JUSTIFICATION OF THE USE OF COMPUTED TOMOGRAPHY FOR INDIVIDUAL HEALTH ASSESSMENT … · CALCIUM...
Transcript of JUSTIFICATION OF THE USE OF COMPUTED TOMOGRAPHY FOR INDIVIDUAL HEALTH ASSESSMENT … · CALCIUM...
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JUSTIFICATION OF THE USE OF COMPUTED TOMOGRAPHY FOR INDIVIDUAL HEALTH
ASSESSMENT (IHA) OF ASYMPTOMATIC PEOPLE
Eugenio Picano
CNR, Institute of Clinical Physiology
Pisa, Italy
Munich, 15-17 October 2014
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AGATSTON CALCIUM SCORE
The detection of coronary artery calcification on electron beam computed tomography (EBCT) and its quantitative expression with the CAC Score seems to be an important predictor of atherosclerotic disease and events
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All-cause survival in 4474 men and 3219 women with >1 risk factor by EBCT coronary
calcium measurements
Coronary Artery Calcium Score
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Agatston Score 400
Normal coronary arteries LAD stenosis
Fig. 3
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B>>>R
IIb (possibly appropriate)
IIa (probably appropriate)
I (appropriate indication)
B>>R
III (inappropriate)
BR
RB
Risk vs Benefit: The code of appropriateness
AHA-ACC-ESC Guidelines 2007
Fig. 1
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• Why
• When
• How
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Exercise-ECG test
Stress echo
Stress scintigraphy
MDCT
Symptoms
Epicardial Coronary Artery
Patients status
Timeline
Normal 0% 20% 50% 75% 90% 100%
Well Worried well
Suspected sick
Sick Very sick
Sickest of the sick
Years 30 40 60 70 80
Pain
Function
ECG
Malperfusion
Coronary anatomy and wall structure
The pathophysiology reasons of screening
Endothelial Dysfunction
IMT
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The political reasons of screening
“The early diagnosis is always to be
recommended, in every case”. (Livia TURCO, Health Minister of the Prodi cabinet) La Repubblica,
4 April 2007
…This screening test likely exposed Mr Obama to significant radiation unnecessarily, increasing his risk of future cancer.
Redberg R. First Physical. Arch Intern Med. 2010;170:583
http://images.google.com/imgres?imgurl=http://www.repubblica.it/speciale/2006/dossier_governo/ministri/4.jpg&imgrefurl=http://www.repubblica.it/speciale/2006/dossier_governo/ministri/4.html&h=324&w=303&sz=22&hl=it&start=1&tbnid=8dUk18SCMvwgfM:&tbnh=118&tbnw=110&prev=/images?q=livia+turco&gbv=2&svnum=10&hl=it
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The screening : the money factor
“Certi dottori, disse Kojo, pagandoli il giusto ti fanno qualunque cosa” Dave Eggers. “How we are
hungry”. (La fame che abbiamo) 2005
“Some doctors are capable to do everything to you – if you pay enough”
“Più esami fai, più il paziente è contento”
“Non so se hai capito bene, Guido. Non è necessario che il cliente che mi mandi abbia davvero bisogno di una radiografia. Basta che ne abbia bisogno secondo te. E il bello è che il cliente paga ed è soddisfatto”.
G. D’Agata, Il medico della mutua. Feltrinelli, Milano, 1964 “It is not necessary that your patient really needs the exam, it is
enough that he or she needs it according to you. The nice thing about it is that the patient pays and is also happy with it. “
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• Why
• When
• How
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Indication to stress echo and competing techniques in symptomatic subjects
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Indication to stress echo and competing techniques in asymptomatic
(without symptoms or ischemic equivalent) subjects
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Use of coronary computed tomography angiography for the
diagnosis of stable coronary artery disease
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• Why
• When
• How
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The radiation issue in
• For each clinical scenario, tests that impact ionizing radiation will be performed by labs that have adopted contemporary dose-radiation techniques.
Wolk MJ, et al.. J Am Coll Cardiol. 2014;63:380-406 Education, justification, and optimization are the
cornerstones to enhance the radiation safety of medical imaging. Limiting the use of imaging to appropriate clinical indications can ensure that the benefits of imaging outweigh any potential risks. The continually expanding repertoire of techniques that allow high quality imaging with lower radiation exposure should be used when available to achieve safer imaging.
Fazel R et al, Circulation, 4 November 2014. A scientific Statement of American Heart Association
• The actual delivered dose should always be recorded and included in patients’ records. Because of the numerous sources of variability, there is no threshold between acceptable and unacceptable exposure for any given examination, but the dose that is not even considered is certainly unacceptable .
Picano E, et al. Eur Heart J. 2014;35:665-72
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Reduction in Radiation
Marraccini P et al. Acta Radiol. 2014;54:42-7
SAME TECHNOLOGY
NEW TECHNOLOGY
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The pandemics of inappropriateness
Inappropriate Appropriate Partially inappropriate
Carpeggiani C et al. PLoS One. 2013;8:e81161
CA (250 cases)
CXr (250 cases)
PCI (250 cases)
CCT (250 cases)
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Take-home message
• X-rays and gamma-rays used in radiology and nuclear medicine are proven (class 1)
carcinogens, and cardiologists should make every effort to give ‘the right imaging
exam, with the right dose, to the right patient’.
• The priority given to radioprotection in every cardiology department is an
effective strategy for primary prevention of cancer, a strong indicator of the quality
of the cardiology division, and the most effective shielding to enhance the safety
of patients, doctors, and staff.
• A smart cardiologist cannot be afraid of the essential and often life-saving use of
medical radiation, but must be very afraid of radiation unawareness.