Anatomic vs. Functional Stress Testing – It’s Complicated! Anatomic vs. Functional Stress Testing – It’s Complicated! Leslee J. Shaw, PhD, MASNC, FACC, FAHA, FSCCT Professor of Medicine Co-Director, Emory Clinical CV Research Institute President SCCT Emory University School of Medicine Atlanta, Georgia E-mail: [email protected]Leslee J. Shaw, PhD, MASNC, FACC, FAHA, FSCCT Professor of Medicine Co-Director, Emory Clinical CV Research Institute President SCCT Emory University School of Medicine Atlanta, Georgia E-mail: [email protected]
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Shaw - Anatomic vs. Functional Stress Testing · COronary CTA EvaluatioN For Clinical Outcomes: An InteRnational Multicenter Registry Dynamic registry of >32,000 consecutive pts 1)
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Anatomic vs. Functional Stress Testing – It’s Complicated!
Anatomic vs. Functional Stress Testing – It’s Complicated!
Leslee J. Shaw, PhD, MASNC, FACC, FAHA, FSCCTProfessor of MedicineCo-Director, Emory Clinical CV Research InstitutePresident SCCTEmory University School of MedicineAtlanta, GeorgiaE-mail: [email protected]
Leslee J. Shaw, PhD, MASNC, FACC, FAHA, FSCCTProfessor of MedicineCo-Director, Emory Clinical CV Research InstitutePresident SCCTEmory University School of MedicineAtlanta, GeorgiaE-mail: [email protected]
Trends in CV ImagingTrends in CV Imaging
Imaging is Essential for CV Disease Diagnosis & Management
Technologic Innovation in Imaging Has Been Dramatic!
Sharp Decline in Utilization -Nuclear, Echo, & CMR Downward pressure on CV imaging AUC, RBM/SBM, Choosing Wisely
Campaign, Reduced Reimbursement (Technical Component) & High Deductibles…
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iac C
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Source: David Levin, MD (ACR), Ferrari J Am Coll Cardiol Img 2014;7:324-332.
A Means to Ensure that the Health of our Population isEnhanced by Health Reform Efforts
Intelligent Cost Containment Can Promote Change Through Quality-Guided Revisions in
Healthcare Financing, Organization, & Delivery
Source: Mushlin NEJM 2010;362:e6
Comparative Evidence from Trials & Registries:
The Optimal Approach to Evaluation of CADBoth Anatomy and Physiology
Evaluation of Integrated CAD Imaging in Ischemic Heart Disease (EVINCI) Trial
Source: Neglia Circ CV Imaging 2015 Mar;8(3).
Diagnostic Accuracy Estimating Obstructive CAD (N=475 from 14 Centers)
• CCTA Plus 1+ Stress Test
• Patients with Abnormal Findings Underwent Invasive Angiography
• Min (ACM): 1,000 patients, >4 yr f/u, >64-row CT• Ostrom (ACM): 2,538 patients, 6.5 yr f/u, EBT• Andreini (MACE): 1,304 patients, 4.3 yr f/u, 64-row CT • Hadamitzky (MACE): 1,584 patients, 5.6 yr f/u, 16- / 64-row CT
Source: Min J Am Coll Cardiol 2011 Aug 16;58(8):849-60 ; Ostrom J Am Coll Cardiol 2008 Oct 14;52(16):1335-43.; Andreini JACC Imaging 2012 Jul;5(7):690-701; Hadamitzky J Am Coll Cardiol 2013 Jul 30;62(5):468-76.
Long-term Annualized Prognosis For Normal CT
“Warranty Period” of Normal CCTA – At least 5 years
6,426 patients, ~5.5 yr f/u
Annu
alize
d Eve
nt Ra
te
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5
10
15
1VD 2VD 3VD
>6-fold higher mortality for patients with 3-vessel mild CAD
HR 1.93 HR 2.74 HR 6.09
Source: Lin J Am Coll Cardiol 2011 Jul 26;58(5):510-9.
DesignN=1,200 - RCT of 3T CMR Stress-Guided Care vs. Standard of Care for Suspected CADHypothesis: CMR-Guided Management is Superior to the Standard of Care Avoiding Unnecessary Coronary Angiography & Reducing Clinical Outcomes
Source: Ripley Am Heart J 2015;169:17–24. Completed in 2018
Utilization of CCTA & Outpatient Invasive Coronary Angiography in Ontario, Canada
RCT Evidence Supports CCTA Use in ED Evaluation of Low Risk Chest Pain Timely Diagnosis & Discharge in
Troponin Neg. Patients
UK’s National Institute of Health & Care Excellence (NICE) - Cost Effective
CT Use ↑ - 0.8% → 4.5% (p<0.001) from 2006-2013
Source: Litt NEJM 2012;366:1393-403.; Hoffmann NEJM 2012;367:299-308., Goldstein JACC 2011;58:1414-22.; Goodacre HTA 2013;17:1-188., Morris Acad Emerg Med 2016 May 7.
434%
-22% -11% -6%
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CCTA ETT StressEcho
StressNuclear
Administrative Claims Analysis:
N=2,047,799 Testing ≤72 hrs
Comparative Trends of CCTA & Stress Testing in Emergency Department (ED) Patients with Chest Pain: Administrative Claims Analysis
N=2,047,799 ED Patients With CCTA or Stress Testing ≤72 hrs
CCTA Use ↑ from 0.8% to 4.5% (p<0.001) from 2006-2013
CCTA associated with higher rates of PCI (OR=1.25) and CABG (OR=1.47)
CCTA associated with more hospitalizations, return ED visits, & repeat noninvasive testing
Source: Morris Acad Emerg Med 2016 May 7.
434%
-22% -11% -6%
-100%
0%
100%
200%
300%
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500%
CCTA ETT StressEcho
StressNuclear
CCTA: Coronary Computed Tomographic Angiography; ETT: Exercise Tolerance Testing without Imaging; Echo: Echocardiography; Nuclear: PET or SPECT.
Patient-Centered Imaging
Right Patients + Right Rx Guidance = Optimal Patient Outcomes
Patient-Centered Imaging – To Optimally Guide Therapeutic Decision Making
High Quality CV Procedures
Right Patient Right Procedure Decision
Appropriate Use CriteriaGuidelines
Patient Preferences
Performance Measures
Quality MetricsPublic Reporting
Right Procedure Execution
Right Outcome
Ongoing Trials & Evidence
Value Equation for CV Procedures: Was Right Procedure Done Promptly in Right Way w/ Right Outcome?
To Identify Optimal Candidates for CV Procedures To Improve Safety - Reduce
Radiation Exposure / Complications Whenever Possible To Foster Efficiency - Eliminate
Unnecessary Testing – Induce Cost Savings
ACC Appropriate Use Criteria Taskforce
Standardize Communication of CCTA Findings & Facilitate OptimalPatient Management
CAD-RADS Classification - Recommendations for Management ofChest Pain Patients
CCTA-Guided Strategy of Care – Framework for Education &Quality Assurance to Facilitate Improve Quality of Care
Source: Cury JCCT 2016 (online).
Patient-Centered Imaging
Desired Patient
OutcomeCAD-RADSAUC
Focus on Patient-Centered Imaging
Quality Metrics in Your Practice – AUC, Structured Reporting, CAD/RADS, Timeliness Standards… Focus Use in Appropriate Patients Populations Establish Utilization in Areas w/ Established Comparative Effectiveness
Evidence in our Core Patient Populations
Institute Quality Assurance Programs – e.g., Cath Correlation Focused Patient & Referring MD Education of Radiation