol 60 mg/dL counts as a “negative” risk factor; its presence removes one risk factor from the total count.

Risk Assessment

Count major risk factors – Framingham Global Risk Score

• For patients with multiple (2+) risk factors

– Perform 10-year risk assessment

• For patients with 0–1 risk factor

– 10 year risk assessment not required

– Most patients have 10-year risk <10%

2001

Risk Assessment

Characteristics 10-year CAD Risk

High Risk CAD or

CAD Equivalents

<20%

Moderate Risk 2 + Risk Factors 10-20%

Low Risk 0-1 Risk Factor >10%

Risk Assessment

Count major risk factors – Framingham Global Risk Score

• For patients with multiple (2+) risk factors– Perform 10-year risk assessment

• For patients with 0–1 risk factor– 10 year risk assessment not required– Most patients have 10-year risk <10%

2004

Risk Assessment

Characteristics 10-year CAD Risk

Very High Risk CAD +

CAD Equivalents or

Major Risk Factor

High Risk CAD or

CAD Equivalents

<20%

Moderate Risk 2 + Risk Factors 10-20%

Low Risk 0-1 Risk Factor >10%

Prognostic Performance of Zero Calcium Score

• 106 (25.1 %) of 422 patient with Calcium Score = 0 developed CS > 0 within 4.1 ± 0.9 years.

• Incidence of conversion to CS > 0 nonlinear & highest at 5th years.

US Multicenter Trial (Min et al 2010)Pre-Test Probability of CAD = 0 % ( no prior myocardial infarction, no prior coronary revascularization

or no prior abnormal stress test )

Prognostic Performance of Zero Calcium Score

• Progression of CS > 0 associated with : age, diabetes mellitus and smoking.

• Predictor of CS progression were : CS > 0, diabetes mellitus and smoking.

US Multicenter Trial (Min et al 2010)Prevalence of CAD = 0 % ( no prior myocardial infarction, no

prior coronary revascularization or no prior abnormal stress test )

CONCLUSIONS :1. Zero Calcium Score does not exclude

obstructive stenosis or need for coronary revascularization (19 % with obstructive CAD and 12.5 % need revascularization).

2. Diagnostic performance of Zero Calcium Score to exclude obstrictive CAD are 45 % sensitivity, 91 % specifictiy, 68 % negative predictive value and 81 % positive predictive value).

CONCLUSIONS :3. Otherwise, Zero Calcium Score in the

absence of Clinically CAD has good prognosis (progress to CS > 0 after 4 years).

4. Progression was associated with age, diabetes mellitus and smoking.

5. We must combine Cardiac CT Findings.and Global Cardiovascular Risk Assessment in the Management of Patient.

OtherwiseThe presence of CAD on msCT do not always presence

of CAD on Invasive Coronary Angiography

The absence of CAD on msCT should be absence also of CAD on Invasive Coronary Angiography

(Budi S Pikir 2006)

Although mdCTA has High Sensitivity, High Specificity & High Negative Predictive Value for detection of Coronary Stenosis,

In low to intermediate prevalence (probability) of CAD have low to intermediate Positive Predictive Value

In high risk patient (High Framingham Risk Score), Zero Calcium Score do not exclude CAD

In the absent of Clinically CAD, Zero Calcium Score has good prognosis

Budi S Pikir 2010

•Coronary Calcium

Thank You