Curriculum Vitae

Membership :
National IDI PAPDI PERKI PUSKI (Indonesian Medical Association) (Indonesian Association of Internal Medicine) (Indonesian Heart Association) (Indonesian Society of Medical Ultrasonography)

PERKAVI (Indonesian Society of Heart Research)

International

ASE AHA

(American Society of Echocardiography) (American Heart Association council on Cardiac Imaging)

ASNC (American Society of Nuclear Cardiology)

SCCT (Society of Cardiac Computerized Tomography) ASFC (ASEAN Society & Federation of Cardiology) ISFC WHL (International Society & Federation of Cardiology) (World Hypertension League)

Curriculum Vitae
Courses and Training :
Sept-Oct 1992 Nuclear Cardiology. Royal Adelaide Hospital. University of Adelaide. South Australia. Australia. Nov 1992-February 1993 Nuclear Cardiology & Other Cardiac Imaging. Academische Zijkenhuijs Leiden. Netherland. Jan 1995 Stress Echocardiography. Hunter-Hill Clinic Cardiology. Sydney. New South Wales. Australia.

April June 2000 Research on Antioxidant Effect of Garlic Extract on Copper and Lypoxygenase-catalyzed oxidation of LDL. Institute of Biochemistry. University Clinic Charite. Humboldt University. Berlin. Germany. Sept Oct 2003 Research on the effect of Garlic Extract on Cholesterol Efflux from Lipid-loaded J-774 Macrophages. Institute of Biochemistry. University Clinic Charite. Humboldt University. Berlin. Germany. Jan 2007 Advanced Course on Tissue Doppler Imaging. Chinese University. Hong Kong. Advanced Course (Level 2 Certification) on Cardiovascular Computed Tomography, Albany, New York, USA

May 2007

Curriculum Vitae
Publications :
1. Effects of Onion on Diabetic patients. 15th International Congress of Internal Medicine. Hamburg, (WEST GERMANY) : 18th - 22nd 1980. 2. Hypertension in the Critical Area of East Java. Singapore: 8th ASEAN Congress of Cardiology. 7-11 December 1990. 3. Blood glucose and other coronary risk factors in critical areas of East Java. Jakarta : 6th Congress of ASEAN Federation of Endocrinology, 2-4 July 1992. 4. The Effect of Garlic extracts (DDS, SAC) on Oxidized-LDL. Measurement of HETE, HODE and its isomeres by HPLC. 1st National,Congress of Indonesian Society of Heart Research. Jakarta : July 2002. 5. The Effect of Garlic extracts (DDS, SAC) on the Efflux of Cholesterol from Acetylated-LDL-loaded J-774 Macrophages. Asian Pacific Congress of Atherosclerosis. Nusadua, Bali 2004. 6. Effects of Garlic & its metabiolites on Atherosclerosis. Focus on Atherosclerotic Regression. Keynote Speaker. International Organization for Chemical Sciences in Development (IOCD). Working Group on Plant Chemistry. Surabaya : April 09-11,2007. 7. 3 Other International Publications 8. > 100 National Publications and Papers

Lessons learned from Recent Multicenter Trial on Cardiac mdCTA Predictor & Prognostic Performance of Cardiac CT In patient with Zero Calcium Score

Prof. Budi Susetyo Pikir MD PhD

Department of Cardiology & Vascular Medicine / Medical Faculty - Dr.Soetomo Hospital

Airlangga University

SURABAYA

Cost-Benefit Analysis of mdCTA

Diagnostic Performance
Assessment the Absent of Atheroscclerosis

Assessment the Present of Atherosccle

Assessment of Coronary Stenosis Assessment of In-Stent Restenosis Asessment of Vulnerable Plaque Assessment of Myocardial Viabilty

Predictor Performance / Prognostic Performance

Predict the Development of CAD Predict Morbidity & Mortality of CAD

Evaluation of Treatment

Cost-Benefit Analysis of mdCTA

Diagnostic Performance
Assessment the Absent of Atheroscclerosis

Assessment the Present of Atheroscclerosis

Assessment of Coronary Stenosis Assessment of In-Stent Restenosis Asessment of Vulnerable Plaque Assessment of Myocardial Viabilty

Predictor Performance / Prognostic Performance

Prognostic Performance of patient with Zero Calcium Score Predict Morbidity & Mortality of CAD

Evaluation of Treatment

The Calcium Scale

The calcium scale is a linear scale with 4 calcium score categories:

none

199 100400 >400

mild moderate severe

*Calcium score correlates directly with risk of events and likelihood of obstructive CAD*

Patient with ZERO CALCIUM SCORE

International Multicenter Trial (9 centers) : CORE-64 Trial Gottlieb et al 2010. USA Multicenter Trial (4 centers) : Min et al 2010

Diagnostic Performance of Zero Calcium Score Core 64 Trial

Prevalence of CAD = 56 % ( 50 % stenosis)

291 patients : 73 % male Age 59.3 10.0 years Pre-test Probability of CAD :
Low 5 % Intermediate 75 % High 20 %

Core 64 Trial
Prevalence of CAD = 56 % ( 50 % stenosis)
Calcium Score 0
(n = 72)

1-10
(n = 24)

> 10
(n = 195)

P value

> 50 % Stenosis Disease Distribution by CCA

No Disease 1-vessel disease 2-vessel disease 3-vessel disease

19 % 46 %
78 % 19 % 3% 0% 46 % 42 % 13 % 0%

71 %
27 % 25 % 31 % 16 %

Revascularization

13 % 25 %

44 %

Core 64 Trial
Prevalence of CAD = 56 % ( 50 % stenosis)
Calcium Score 0
(n = 72)

1-10
(n = 24)

> 10
(n = 195)

P Value

> 50 % Stenosis
Coronary Risk Factor Hypertension Diabetes Mellitus Dyslipidemia Smoking Family History of CAD Emergency Department presentation Chest Pain (within 30 days) Revascularization

19 % 46 % 71 %
60 % 17 % 49 % 21 % 22 % 22 % 53 % 13 % 67 % 13 % 58 % 13 % 17 % 17 % 48 % 25 % 68 % 27 % 65 % 19 % 25 % 25 % 62 % 44 % 0.43 0.083 0.059 0.048 0.30 0.035 0.25

Core 64 Trial

(International Multicenter Trial)

72 patients with Ca Score = 0

Prevalence of CAD = 19 % ( 50 % stenosis)

< 50 % Stenosis Patient Based

Sensitivity

Specificity

PPV

NPV

45 %

91 %

68 %

81 %

Revascularization 12.5 % (9 pts)

Prognostic Performance of Zero Calcium Score Core 64 Trial

Prevalence of CAD = 56 % ( 50 % stenosis)

383 Vessel without Calcification 12 % with significant stenosis 64 of Total Occluded Vessels 20 % with No Calcium

 Total Coronary Artery Plaque and EBCT Coronary Calcium

20% Calcified 20%

Fibrotic

80%
Lipid Rich

Plaque Detectable by IVUS, Pathology

80%
80%

GLOBAL RISK ASSESSMENT SCORING SYSTEMS FRAMINGHAM Scoring System PROCAM Scoring System HEART SCORE Project INDIANA Project

ASSESSMENT OF ABOLUTE RISK

METHODS
Calculate The Number Of Points For Each Risk Factor Estimate Global Risk Score ( Sum Of Points ) Consult Coronary/CV Risk Chart Assess 10-years Asolute Risk Level For CHD or CV event

Use of Risk Prediction Models in International Guidelines

US: Risk factor counting and three levels of the 10-year hard CHD risk using a Framingham model (> 20%, 10-20% & < 10%). Australia: 5-year CVD risk 10-15% using a Framingham model or risk factor counting. Europe: 10-year total CHD risk > 20% now or as projected to age 60 using a Framingham model.

Categories of Risk Factors

Major, independent risk factors
Obesity (BMI 30) Physical inactivity Atherogenic diet
Lipoprotein (a) Homocysteine Prothrombotic factors Proinflammatory factors Impaired fasting glucose Subclinical atherosclerosis

Life-habit risk factors

Emerging risk factors

Major Risk Factors (Exclusive of LDL Cholesterol) That Modify LDL Goals
Cigarette smoking Hypertension (BP 140/90 mmHg or on antihypertensive medication) Low HDL cholesterol ( < 40 mg/dL) Family history of premature CHD

CHD in male first degree relative <55 years CHD in female first degree relative <65 years
Age (men 45 years; women 55 years)
HDL cholesterol 60 mg/dL counts as a negative risk factor; its presence removes one risk factor from the total count.

Risk Assessment
Count major risk factors Framingham Global Risk Score

For patients with multiple (2+) risk factors

Perform 10-year risk assessment

For patients with 01 risk factor 10 year risk assessment not required

Most patients have 10-year risk <10%

Risk Assessment Characteristics 10-year CAD Risk

2001

High Risk Moderate Risk Low Risk

CAD or CAD Equivalents 2 + Risk Factors 0-1 Risk Factor

> 20 % 10-20 % < 10 %

Risk Assessment
Count major risk factors Framingham Global Risk Score
For patients with multiple (2+) risk factors Perform 10-year risk assessment For patients with 01 risk factor 10 year risk assessment not required Most patients have 10-year risk <10%

Risk Assessment
Very High Risk

Characteristics
CAD + CAD Equivalents or Major Risk Factor CAD or CAD Equivalents 2 + Risk Factors 0-1 Risk Factor

10-year CAD Risk

2004

High Risk

> 20 %

Moderate Risk Low Risk

10-20 % < 10 %

Prognostic Performance of Zero Calcium Score

US Multicenter Trial
(Min et al 2010) Pre-Test Probability of CAD = 0 %

( no prior myocardial infarction, no prior coronary revascularization or no prior abnormal stress test )

106 (25.1 %) of 422 patient with Calcium Score = 0 developed CS > 0 within 4.1 0.9 years.

Incidence of conversion to CS > 0 nonlinear & highest at 5th years.

Prognostic Performance of Zero Calcium Score

US Multicenter Trial
Prevalence of CAD = 0 % (
(Min et al 2010)
no prior myocardial infarction, no
prior coronary revascularization or no prior abnormal stress test )

Progression of CS > 0 associated with : age, diabetes mellitus and smoking.

Predictor of CS progression were : CS > 0, diabetes mellitus and smoking.

CONCLUSIONS :
1. Zero Calcium Score does not exclude obstructive stenosis or need for coronary revascularization (19 % with obstructive CAD and 12.5 % need revascularization).

2. Diagnostic performance of Zero Calcium Score to exclude obstrictive CAD are 45 % sensitivity, 91 % specifictiy, 68 % negative predictive value and 81 % positive predictive value).

CONCLUSIONS :
3. Otherwise, Zero Calcium Score in the absence of Clinically CAD has good prognosis (progress to CS > 0 after 4 years).

4. Progression was associated with age, diabetes mellitus and smoking.

5. We must combine Cardiac CT Findings.and Global Cardiovascular Risk Assessment in the Management of Patient.

Although mdCTA has High Sensitivity, High Specificity & High Negative Predictive Value for detection of Coronary Stenosis, In low to intermediate prevalence (probability) of CAD have low to intermediate Positive Predictive Value

The absence of CAD on msCT should be absence also of CAD on Invasive Coronary Angiography

Otherwise
The presence of CAD on msCT do not always presence of CAD on Invasive Coronary Angiography

(Budi S Pikir 2006)

In high risk patient (High Framingham Risk Score), Zero Calcium Score do not exclude CAD

In the absent of Clinically CAD, Zero Calcium Score has good prognosis

Budi S Pikir 2010

Coronary Calcium

Thank You