Cardiovascular Business - July/August 2008 - (Page 32)

News & Views á Does our understanding of vulnerable plaque warrant different tests? diovascular field, says Robert J. Gropler, MD, division of nuclear medicine at the Washington University School of Medicine in St. Louis. “Russert received the appropriate treatment considering what is available to us today,” he says. Nevertheless, many people are questioning the value of cluded Russert’s blood flow, Schoepf notes. Gropler adds that since these tests are “the best we have right now,” there does not seem to be fault in using them. But CT angiography is gaining converts as a potential noninvasive, low-risk imaging exam that can detect soft Tim Russert’s stress echo exam in April did not indicate life-threatening coronary artery disease. He died in June from an occlusive coronary thrombus. T he sudden death in June of Tim Russert, the popular television host of “Meet the Press,” has physicians and laypeople alike wondering if his coronary thrombosis could potentially have been prevented with more sensitive imaging techniques and through better lifestyle management. Russert, 58, had asymptomatic coronary artery disease, a calcium score 10 years ago in the mid 200s, an enlarged heart, and, depending on the source, either borderline or early diabetes. In April, Russert had a negative stress echo exam. His death has stirred a debate about management and imaging of asymptomatic CAD patients, especially given medicine’s understanding of vulnerable plaque. “Unfortunately, in this country and most industrialized countries, the most common first manifestation of heart disease is sudden cardiac death,” according to U. Joseph Schoepf, MD, director of CT research at the Medical University of South Carolina in Charleston. In the case of Russert, and other high-risk patients, not many preventive methods are currently available in the car- “Unfortunately, the most common first manifestation of heart disease is sudden cardiac death.”  U. Joseph Schoepf, MD, Medical University of South Carolina stress echo, especially since Russert’s exam in April gave him the green light in terms of life-threatening cardiovascular disease. “Unfortunately, this is probably the most common scenario that occurs with CAD patients,” Schoepf says. Like any physiological tests, an exercise stress echo will only become positive when arteries are significantly stenotic. Even a catheter angiogram and SPECT imaging, which are sensitive to stenosis directly and indirectly, respectively, most likely would not have revealed the soft plaque that ruptured and oc- plaque. The cross-sectional nature of CT can see the atherosclerotic disease changes in the arterial wall, which may or may not be stenotic, Schoepf says. In fact, current research has suggested that a CT scan can determine whether the plaque is more lipid-rich and, therefore, more prone to rupture. Gropler admits that cardiovascular imaging is improving, but even when CTA or molecular imaging detects vulnerable plaque, neither can predict when or if it will rupture. Coronary CTA is rarely recommended for asymptomatic CAD patients, such as Russert, because it is associat- ed with a fairly high radiation dose and “we do not know exactly what an eventual costbenefit analysis will show,” Schoepf says. Intravascular ultrasound offers clinicians the ability to identify soft plaque, but is rarely performed because it is expensive and highly invasive with a significant rate of complications, Schoepf notes. Without a routine exam that can help to determine when and if any particular vulnerable lesion will rupture, the best course of action is aggressive lifestyle management including weight, stress, diet and exercise. Along with these components, physicians should ensure patients at risk of cardiac events are prescribed the appropriate statins and blood pressure medications. It’s been reported that Russert took statins and blood pressure pills, exercised regularly and watched his diet. “Hopefully, in the next 10 years, we will have the technology to predict at-risk heart attack patients, but we’re just not there yet,” Gropler concludes. By JUSTine CADeT 32 Cardiovascular Business July/April 2008

Table of Contents Feed for the Digital Edition of Cardiovascular Business - July/August 2008

Cardiovascular Business - July/August 2008 Table of Contents First Word Cover Story: Planning for the Ideal Cath Lab Requires the Multidisciplinary Approach Clinical Study Digest: Cell Phone Technology Speeds Ecgs As Real-Time 3d Echo Matures, It Finds a Clinical Niche Ecg Image Management Brings Increased Productivity and Confidence Overcoming Barriers to Cath Lab Inventory Control Maximizing Reimbursement, Minimizing Penalties News & Views Calendar Reader Resources The Back Page

Cardiovascular Business - July/August 2008

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