Early Detection of Cardiovascular Disease:

What GP should know?

Astri Astuti, MD, FIHA

01
Introduction
 Introduction
● Coronary artery disease (CAD) àmorbidity and mortality àthe leading
cause of premature death.

● The most common cause of CAD à atherosclerosis.

● Sudden rupture of a previously undiagnosed, usually shallow, non-calcified

atherosclerotic plaque à acute coronary syndrome and potentially sudden
cardiac death.

● Early diagnosis of coronary atherosclerosis is desirable in patients at risk

to prevent acute myocardial infarction.

Melgies, Joanna, Mark CK Hamilton, and Nathan E. Manghat. "Computed tomographic coronary angiography–is it ready as a screening tool for coronary artery disease?." Clinical medicine13.5 (2013): 465.
Graby, J., et al. "CT coronary angiography-guided cardiovascular risk screening in asymptomatic patients: is it time?." Clinical Radiology 76.11 (2021): 801-811.
 ● Current focus à optimisation of CVD prevention with risk screening à a
key role.

● Risk modifier à clinical, biomarker and imaging modalities

● Coronary artery calcium score àa screening tool in national and

international guidance

Melgies, Joanna, Mark CK Hamilton, and Nathan E. Manghat. "Computed tomographic coronary angiography–is it ready as a screening tool for coronary artery disease?." Clinical medicine13.5 (2013): 465.
Graby, J., et al. "CT coronary angiography-guided cardiovascular risk screening in asymptomatic patients: is it time?." Clinical Radiology 76.11 (2021): 801-811.
 Early detection of CVD
CAD Primary
Prevention
1. Clinical data à Tradisional risk factors: gender, Smoking,
Dyslipidemia, hyper tension, diabetes, obesity,
2. Risk Score
3. Risk modifier
1. Psychosocial stress
2. Etnis
3. Riwayat keluarga
4. Frailty, inflammatory disease, COPD
5. Biomarker: CRP, Lp(a)
6. Imaging modalities:
● CT cardiac non contras: Ca score
● CTCA
● USG karotis
● Arterial stiffness
● Ankle brachial index

ESC Scientific Document Group. "2021 ESC Guidelines on cardiovascular disease prevention in clinical practice." European Journal of Preventive Cardiology 29.1 (2021): 5-115.
WHO risk score

PERKI panduan prevensi penyakit kardiovaskular Aterosklerosis

WHO risk score

1. Gender
2. Usia
3. Merokok
4. Tekanan darah sistolik
5. Kolesterol total
SCORE 2: risk chart for fatal and nom-fatal ASCVD (MI, stroke) in Very high
CVD risk

Gender
Age
Smoking
Systolic blood pressure
Non- HDL Cholesterol
Pool cohort equation risk score
02
Risk Modifier
 Risk modifier

1. Psychosocial stress, mental disorder

2. Etnis
3. Riwayat keluarga
4. Inflammatory disease, COPD
5. Biomarker: CRP, Lp(a)
6. Imaging modalities:
● CT cardiac non contras: Ca score
● CTCA
● USG karotis
● Arterial stiffness
● Ankle brachial index
Williams MC, Abbas A, Tirr E, et al. Reporting incidental coronary, aortic valve and cardiac calcification on non-gated thoracic computed tomography, a consensus statement from the BSCI/BSCCT and BSTI. Br J Radiol 2020;(July):20200894
02
Current Role for
Imaging in early
detection of CAD
and Primary
prevention
 Non-contrast cardiac CT
● Ca score à Risk Modifier in Dyslipidemia ESC 2018,

● no current role for the routine use of coronary artery calcium scoring
(CACS) in NICE guidance;
● European Society of Cardiology (ESC)/European Atherosclerosis Society
guidelines, à Ca Score may be used in asymptomatic patients at
intermediate or low risk of CVD.

NICE. Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis. 2010. Clinical guideline CG95. (updated November 2016).
Budoff MJ, Dowe D, Jollis JG, et al. Diagnostic performance of 64multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective
multicenter ACCURACY (Assessment by Coro). J Am Coll Cardiol 2008;52(21):1724e32.
Ca score indication
● Asymptomatic patients at intermediate risk and low-intermediate (6–
10% 10-year risk)
● Strong family history of premature coronary heart disease
● Diabetes Mellitus
● Adults <40 years of age with multiple major ASCVD risk factors or a
family history of premature ASCVD
● Severe Familial hypercholesterolemia evaluate add on therapy (COR
IIb, C-LD).
 MESA trial 2016
1. Ca score is an independent
Predictor of cardiovascular risk

2. Zero coronary calcium à

mainly beneficial in intermediate
risk by risk calculators

3. Improvement on risk
calculators
 The Cardiac Society of Australia and New Zealand’s recommended
indications for coronary artery calcium scoring

Australian Journal of
General Practice 2020
What Info we get from Ca score?
Aspirin

• CAC≥100 and CAC≥400 identify

asymptomatic individuals (<70 yo and
no high bleeding risk features) à
Benefit aspirin

• High ASCVD risk + CAC=0 à

avoid aspirin for primary prevention
Statin

1. Ca Score >= 100 à risk modifier and

beneficial in adding statin
2. Ca score 0 à no statin needed
3. Ca score 1-99 à individual based

Mitchell et al J Am Col Cardiol 2018

AHA Dyslipidemia guidelines 2018
CA score not recommended!
● General population with <5% 10-year risk of ASCVD (low risk).
● 10-year estimated ASCVD risk ≥20% (high risk) , except in older
patients with major risk factors
● Non calcified plaques
● Clinical ASCVD:
○ Acute coronary syndrome, history of acute myocardial infarction,
stable or unstable angina or coronary or other arterial
revascularization, stroke, transient ischemic attack, or peripheral
artery disease, including aortic aneurysm, all of atherosclerotic
origin.1
 Recommendation based on Ca score

● Aspirin and a statin is appropriate

for individuals with CAC >100 (COR I,
LOE B-NR).
● No therapy for individuals with CAC = 0
● Ca score 1-99 à individualisation
● CAC scores ≥300, and especially CAC scores ≥ 1000,
àhigh intensity statin therapy, guideline-based add-on LDL-C
lowering therapies à target ≥50% reduction in LDL-C,
and optimally and LDL-C <70 mg/dL (COR IIa, LOE C-LD).
03
Should we wait for
symptoms or macroscopic
coronary calcification?
 ● Current guidance recommends waiting for the onset of symptoms before considering
investigation with a CTCA, or using CACS for some asymptomatic patients.

● calcification is a healing process in the pathogenesis of atherosclerosis à represents

a later stage of established CAD.

● Coronary calcification à challenging target of true primary prevention?

NICE. Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis. 2010. Clinical guideline CG95. (updated November 2016).
Graby, J., et al. "CT coronary angiography-guided cardiovascular risk screening in asymptomatic patients: is it time?." Clinical Radiology 76.11 (2021): 801-811.
 ● A more sensitive screening tool to detect earlier-stage disease, with
availability of an evidence-based treatment to address this.

● A low burden of coronary artery calcium à reduced risk of major adverse

cardiovascular events (MACE).
● However, 8.3% risk of MACE inpatients with a CACS of 0, à suggesting an
important group of patients who were incorrectly re-classified based on
calcification alone.

● Therefore, a CACS of 0 clearly does not exclude the presence of sub-

clinical CAD.

● Importantly, non-calcific plaques are now well recognised to both be

more unstable and more likely to predict adverse outcomes than calcific
disease.

Graby, J., et al. "CT coronary angiography-guided cardiovascular risk screening in asymptomatic patients: is it time?." Clinical Radiology 76.11 (2021): 801-811.
Dohi T, Mintz GS, McPherson JA, et al. Non-fibroatheroma lesion phenotype and long-term clinical outcomes: a substudy analysis from the PROSPECT study. JACC Cardiovasc Imag 2013;6(8):908e16.
What Guidelines said about CT
angiography coronary for primary
prevention?

● NICE Clinical Guidance 2016, CTCA became the first-line investigation for all patients with chest
pain à + clinically suspected CAD

● Patients with typical or atypical angina, or non-anginal chest pain + ECG changes + potential CAD.

● Symptomatic patients, CTCA à high diagnostic accuracy for CAD, improve clinical pathways, and
reduce the primary composite end-point of death from coronary heart disease or non-fatal MI.

● Coronary calcification à evidence of CAD (regardless of the presence of symptoms) for a CVD review
by the clinical referrer or general practitioner.
04
The Incremental
Benefit of CTCA
 ● CTCA benefit:
○ the anatomical location of
plaque (e.g., a proximal left
anterior descending lesion
versus a distal non-dominant
right coronary artery lesion),
○ plaque composition (non-
calcified plaque) , and
○ degree of luminal stenosis.

● This enables a greater analysis of the

phenotypic risk

Graby, J., et al. "CT coronary angiography-guided cardiovascular risk screening in asymptomatic patients: is it time?." Clinical Radiology 76.11 (2021): 801-811.
Cury RC, Abbara S, Achenbach S, et al. Coronary artery disease reporting and data system (CAD-RADS): an expert consensus document of SCCT, ACR and NASCI: endorsed by the ACC. JACC Cardiovasc Imag 2016;9(9):1099e113.
Graby, J., et al. "CT coronary angiography-guided cardiovascular risk screening in asymptomatic patients: is it time?." Clinical Radiology 76.11 (2021): 801-811.
Cury RC, Abbara S, Achenbach S, et al. Coronary artery disease reporting and data system (CAD-RADS): an expert consensus document of SCCT, ACR and NASCI: endorsed by the ACC. JACC Cardiovasc Imag 2016;9(9):1099e113.
05
CTCA in Asymptomatic
Populations
 ● Currently, the use of CTCA for screening asymptomatic individuals is not
recommended in UK or European guidelines.

● CTCA, in various instances, already being used in asymptomatic patients

à wise consideration.
○ CONFIRM registry, à > quarter of patients (>7,500) that had a CTCA were
asymptomatic.
○ Non-anginal chest pain/ asymptomatic + ECG changes + multiple risk
factors of ASCVD.
○ Specific asymptomatic patients à high-risk occupations (e.g., aircrew)
or the pre-operative assessment of patients prior to non-cardiac
surgery.
○ 2009 survey incorporating 169 institutions across 38 countries à 34%
reported CTCA indication as “for the exclusion of CAD in clinically
healthy patients”
Graby, J., et al. "CT coronary angiography-guided cardiovascular risk screening in asymptomatic patients: is it time?." Clinical Radiology 76.11 (2021): 801-811.
Cho I, Chang HJ, Sung JM, et al. Coronary computed tomographic angiography and risk of all-cause mortality and nonfatal myocardial infarction in subjects without chest pain syndrome from the CONFIRM registry (Coronary CT angiography evaluation for clinical outcomes: an international multicenter registry).
Circulation 2012;126(3):304e13.
Maurer MH, Zimmermann E, Schlattmann P, et al. Indications, imaging patients with suspected angina undergoing CT coronary angiography: a technique, and reading of cardiac computed tomography: survey of randomised controlled trial. Heart 2017;103(13):995e1001. https:// clinical practice. Eur Radiol
2012;22:59e72.
07
CTCA Limitations
 ● Regarding patient safety, CTCA has traditionally involved a higher radiation exposure than CACS.

● potential for non-diagnostic or suboptimal image quality à repeat scans?

● incidental findings on CTCA screening àincreased workload in the form of face-to-face

appointments to discuss results or surveillance imaging (e.g., of a dilated aorta or a lung nodule).

● The possible to further assess an asymptomatic patient with invasive techniques when
potentially significant obstructive (“prognostic”) or “flow-limiting” CAD is identified (e.g., in the
left main stem or proximal left anterior descending artery) à careful consideration.

Graby, J., et al. "CT coronary angiography-guided cardiovascular risk screening in asymptomatic patients: is it time?." Clinical Radiology 76.11 (2021): 801-811.
Other imaging modalities as risk modifier
Carotid Ultrasound

1. Carotid artery imaging :maximal plaque thickness, soft plaque, and

ulceration à associated with the 10-year ASCVD risk

2. Carotid plaque detection and characterization à increased CVD risk

Ankle brachial index

Ankle-brachial index (ABI) à ratio of

systolic blood pressure in the ankle to arm

Lower ABI àassociated with an increased

risk of CHD/stroke and heart failure in non
ASCVD

ARIC study
08
The Future
09
Conclusions
 ● CAD, the leading cause of morbidity and mortality, could be prevented by early
detection and screening process for CVD primary prevention.

● Primary prevention pathway: Clinical evaluation, risk score assessment, risk

modifier analysis including imaging: Ca score and others

● Coronary calcium score is a surrogate marker of calcified atherosclerotic burden that

independently predicts cardiovascular risk and mortality

● Current guidance does not recommend CTCA in the asymptomatic population,

despite its capacity to image early CAD in the pre-clinical state à individualized
(aircraft)
● Other imaging modalities: Carotid ultrasound, ABI

● GP role: Actively involve in CVD prevention pathway, public health policy and
advocacy for Risk factors intervention
Graby, J., et al. "CT coronary angiography-guided cardiovascular risk screening in asymptomatic patients: is it time?." Clinical Radiology 76.11 (2021): 801-811.
THANK YOU