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CDA 10-032 – HSR&D Study

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CDA 10-032
The Impact and Value of Non-invasive Testing in the Management of Obstructive CAD
Patricia K. Nguyen MD MBA
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: October 2011 - September 2016

BACKGROUND/RATIONALE:
Coronary artery disease (CAD), a condition resulting from obstruction of the heart arteries, is very common among veterans. Obstruction of the arteries can cause irreversible tissue death, resulting in myocardial infarction, heart failure, dangerous arrhythmias, and even death. Obstructive CAD is a leading cause of increased morbidity and mortality and decreased quality of life in veterans. Non-invasive imaging is the cornerstone for the diagnosis and risk stratification of patients with obstructive CAD. Recent studies, however, have questioned the effectiveness of current diagnostic strategies and raised potential concerns regarding radiation exposure from some diagnostic imaging tests.
Objectives: The primary objectives of these projects are: 1) to understand how imaging tests are utilized to diagnose and risk stratify patients with obstructive CAD and 2) how to optimize their utilization of non-invasive imaging for the care of patients with obstructive CAD.


OBJECTIVE(S):
The primary objectives of these projects are: 1) to understand how imaging tests are utilized to diagnose and risk stratify patients with obstructive CAD and 2) how to optimize their utilization of non-invasive imaging for the care of patients with obstructive CAD.

METHODS:
In Aim 1, we will determine the utilization pattern of non-invasive testing and the factors affecting utilization. Based on information collected from our newly created database, we describe the imaging strategies for the diagnosis and risk stratification of veterans with suspected obstructive CAD and identify predictors of strategy selection (i.e. patient-, provider-, and facility-level factors). In Aim 2, we will perform a cost-effectiveness analysis to determine the most cost-effective imaging modality including new technology as well as the risk of radiation exposure. In Aim 3, we will develop a clinical decision support system for VA care providers to select the most 'appropriate strategy' for risk stratification and diagnosis of obstructive CAD. We will set up a clinical decision support system (CDSS) to guide providers in choosing the most 'appropriate' imaging strategy based on published guidelines, studies from the literature, and results from Aims 2 and 3.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
Obstructive CAD is a leading cause of morbidity and mortality for Veterans. Proper utilization of imaging services will improve the quality of care leading to reduced morbidity, mortality and costs.

PUBLICATIONS:

Journal Articles

  1. Liang G, Nguyen PK. Molecular probes for cardiovascular imaging. Journal of Nuclear Cardiology : Official Publication of The American Society of Nuclear Cardiology. 2016 Aug 1; 23(4):783-9.
  2. Nguyen PK, Lin S, Heidenreich P. A systematic comparison of sugar content in low-fat vs regular versions of food. Nutrition & diabetes. 2016 Jan 25; 6:e193.
  3. Roam JL, Yan Y, Nguyen PK, Kinstlinger IS, Leuchter MK, Hunter DA, Wood MD, Elbert DL. A modular, plasmin-sensitive, clickable poly(ethylene glycol)-heparin-laminin microsphere system for establishing growth factor gradients in nerve guidance conduits. Biomaterials. 2015 Dec 1; 72:112-24.
  4. Ong SG, Huber BC, Hee Lee W, Kodo K, Ebert AD, Ma Y, Nguyen PK, Diecke S, Chen WY, Wu JC. Microfluidic Single-Cell Analysis of Transplanted Human Induced Pluripotent Stem Cell-Derived Cardiomyocytes After Acute Myocardial Infarction. Circulation. 2015 Aug 25; 132(8):762-71.
  5. Nguyen PK, Lee WH, Li YF, Hong WX, Hu S, Chan C, Liang G, Nguyen I, Ong SG, Churko J, Wang J, Altman RB, Fleischmann D, Wu JC. Assessment of the Radiation Effects of Cardiac CT Angiography Using Protein and Genetic Biomarkers. JACC. Cardiovascular imaging. 2015 Aug 1; 8(8):873-84.
  6. Nguyen PK, Wu JC. Large Animal Models of Ischemic Cardiomyopathy: Are They Enough to Bridge the Translational Gap? Journal of Nuclear Cardiology : Official Publication of The American Society of Nuclear Cardiology. 2015 Aug 1; 22(4):666-72.
  7. Dash R, Kim PJ, Matsuura Y, Ikeno F, Metzler S, Huang NF, Lyons JK, Nguyen PK, Ge X, Foo CW, McConnell MV, Wu JC, Yeung AC, Harnish P, Yang PC. Manganese-Enhanced Magnetic Resonance Imaging Enables In Vivo Confirmation of Peri-Infarct Restoration Following Stem Cell Therapy in a Porcine Ischemia-Reperfusion Model. Journal of the American Heart Association. 2015 Jul 27; 4(7).
  8. Lee WH, Nguyen P, Hu S, Liang G, Ong SG, Han L, Sanchez-Freire V, Lee AS, Vasanawala M, Segall G, Wu JC. Variable activation of the DNA damage response pathways in patients undergoing single-photon emission computed tomography myocardial perfusion imaging. Circulation. Cardiovascular imaging. 2015 Feb 1; 8(2):e002851.
  9. Nguyen PK, Riegler J, Wu JC. Stem cell imaging: from bench to bedside. Cell stem cell. 2014 Apr 3; 14(4):431-44.
  10. Liang G, Tremmel J, Nguyen PK. Diagnostic Accuracy of MRI Assessment of Coronary Endothelial Function Compared with Invasive Angiography. JACC. Cardiovascular imaging. 2014 Apr 1; 63(12_S):doi:10.1016/S0735-1097(14)61255-9.
  11. Liang P, Lan F, Lee AS, Gong T, Sanchez-Freire V, Wang Y, Diecke S, Sallam K, Knowles JW, Wang PJ, Nguyen PK, Bers DM, Robbins RC, Wu JC. Drug screening using a library of human induced pluripotent stem cell-derived cardiomyocytes reveals disease-specific patterns of cardiotoxicity. Circulation. 2013 Apr 23; 127(16):1677-91.
  12. Lan F, Lee AS, Liang P, Sanchez-Freire V, Nguyen PK, Wang L, Han L, Yen M, Wang Y, Sun N, Abilez OJ, Hu S, Ebert AD, Navarrete EG, Simmons CS, Wheeler M, Pruitt B, Lewis R, Yamaguchi Y, Ashley EA, Bers DM, Robbins RC, Longaker MT, Wu JC. Abnormal calcium handling properties underlie familial hypertrophic cardiomyopathy pathology in patient-specific induced pluripotent stem cells. Cell stem cell. 2013 Jan 3; 12(1):101-13.
  13. Gu M, Nguyen PK, Lee AS, Xu D, Hu S, Plews JR, Han L, Huber BC, Lee WH, Gong Y, de Almeida PE, Lyons J, Ikeno F, Pacharinsak C, Connolly AJ, Gambhir SS, Robbins RC, Longaker MT, Wu JC. Microfluidic single-cell analysis shows that porcine induced pluripotent stem cell-derived endothelial cells improve myocardial function by paracrine activation. Circulation Research. 2012 Sep 14; 111(7):882-93.
  14. Lan F, Liu J, Narsinh KH, Hu S, Han L, Lee AS, Karow M, Nguyen PK, Nag D, Calos MP, Robbins RC, Wu JC. Safe genetic modification of cardiac stem cells using a site-specific integration technique. Circulation. 2012 Sep 11; 126(11 Suppl 1):S20-8.
  15. Nguyen PK, Lan F, Wang Y, Wu JC. Imaging: guiding the clinical translation of cardiac stem cell therapy. Circulation Research. 2011 Sep 30; 109(8):962-79.
  16. Wu JC, Nguyen PK. Imaging atherosclerosis with F18-fluorodeoxyglucose positron emission tomography: What are we actually seeing? Journal of the American College of Cardiology. 2011 Aug 2; 58(6):615-7.
  17. Nguyen PK, Schnittger I, Heidenreich PA. A comparison of echocardiographic measures of diastolic function for predicting all-cause mortality in a predominantly male population. American heart journal. 2011 Mar 1; 161(3):530-7.
Journal Other

  1. Nguyen PK, Lee WH, Hong WX, Hu S, Ong SG, Churko J, Chan C, Wang J, Longaker MT, Hlatky M, Fleischmann D, Wu JC. Cell Damage and Even Death Detected in Peripheral T-Lymphocytes in Patients Undergoing Cardiac Computed Tomographic Angiography. Core 1. Cardiovascular Imaging - Session Title: Noncoronary Vascular Imaging (CT/MRI/Other). [Abstract]. Circulation. 2014 Nov 25; 130(Supplement 2):Abstract 17674.
  2. Hong WX, Lee WH, Wu JC, Nguyen PK. Low Dose Radiation from Cardiac Computed Tomography is Associated with DNA Damage and Cellular Death. [Abstract]. JACC. Cardiovascular imaging.. 2014 Apr 1; 63(12_S):doi:10.1016/S0735-1097(14)61047-0.
  3. Lee BK, Yong AC, Fearon WF, Lim HS, Nguyen PK, Yeung AC, Tremmel JA. Invasive Evaluation of Chest Pain in Patients with Angiographically Normal Coronary Arteries. [Abstract]. Circulation. 2013 Nov 26; 2013(128):A19113.
  4. Lee WH, Nguyen PK. Quantitative flow cytometry detects DNA damage in patients undergoing cardiac SPECT. [Abstract]. Circulation. 2012 Nov 2; 2012(126: A18210).
Book Chapters

  1. Huber BC, Nguyen PK, Wu JC. In vivo tomographic cardiac imaging: positron emission tomography and magnetic resonance imaging. In: Ardehali H, Bolli R, Losordo DW, editors. Manual of research techniques in cardiovascular medicine. Oxford, United Kingdom: Wiley-Blackwell; 2014. Chapter 34. 287-294 p.
  2. Nguyen PK, Nag D, Wu JC. Molecular Imaging of Cardiovascular Disease. In: Patterson C, Willis MS, editors. Translational Cardiology: Molecular Basis of Cardiac Metabolism, Cardiac Remodeling, Translational Therapies and Imaging Techniques (Molecular and Translational Medicine). New York, NY: Humana Press, Springer Science+Business Media; 2012. Chapter 14. 485-532 p.
Center Products

  1. Nguyen PK. Low Dose Radiation: Are We Giving Ourselves Cancer? Stanford Cardiovascular Institute (CVI) Science Talk. 2014 Feb 5.
Conference Presentations

  1. Nguyen PK, Wu J, Davis M, Wu S. Sex Differences in Myocarditis. Poster session presented at: Organization for the Study of Sex Differences Annual Meeting; 2015 Apr 21; Stanford, CA.
  2. Rahatloo KI, Liang G, Vo D, Nguyen I, Elbert AD, Wu JC, Nguyen PK. Sexually dimorphic gene expression in human left ventricle tissue. Poster session presented at: Organization for the Study of Sex Differences Annual Meeting; 2015 Apr 21; Stanford, CA.
  3. Nguyen PK, Lee WH, Hong WH, Hu S, Ong SG, Churko J, Chan C, Wang J, Longaker MT, Hlatky M, Fleischmann D, Wu JC. Cell Damage and Even Death Detected in Peripheral T-Lymphocytes in Patients Undergoing Cardiac Computed Tomographic Angiography. Poster session presented at: American Heart Association Scientific Sessions and Resuscitation Annual Science Symposium; 2014 Nov 7; Chicago, IL.
  4. Liang G, Tremmel J, Nguyen PK. Diagnostic Accuracy of MRI Assessment of Coronary Endothelial Function Compared with Invasive Angiography. Poster session presented at: American College of Cardiology Annual Scientific Session; 2014 Mar 31; Washington, DC.
  5. Hong WX, Lee WH, Wu JC, Nguyen PK. Low Dose Radiation from Cardiac Computed Tomography is Associated with DNA Damage and Cellular Death. Poster session presented at: American College of Cardiology Annual Scientific Session; 2014 Mar 29; Washington, DC.
  6. Nguyen PK. Hurdles of pluripotent stem cell therapy: insights from molecular imaging. Presented at: Radiological Society of North America Annual Meeting; 2012 Nov 25; Chicago, IL.


DRA: Aging, Older Veterans' Health and Care, Cardiovascular Disease
DRE: none
Keywords: none
MeSH Terms: none

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