1. Investigations in perspective Search for EBM Do all if all can be done ? Choices and Sharing in Care 2-4-20151© Eduard van den Berg, cardio.nl

2. Question to start with What does the department Cardiology Atrium Medical Center endorse as guidelines ? 2-4-2015Eduard van den Berg, cardio.nl2

3. De Orde Definition Guideline 2-4-2015Eduard van den Berg, cardio.nl3

4. 2-4-2015Eduard van den Berg, cardio.nl4 De Orde Legal status Guideline

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7. 3-th Definition MI 250812 2-4-2015Eduard van den Berg, cardio.nl7

8. 2-4-2015Eduard van den Berg, cardio.nl8

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10. Does Cardiology Atrium agree with GL hierarchy ? 2-4-2015Eduard van den Berg, cardio.nl10 1.Dutch GL 2.Endorsed ESC GL 3.Non-endorsed ESC GL 4.US GL YES

11. NSTE ACS GL 2011 2-4-2015Eduard van den Berg, cardio.nl11

12. NSTE ACS endorsed by ? 2-4-2015Eduard van den Berg, cardio.nl12

13. NO complaints 2-4-2015Eduard van den Berg, cardio.nl13

14. Primairy Prevention 2-4-2015© Eduard van den Berg, cardio.nl14 No complaints but in the foodlight The general physician participates in CVRM

15. CVRM ESC 2012 2-4-2015© Eduard van den Berg, cardio.nl15

16. CVRM – CVD Prevention 2-4-2015Eduard van den Berg, cardio.nl16

17. Not (yet) endorsed by NVVC (luckily ?) 2-4-2015Eduard van den Berg, cardio.nl17

18. Decrease † in about 10 yrs 2-4-2015© Eduard van den Berg, cardio.nl18

19. NICE report 2-4-2015© Eduard van den Berg, cardio.nl19 According to the report of NICE, implementation of the population approach may bring numerous benefits and savings: † Narrowing the gap in health inequalities. † Cost savings from the number of CVD events avoided. † Preventing other conditions such as cancer, pulmonary diseases, and type 2 diabetes. † Cost savings associated with CVD such as medications, primary care visits, and outpatient attendances. † Cost savings to the wider economy as a result of reduced loss of production due of illness in those of working age, reduced benefit payments, and reduced pension costs from people retiring early from ill health. † Improving the quality and length of people’s lives.

20. Remarks vdB I 2-4-2015© Eduard van den Berg, cardio.nl20 Patiënt Awareness only postpones disease but increases both whished and unwished consumption Assumed is that disease could be extended to the ‘inproductive’ period in life but retirement age will tan also increase with survival until 18.5 yrs life- expectancy remains So we live longer but is it with good overall (mental) health ? Qualies ? At the end interference always costs money (FFR + FU)

21. Remarks vdB After the civilization stage of obvious welfare (thick, smoking, alcohol, cars, Russia ?) comes the stage of prevention (no smoking, sport, nutritial habits, Netherlands) Doctors Awareness of patients whishes if informed consent is there could reduce costs with 25 % ? The survival of Elderly due to interference can transcend that of younger pts but may be the younger will never become old primary because of the genetics, look at years to be gained and Qualies 2-4-2015© Eduard van den Berg, cardio.nl21

22. CVRM recommendations 2012 2-4-2015© Eduard van den Berg, cardio.nl22

23. 2-4-2015Eduard van den Berg, cardio.nl23

24. 2-4-2015Eduard van den Berg, cardio.nl24 CONCEPTOFRiSkAgeCONCEPTOFRiSkAge

25. Risk categories, 15 % / 10 yr = highest 2-4-2015© Eduard van den Berg, cardio.nl25

26. Differences with Framingham score In SCORE 10 year fatal event In Framingham 10 year incidence of coronary deaths and recognised non-fatal myocardial infarction Great difference in conception of Risk 2-4-2015© Eduard van den Berg, cardio.nl26

27. 2-4-2015Eduard van den Berg, cardio.nl27

28. Categories Framingham 2-4-2015Eduard van den Berg, cardio.nl28

29. Combination of Risk Factors SCORE ® 2-4-2015© Eduard van den Berg, cardio.nl29

30. Risk and Survival 2-4-2015Eduard van den Berg, cardio.nl30

31. Heartscore ®, now the Netherlands are at high risk 2-4-2015© Eduard van den Berg, cardio.nl31 Risk age is also automatically calculated as part of the latest revision of the SCORE system the HeartScore (260811). Upgraded with HDL, BMI and Risk Age http://www.HeartScore.org Europe high risk (English) Albania, Algeria, Armenia, Austria, Belarus, Bulgaria, Croatia, Czech Republic, Denmark, Egypt, Estonia, Finland, Georgia, Hungary, Iceland, Ireland, Israel, Latvia, Libanon, Libya, Lithuania, Former Yugoslav Republic of Macedonia, Moldova, Morocco, Norway, Romania, San Marino, Serbia and Montenegro, Slovakia, Slovenia, The Netherlands, Tunisia, Turkey, Ukraine, United Kingdom

32. 2-4-2015Eduard van den Berg, cardio.nl32

33. 2-4-2015© Eduard van den Berg, cardio.nl33 https://escol.escardio.org/Heartscore/pmsCenter.aspx?model=EuropeHigh All your patients can be registered online And patiënt Tailored advice is given, also for the pt self

34. 2-4-2015Eduard van den Berg, cardio.nl34

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38. 2-4-2015© Eduard van den Berg, cardio.nl38

39. 2-4-2015Eduard van den Berg, cardio.nl39 Does Cardiology Atrium agree with Score hierarchy ? 1.Heartscore® 2.Score® 3.Framingham Score 4.UKPDS 5.PROCAM So the heartscore® will be used for initial risk calculation ? YES

40. Heartscore ® Risk categories, Remarks 2-4-2015© Eduard van den Berg, cardio.nl40 no threshold is universally applicable, the intensity of advice should increase with increasing risk In persons older than 60, these thresholds should be interpretedmore leniently, because their age-specific risk is normally around these levels, even when other cardiovascular risk factor levels are ‘normal’. The higher the risk the greater the benefit from preventive efforts compatible with the joint European Atherosclerosis Society/ESC lipid guidelines

41. 1 Very High Risk 2-4-2015© Eduard van den Berg, cardio.nl41 Subjects with any of the following: † Documented CVD by invasive or non-invasive testing (such as coronary angiography, nuclear imaging, stress echocardiography, carotid plaque on ultrasound), previous myocardial infarction, ACS, coronary revascularization (PCI, CABG), and other arterial revascularization procedures, ischaemic stroke, peripheral artery disease (PAD). † Diabetes mellitus (type 1 or type 2) with one or more CV risk factors and/or target organ damage (such as microalbuminuria: 30–300 mg/24 h). † Severe chronic kidney disease (CKD) (GFR,30 mL/min/1.73 m2). † A calculated SCORE ≥10%.

42. 2 High Risk 2-4-2015Eduard van den Berg, cardio.nl42 Subjects with any of the following: † Markedly elevated single risk factors such as familial dyslipidaemias and severe hypertension. † Diabetes mellitus (type 1 or type 2) but without CV risk factors or target organ damage. † Moderate chronic kidney disease (GFR 30–59 mL/min/1.73 m2). † A calculated SCORE of ≥5% and,10% for 10-year risk of fatal CVD.

43. 3 Moderate Risk 2-4-2015Eduard van den Berg, cardio.nl43 Subjects are considered to be at moderate risk when their SCORE is ≥1 and,5% at 10 years. Many middle-aged subjects belong to this category. This risk is further modulated by factors mentioned above.

44. 4 Low Risk 2-4-2015Eduard van den Berg, cardio.nl44 The low-risk category applies to individuals with a SCORE,1% and free of qualifiers that would put them at moderate risk.

45. Recommendations, Imaging Remarks, MR 2-4-2015© Eduard van den Berg, cardio.nl45 Non-invasive tests such as carotid artery scanning, electron- beam computed tomography, multislice computed tomography, ankle–brachial BP ratios, and magnetic resonance imaging (MRI) techniques offer the potential for directly or indirectly measuring and monitoring atherosclerosis in asymptomatic persons,

46. Recommendations, Imaging I, MR 2-4-2015Eduard van den Berg, cardio.nl46

47. Recommendations, Imaging II, MR 2-4-2015Eduard van den Berg, cardio.nl47

48. Asymptomatic pts, MRI 2012 2-4-2015© Eduard van den Berg, cardio.nl48 At present, MRI is a promising research tool, but its routine use remains limited and it is not yet appropriate for identifying patients at high risk for CVD. Early detection by magnetic resonance imaging of cardiovascular disease in asymptomatic subjects

49. Asymptomatic pts Agatston score 2012 2-4-2015© Eduard van den Berg, cardio.nl49 In contrast, coronary calcium scanning shows a very high negative predictive value: the Agatston score of 0 has a negative predictive value of nearly 100% for ruling out a significant coronary narrowing. However, recent studies have questioned the negative predictive value of the calcium score: the presence of significant stenosis in the absence of coronary calcium is possible. Although calcium scanning is widely applied today, it is especially suited for patients at moderate risk. The presence of coronary calcium proves a ‘coronary disease’ (coronary atherosclerosis)—it does not necessarily reflect ‘CHD’ defined as ≥50% narrowing.

50. Asymptomatic pts, CTA 2-4-2015 ©Eduard van den Berg, cardio.nl50 Recent studies have also shown that multislice computed tomography coronary angiography with decreased radiation levels is highly effective in re-stratifying patients into either a low or high post-test risk group

51. Asymptomatic pts, Carotid ultrasound 2-4-2015 © Eduard van den Berg, cardio.nl51 Carotid ultrasound can add information beyond assessment of traditional risk factors that may help to make decisions about the necessity to institute medical treatment for primary prevention. Arterial stiffness has been shown to provide added value in stratification of patients. An increase in arterial stiffness is usually related to damage in the arterial wall, as has been suggested in hypertensive patients.

52. Asymtomatic pts, Ankle–brachial index 2-4-2015Eduard van den Berg, cardio.nl52 The ABI predicts further development of angina, myocardial infarction, congestive heart failure, CABG surgery, stroke, or carotid surgery. ABI is inversely related to CVD risk

53. Asymptomatic pts, Ophthalmoscopy 2-4-2015© Eduard van den Berg, cardio.nl53 Most important new information † Vascular ultrasound screening is reasonable for risk assessment in asymptomatic individuals at moderate risk. † Measurement of coronary artery calcifications may be reasonable for cardiovascular risk assessment in asymptomatic adults at moderate risk.

54. RI, OSAS and Viagra 2-4-2015© Eduard van den Berg, cardio.nl54

55. Smoking 2-4-2015© Eduard van den Berg, cardio.nl55 Use WHO Algorithm

56. Diet 2-4-2015Eduard van den Berg, cardio.nl56

57. Physical Activity 2-4-2015Eduard van den Berg, cardio.nl57

58. Other factors, stress, Weight, RR, DM, Chol 2-4-2015© Eduard van den Berg, cardio.nl58 Specific interventions to reduce depression, anxiety, and distress Systematic reviews of patients with coronary artery disease or undergoing PCI have suggested an ‘obesity paradox’ whereby obesity appears protectiveagainst an adverse prognosis DM is a cardiovascular disease BP is a major factor

59. MEDICATION 2-4-2015Eduard van den Berg, cardio.nl59

60. Lifestyle ans Lipid intervention 2-4-2015© Eduard van den Berg, cardio.nl60

61. ATT 2-4-2015© Eduard van den Berg, cardio.nl61

62. Whom CVRM, Take home I 2-4-2015© Eduard van den Berg, cardio.nl62 In apparently healthy persons, CVD risk is most frequently the result of multiple interacting risk factors. A risk estimation system such as HEARTSCORE can assist in making logical management decisions, and may help to avoid both under- and over-treatment. Total risk estimation using multiple risk factors (such as HEARTSCORE) is recommended for asymptomatic adults without evidence of CVD. High-risk individuals can be detected on the basis of established CVD, diabetes mellitus, moderate to severe renal disease, very high levels of individual risk factors or a high HEARTSCORE risk.

63. Whom CVRM, Take home II 2-4-2015Eduard van den Berg, cardio.nl63 Low socio-economic status, lack of social support, stress at work and in family life, depression, anxiety, hostility and the type D personality, contribute both to the risk of developing CVD and the worsening of clinical course and prognosis of CVD. Novel biomarkers have only limited additional value when added to CVD risk assessment with the HEARTSCORE algorithm. High-sensitive CRP and homocysteine may be used in persons at moderate CVD risk.

64. Whom CVRM, Take home III 2-4-2015Eduard van den Berg, cardio.nl64 Measurement of carotid intima-media thickness and/or screening for atherosclerotic plaques by carotid artery scanning should be considered for cardiovascular risk assessment in asymptomatic adults at moderate risk. Measurement of ankle- brachial index and computed tomography for coronary calcium may also be considered. All persons with obstructive sleep apnoea and all men with erectile dysfunction should undergomedical assessment, including risk stratification and risk management.

65. complaints Investigations in the foodlight 2-4-2015Eduard van den Berg, cardio.nl65

66. Complaints sec Type of chest pain, chest disconfort 2-4-2015Eduard van den Berg, cardio.nl66

67. ANGINA PECTORIS 2-4-2015Eduard van den Berg, cardio.nl67 We talk about: 1) Chest discomfort 2) provoked by exertion or emotional stress and is 3) relieved by rest or NTG Typical angina Meets all three of the above characteristics Atypical angina Meets two of the above characteristics Non-cardiac chest pain Meets one or none of the typical anginal features

68. Chest Pain 2-4-2015Eduard van den Berg, cardio.nl68 Type of chest pain Severity (Canadian Cardiovascular Society, CCS) cardiac functional status (New York Heart Association, NYHA)

69. 2-4-2015Eduard van den Berg, cardio.nl69

70. 2-4-2015Eduard van den Berg, cardio.nl70

71. 2-4-2015Eduard van den Berg, cardio.nl71

72. complaints STABLE 2-4-2015Eduard van den Berg, cardio.nl72

73. 2-4-2015Eduard van den Berg, cardio.nl73

74. Stable AP, 2006 (newest !!) 2-4-2015Eduard van den Berg, cardio.nl74

75. AP classes and related P(CAD) 2-4-2015Eduard van den Berg, cardio.nl75

76. ECG Who, when 2-4-2015Eduard van den Berg, cardio.nl76

77. Who should get when an ECG 2-4-2015Eduard van den Berg, cardio.nl77

78. X-ECG 2-4-2015Eduard van den Berg, cardio.nl78

79. X-ECG, SENS, SPEC 2-4-2015Eduard van den Berg, cardio.nl79

80. What is a pos X-ECG test 2-4-2015Eduard van den Berg, cardio.nl80

81. Changing the treshold, Harmless ? 2-4-2015Eduard van den Berg, cardio.nl81

82. Quantitative, prevalence CAD 2-4-2015Eduard van den Berg, cardio.nl82 Typical anginaAtypical anginaNon anginal chest pain AGEMenWomenMenWomenMenWomen 30-3969.725.821.84.25.20.8 40-4987.355.246.113.314.12.8 50-5992.079.458.932.421.58.4 60-6994.390.6 54.628.118.6 3 of 3 criteria2 of 3 criteria1 of 3 criteria 1) Retrosternal discomfort.2) Provoked by exercise or stress.3) Relieved by rest or NTG

83. Post X-ECG P(CAD), Age and AP related 2-4-2015Eduard van den Berg, cardio.nl83

84. 2-4-2015Eduard van den Berg, cardio.nl84

85. Routine X-ECG every yr ? 2-4-2015Eduard van den Berg, cardio.nl85

86. Remember Classes of recommendation 2-4-2015Eduard van den Berg, cardio.nl86

87. And levels of evidence 2-4-2015Eduard van den Berg, cardio.nl87

88. X-ECG, Tl-201, X-Echo I 2-4-2015Eduard van den Berg, cardio.nl88

89. 2-4-2015Eduard van den Berg, cardio.nl89 X-ECG, Tl-201, X-Echo II

90. Pharmalogical stress tests 2-4-2015Eduard van den Berg, cardio.nl90

91. Adenosine MRI 2-4-2015Eduard van den Berg, cardio.nl91

92. SENS and SPEC of CAD tests 2-4-2015Eduard van den Berg, cardio.nl92

93. Sensitivity and Specificity NI tests for CAD 2-4-2015Eduard van den Berg, cardio.nl93 Diagnostic Test Sensitivity % (range) Specificity% (range) # Studies# Patients TMT687713224,027 Planar MPI79 (70-94) 73 (43-97) 6510 SPECT88 (73-98) 77 (53-96) 8628 Stress echo76 (40-100) 88 (80-95) 101174

94. Echocardiography at rest 2-4-2015Eduard van den Berg, cardio.nl94

95. Ambulatory ECG 2-4-2015Eduard van den Berg, cardio.nl95

96. CTA 2-4-2015Eduard van den Berg, cardio.nl96

97. Coronary MRA 2-4-2015Eduard van den Berg, cardio.nl97

98. Coronary angiography I 2-4-2015Eduard van den Berg, cardio.nl98

99. 2-4-2015Eduard van den Berg, cardio.nl99 Coronary angiography II

100. 2-4-2015Eduard van den Berg, cardio.nl100

101. Risk assessment I 2-4-2015Eduard van den Berg, cardio.nl101

102. 2-4-2015Eduard van den Berg, cardio.nl102 Risk assessment II

103. 2-4-2015Eduard van den Berg, cardio.nl103 Risk assessment III

104. Summary of recommendations Routine non invasive Investigations 2-4-2015Eduard van den Berg, cardio.nl104

105. Non Invasive Investigations in stable AP I 2-4-2015Eduard van den Berg, cardio.nl105

106. 2-4-2015Eduard van den Berg, cardio.nl106 Non Invasive Investigations in stable AP II

107. 2-4-2015Eduard van den Berg, cardio.nl107 Non Invasive Investigations in stable AP III

108. Be able to establish Risk quantitatively 2-4-2015Eduard van den Berg, cardio.nl108 In mortality % / year

109. Prognostic Angina Score 2-4-2015Eduard van den Berg, cardio.nl109

110. Treatment, low Risk, Mort<1 % /yr 2-4-2015Eduard van den Berg, cardio.nl110

111. Treatment intermediate Risk 1-2%/yr 2-4-2015Eduard van den Berg, cardio.nl111

112. Treatment, High Risk >2 % / yr 2-4-2015Eduard van den Berg, cardio.nl112

113. First Medical therapy, but if……. 2-4-2015Eduard van den Berg, cardio.nl113

114. If CAG done, then if…… 2-4-2015Eduard van den Berg, cardio.nl114

115. Risk Stratification I 2-4-2015Eduard van den Berg, cardio.nl115

116. Risk Stratification II 2-4-2015Eduard van den Berg, cardio.nl116

117. Risk Stratification III 2-4-2015Eduard van den Berg, cardio.nl117

118. Risk Stratification IV 2-4-2015Eduard van den Berg, cardio.nl118

119. 2-4-2015Eduard van den Berg, cardio.nl119 Risk Stratification V

120. 2-4-2015Eduard van den Berg, cardio.nl120 Risk Stratification VI

121. Stable AP 2006 needs revision For instance Ca-score is not included 2-4-2015Eduard van den Berg, cardio.nl121

122. complaints ER, Unstable ? 2-4-2015Eduard van den Berg, cardio.nl122

123. GL NSTE-ACS, nov 2011 2-4-2015Eduard van den Berg, cardio.nl123

124. Summary ESC GL NSTE-ACS, ER 2-4-2015© Eduard van den Berg, cardio.nl124 Establish the working diagnosis NSTE-ACS < 10 min from entrance from complaints, CAD Likelihood, Physical Examination and ECG Validate the working diagnosis from the moment of establishing As long as the WD is not rejected treat the pt as such Repeatedly establish the risk assessment

125. ER 1 2-4-2015Eduard van den Berg, cardio.nl125

126. 2-4-2015Eduard van den Berg, cardio.nl126 ER 2

127. 2-4-2015Eduard van den Berg, cardio.nl127 ER 3

128. 2-4-2015Eduard van den Berg, cardio.nl128 ER 4

129. 2-4-2015Eduard van den Berg, cardio.nl129 ER 4

130. 2-4-2015Eduard van den Berg, cardio.nl130 ROC curves of four models for predicting the composite MACE measure. Model I incorporated traditional risk factors, including age, sex, hypertension, diabetes, and dyslipidemia; model II, CAC scoring; model III, coronary CT angiography model IV, the combination of CAC scoring and coronary CT angiography. P =.031 for model II versus model I, P <.001 for model III versus model II, and P =.198 for model IV versus model III. SE = standard error of the estimate. IV = BEST

131. 2-4-2015Eduard van den Berg, cardio.nl131

132. 2-4-2015Eduard van den Berg, cardio.nl132

133. 2-4-2015Eduard van den Berg, cardio.nl133

134. Incremental value of X-ECG for classes of Angina depending on ST-depression Most of the findings of the early days are still valid at this moment Also the starting points !!!! 2-4-2015Eduard van den Berg, cardio.nl134

135. X-ECG Legend and Steps 2-4-2015Eduard van den Berg, cardio.nl135

136. Young Women 30-39 2-4-2015Eduard van den Berg, cardio.nl136

137. Young men 30-39 2-4-2015Eduard van den Berg, cardio.nl137

138. Women 40-49 2-4-2015Eduard van den Berg, cardio.nl138

139. Men 40-49 2-4-2015Eduard van den Berg, cardio.nl139

140. Women 50-59 2-4-2015Eduard van den Berg, cardio.nl140

141. Men 50-59 2-4-2015Eduard van den Berg, cardio.nl141

142. Women 60-69 2-4-2015Eduard van den Berg, cardio.nl142

143. Men 60-69 2-4-2015Eduard van den Berg, cardio.nl143

144. To present it another way 2-4-2015Eduard van den Berg, cardio.nl144

145. Posttestprob, women, age, ST related 2-4-2015Eduard van den Berg, cardio.nl145

146. Posttestprob, men, age, ST related 2-4-2015Eduard van den Berg, cardio.nl146

147. X-ECG what do we learn from Forrester At higher age the a priori probability for sign CAD is very high even with a negative bicycle test With a high pre-test probability an X-ECG can be done for best estimation of the max wait for intervention if applicable 2-4-2015Eduard van den Berg, cardio.nl147

148. 2-4-2015Eduard van den Berg, cardio.nl148