Asymptomatic Males over age 45

[Chandler]

Anyone else find it interesting that the American Journal of Cardiology in the July 21, 2006 issue recommends Cardiac CTs or Ultrasound for all men over 45 (and all women over 55) as a routine screen for CAD.

I'm sure Toshiba, GE, and Siemens are excited about this announcement.

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[Dr. J?]

Anyone else find it interesting that the American Journal of Cardiology in the July 21, 2006 issue recommends Cardiac CTs or Ultrasound for all men over 45 (and all women over 55) as a routine screen for CAD.

I'm sure Toshiba, GE, and Siemens are excited about this announcement.

B/c the cards fellas want it as good as the GI fellas....re: everybody needs a colonoscopy as soon as they hit age 50. You get a rule like this for CAD - something that most laypeople are quite scared of - and you'll rule the world (oh and you just might save a lot of lives too! although I don't think anyone knows the spec or sens of cardiac CT's - someone please post if I'm wrong).

 

[hookaman]

Yes, but this would benefit radiologists not cardiologists

 

[spyyder]

nuclear cardiologist should pre-empt the radiologist on cards cases.

 

[AJM]

B/c the cards fellas want it as good as the GI fellas....re: everybody needs a colonoscopy as soon as they hit age 50. You get a rule like this for CAD - something that most laypeople are quite scared of - and you'll rule the world (oh and you just might save a lot of lives too! although I don't think anyone knows the spec or sens of cardiac CT's - someone please post if I'm wrong).

The specificity and sensitivity of cardiac CTs has been studied. I don't remember the exact data or where it came from, but from what I recall, cardiac CTs are relatively sensitive for detecting CAD but they have very low specificity.

BTW - the cardiologists would benefit from these recs all around, since they do the echos as well as the cardiac CTs. I think there's a bit of a turf war between cardiologists and radiologists around cardiac CTs, but I haven't really paid much attention to the politics of it. But echos are safely in the turf of the cardiologists.

 

[Qtip96]

The specificity and sensitivity of cardiac CTs has been studied. I don't remember the exact data or where it came from, but from what I recall, cardiac CTs are relatively sensitive for detecting CAD but they have very low specificity.

BTW - the cardiologists would benefit from these recs all around, since they do the echos as well as the cardiac CTs. I think there's a bit of a turf war between cardiologists and radiologists around cardiac CTs, but I haven't really paid much attention to the politics of it. But echos are safely in the turf of the cardiologists.

this thread is really off in the wrong direction. let me clarify a number of points.

1. this is a publication for the Screening for Heart Attack Prevention Education task force. it is NOT ACC/AHA guideline as of yet.

2. the purpose is to screen asymptomatic people for coronary or systemic atherosclerosis primarily for implementation of lifestyle and risk factor modification. we already use clinical data as surrogates for placing patients in higher risk groups, such as already established CAD, HTN, DM, PAD, dyslipidemia, family history, tobacco, metabolic syndrome, etc. this task force just encourages using any array of objective tests to look for athero anywhere in the body for risk stratification in patients who have not manifested athero otherwise. potential screening tests include: coronary calcium, ABIs, carotid intimal thickness (carotid US, NOT CARDIAC ECHO), aortic calcium, vascular impedence, etc.

3. in what way does a postive result change management? like i said, primarily in earlier implementation of risk factor modification: dietary change, exercise, smoking cessation, earlier initiation of ASA and statins, different target thresholds for lipids, etc.

4. should this practice change current practice for coronary angiography? not appreciably (i.e. for symptoms, ACS/MI, suspicion for LM/multivessel disease, etc.).

5. would probably widen the scope of statin prescriptions tho'. no surprise this 'task force' was subsidized by Pfizer, the maker of Lipitor

 

[p53]

Is it just me or is Cardiology overextending itself. Don't get me wrong. I love Cardiology (and might even love it more 6 years from now) but this talk of screening is ridiculous. The dose of radiation in a CT scan is NOT negligible. I wonder how much of a role "the Benjamins" play in this drive.

That's the funny thing about life. One's take on an issue is highly influenced by self interest. If I was a Cardiologist would I care if a patient is receiving unnecessary radiation exposure? I would rationalize it by saying that there is current literature that supports the screening.

We shall see how it unfolds. The real question is will the health insurance companies pay for this.

My verdict is NO.

 

[Qtip96]

Is it just me or is Cardiology overextending itself. Don't get me wrong. I love Cardiology (and might even love it more 6 years from now) but this talk of screening is ridiculous. The dose of radiation in a CT scan is NOT negligible. I wonder how much of a role "the Benjamins" play in this drive.

That's the funny thing about life. One's take on an issue is highly influenced by self interest. If I was a Cardiologist would I care if a patient is receiving unnecessary radiation exposure? I would rationalize it by saying that there is current literature that supports the screening.

We shall see how it unfolds. The real question is will the health insurance companies pay for this.

My verdict is NO.

i agree with your verdict of NO for now, but with a few caveats.

by the time a patient comes to my attention, he/she has already declared himself/herself high risk as a referral for new presentation, pre-existing disease, risk factors, symptoms, or marked family history. the central OPINION addressed by this grass-roots organization (again, NOT ACC/AHA) is how to address primary prevention in asymptomatic elder patients without identifiable risk factors for athero. given the prevalence and morbidity of CAD, should screening for this population be a legitimate goal? i say UNEQUIVOCALLY YES! the problem is that there is no viable technology as of yet that can identify the vulnerable plaque. the screening methods under discussion are simply surrogates to look for systemic atherosclerosis anywhere in the body (lower extremities for ABIs, carotids for intimal US, or CT for coronary calcium).

major problem: there are no good prospective outcomes data for these screening technologies.

CT, especially with contemporary multislice CT, as you stated includes a significant radiation exposure.

1. i am quite sure that some form of screening protocol will be implemented into ACC/AHA guidelines in the near future. we will see whether it will be as soon as this fall with the release of the new guidelines. discussion over Medicare/insurance reimbursements will follow.

2. the gatekeepers for the tests will need to be PMDs (NOT cardiologists), as are mammograms. there will likely be more cardiology referrals for positive tests.

3. the cost of the screening tests will be negligible compared to the financial burden of the likely increase of lifetime medications (i.e. statins, ACEi, etc.).

4. saying that cardiologists should not be interested in screening and primary prevention for CAD is utterly naive.

 

[Dr. J?]

Can someone post the article that Chandler referenced? That way we'll all know what we're talking about, as far as, what is being recommended. (I don't have access to that journal)

 

[Chandler]

I don't have online access but here is link for those that would like to download it for us. It is at the bottom of the page under "Cardiovascular Screening of the Asymptomatic Population."

www.ajconline.org



As for the radiation exposure, Siemens just released a DUAL source 64 slice multidector CT (I won't go into the boring physics). Suffice to say, this CT cuts radiation exposure in half for cardiac CT angiography. Unfortunately, this baby costs over 2.8 million dollars as oppose to a mono source multidector CT that costs around 1.5 million. Most hospital administrators will likely stick with the mono source for now to minimize overhead, but there is technology available to minimize radiation dose.

Another interesting thing about the Dual Source 64 slice MDCT is the fact it doesn't need a beta blocker to decrease heart rate to get a good image.

 

[Qtip96]

Suffice to say, this CT cuts radiation exposure in half for cardiac CT angiography...

you want to add 120cc of IV iodinated contrast dye to what is supposed to be a routine screening test for asymptomatic patients? what planet are you from?

like i said, without legitimate outcomes data, i doubt that MDCT can become official guidelines as are mammograms or colonoscopies. rather, it is likely to be an optional test upon discretion of the physician (and not likely to become reimbursible and would represent an out-of-pocket expense).

as far as routine screening tests for systemic athero, the most non-invasive and cost-effective test is the simple ABI (ankle-brachial index). all it requires is a blood pressure cuff and a hand-held vascular doppler (device cost: ~$500-800). ABIs take ~10 minutes, and can be performed at the bedside with routine vitals.

 

[Chandler]

you want to add 120cc of IV iodinated contrast dye to what is supposed to be a routine screening test for asymptomatic patients? what planet are you from?

like i said, without legitimate outcomes data, i doubt that MDCT can become official guidelines as are mammograms or colonoscopies. rather, it is likely to be an optional test upon discretion of the physician (and not likely to become reimbursible and would represent an out-of-pocket expense).

as far as routine screening tests for systemic athero, the most non-invasive and cost-effective test is the simple ABI (ankle-brachial index). all it requires is a blood pressure cuff and a hand-held vascular doppler (device cost: ~$500-800). ABIs take ~10 minutes, and can be performed at the bedside with routine vitals.

Okay tough guy, I'll bite.

What the hell is wrong with you?

If you were perceptive you would realize I was talking about alternatives (rather than championing the use of dual source CTs). Let's not get emotional shall we?

 

[Qtip96]

Okay tough guy, I'll bite.

What the hell is wrong with you?

If you were perceptive you would realize I was talking about alternatives (rather than championing the use of dual source CTs). Let's not get emotional shall we?

i emphasized how irrational it is to reconcile the risk of using iodinated IV contrast dye in a screening test for asymptomatic people without identifiable risk factors. verbatim, my words were "what planet are you from?"

given your response, you are the one who is hysterical, and emotionally tied to your ideas. if you read my posts, you will realize i am the voice of common sense in your otherwise useless thread.

 

[p53]

i emphasized how irrational it is to reconcile the risk of using iodinated IV contrast dye in a screening test for asymptomatic people without identifiable risk factors. verbatim, my words were "what planet are you from?"

given your response, you are the one who is hysterical, and emotionally tied to your ideas. if you read my posts, you will realize i am the voice of common sense in your otherwise useless thread.

How many friends do you have (not counting the strangers you know on the internet) ?

 

[Qtip96]

How many friends do you have (not counting the strangers you know on the internet) ?

tsk tsk tsk...

resorting to ad hominem attacks simply because you have a fragile ego and lack the capacity to have a reasonable discussion...

 

[Impressions]

Qtip, people that read this thread will notice that you started this disharmony.

 

[Qtip96]

Qtip, people that read this thread will notice that you started this disharmony.

i don't give a rat's a** about "disharmony".

what i do care about is having diagnostic tests discussed in the right clinical context.

new procedures, drugs, protocols, and diagnostic tests will always be evolving. if you are incapable of intelligently processing appropriate usage in the context of clinical utility, as well as risks and benefits, you should not be practicing medicine.

bah, i'm done anyway. "harmonize" amongst yourselves.