C L I N I C A L
U P D A T E
By Dr Brendan McQuillan, Cardiologist, Western Cardiology. Tel 9346 9300
PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services
FERTILITY NEWS
Medical Director Dr John Yovich
Coronary calcium scores and CT coronary angiography Risk prediction with coronary artery calcium scores (CACS)
By Drs John Yovich and Philip Rowlands
Outside the Box – Appendix
In recent months we have had the surprise finding of appendix pathology masquerading as gynaecological “pelvic” pain. The first was a patient aged 47 years who presented with RIF pain in Queensland whilst on holidays, considered to be a possible ruptured corpus luteal cyst. The pain grumbled on for several weeks and on return to Perth her GP arranged pelvic scan which showed a right tuboovarian mass. At PIVET this led to an arrangement for laparoscopic hysterectomy with BSO. At the procedure, unravelling the inflammatory complex of the right adnexae revealed an appendix abscess, carefully dissected out and removed laparoscopically at the same time (fig 1) with an excellent post-op outcome.
Figure 1 Appendix unravelled from right tubo-ovarian mass
Figure 2 Endo-knot excision of nodular appendix removed in Endo-bag
The second was a case I managed in Cairns on my recent quarterly stint. This was a 37 year old woman with infertility, failed IVF procedures and background colicky pelvic pain with previous laparoscopy in Melbourne for severe pelvic endometriosis. On my review hysteroscopy & laparoscopy, there was minimal residual endometriosis but an oddlooking thick and hard nodular appendix. Although not consented for such, the appendix was removed (fig 2) and subsequent histology showed a mucinous epithelial neoplasm. In discussion with the Pathologist, such tumours are graded potentially malignant and may be the main underlying cause for that enigmatic condition known as pseudomyxoma peritonei. The patient is very well now and will proceed with fertility management but an MRI follow-up is planned.
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Our ability to predict those at high risk prior to their first clinical coronary artery disease (CAD) event is limited. CACS has become established as a strong predictor of cardiovascular (CV) events in asymptomatic subjects. While a low CACS (zero score) indicates truly low risk, high scores (typically above 100) indicate a relative risk of greater than four when compared with no calcium. When considered in age and gender-specific percentiles, CACS gives a near linear prediction of CV risk. CACS has great clinical value in refinement of risk among asymptomatic subjects that would be considered at intermediate risk by conventional risk scores (e.g. the Framingham, Cardiac Society of Australia and New Zealand or EuroScores). Approximately half of subjects considered at intermediate risk may be more accurately reclassified. Among these subjects CACS can usefully identify those at true low risk in whom ongoing lifestyle advice rather than additional pharmacological therapies may be appropriate. About 20% of subjects may be reclassified from intermediate to high risk by CACS and should be carefully assessed and managed for all modifiable CV risk factors. It may also be appropriate to perform exercise or pharmacological stress testing in some asymptomatic individuals with very high CACS to further assess the functional significance of the atherosclerotic coronary plaques that are likely to be present. Disappointingly, there remains limited long-term clinical trial data using CACS-guided therapy but it does appear to improve treatment compliance. CACS results appear valid for at least four years, with very few subjects changing their score from zero to a low score or a low to high score within this time frame in longitudinal studies. The CACS may also improve risk prediction among patients undergoing myocardial perfusion scans (MPS). With no contrast injection and very low overall radiation exposure, a CACS obtained at the time of a MPS can increase the sensitivity for the detection of clinically important coronary artery disease as well as improving the negative predictive (rule-out) value of a normal or negative scan.
Evaluation of chest pain with computed tomography coronary angiography (CTCA) CTCA is the most accurate and reproducible tool for noninvasive coronary angiography. While patients with irregular heart rhythms remain a challenge, recent technical advances and development of scanning protocols have enabled CTCA to be performed with low radiation exposure in the majority of subjects. Diagnostic accuracy is probably higher than early studies suggest, comparing older CT technology to invasive coronary angiography. In fact, evaluations using the current gold-standard of invasive coronary intravascular ultrasound indicate that 64-slice CTCA may exceed the ability of invasive coronary angiography to detect non-obstructive plaques within the vessel wall. CTCA has been well established in the assessment of patients with chest pain presenting to the ED. CTCA carries a very high NPV – close to 100% – and can effectively rule out CAD in symptomatic subjects with a low to intermediate pre-test likelihood. Conversely, those subjects found to have coronary atherosclerosis with greater than 50% stenosis of a major vessel by CTCA are at increased risk of adverse CV outcomes with up to a third suffering an event within two years. For stable patients with positive stress test results but a pre-test likelihood still less than 50%, stress echocardiography is still a valuable test. CTCA however, is becoming an important alternative to invasive coronary angiography when more definite exclusion of CAD is required especially for patients at higher risk from an invasive approach because of limited vascular access, extensive aortic atherosclerosis or prior ischaemic stroke. High-risk patients presenting with typical angina-like pain remain best suited to an invasive angiography strategy that permits early percutaneous coronary intervention. n
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