Diagnostica nella cardiopatia ischemica: confronto tra scintigrafia e ecostress. Francesco Nudi e Marco Giovagnoni
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1 Diagnostica nella cardiopatia ischemica: confronto tra scintigrafia e ecostress Francesco Nudi e Marco Giovagnoni Aprilia, 13 ottobre 2012
2 Nuclear Cardiology and Molecular Imaging Myocardial Perfusion Ventricular Function and Remodeling Myocardial Viability Mechanical Dyssynchrony Neurotransmission Integrity
3 Nuclear Cardiology and Molecular Imaging Myocardial Perfusion Ventricular Function and Remodeling Myocardial Viability Mechanical Dyssynchrony Neurotransmission Integrity
4 High-Speed Myocardial Perfusion Imaging: Dawn of a New Era in Nuclear Cardiology? energy resolution count sensitivities spatial resolution Anger cameras 9-10% Kcps 9-11 mm CZT cameras 5.7% Kcps mm HIGHER IMAGE CONTRAST FEWER SCATTERED GAMMA RAYS DUAL ISOTOPE IMAGING ACQUISITION TIME <3 MINUTES SIGNIFICANT DOSE REDUCTION (<3 msv) REDUCED MOTION ARTIFACTS FIRST PASS STUDIES CORONARY FLOW RESERVE MULTIVESSEL DISEASE MYOCARDIAL MASS RV INFARCTION MORE ACCURATE EF HYBRID SPECT/CT Bonow RO (JACC 2008)
5 Stress Thallium-201/Rest Technetium-99m Sequential Dual Isotope High-Speed Myocardial Perfusion Imaging Berman et al. (JACC Img 2009;2:273 82)
6 SPECT Imaging
7 SPECT Imaging
8 SPECT Imaging
9 Risk Assessment Using SPECT Imaging
10 Spatial Resolution
11 Risk Assessment Using SPECT Imaging
12 Risk Assessment Using SPECT Imaging
13 Myocardial Perfusion Scintigraphy Assessment of the Functional Severity of Coronary-artery Stenoses EXCLUSION CRITERIA: EDV>130 Previous RT SM-Coro > 12 months 100% 90% Stenosis < 70% MPS NEG MPS POS 80% 70% 60% 50% 40% 30% 20% 10% 0% 1V 2V 3V (269) (188) (150) (20) (4) (3) n. of vessels Nudi F et al, personal data on file
14 Treadmill Exercise Produces Larger Perfusion Defects Than Dipyridamole Stress N-13 Ammonia PET Chow B.J.W. et al., JACC 2006
15 Pre-Percutaneous Coronary Intervention 2008
16 Pre-Percutaneous Coronary Intervention 2008
17 Post-Percutaneous Coronary Intervention 2009
18 Post-Percutaneous Coronary Intervention 2009
19 Risk Assessment Using SPECT Imaging EXCLUSION CRITERIA Previous MI Previous RT n = % 50% 4548 ET NEG ET NV ET POS 40% 30% 20% 10% % MPS POS Nudi F et al, personal data on file
20 Cardiac Positron Emission Tomography/Computed Tomography Imaging Accurately Detects Anatomically and Functionally Significant Coronary Artery Disease Kajander S, et al. (Circulation. 2010;122: )
21 Cardiac Positron Emission Tomography/Computed Tomography Imaging Accurately Detects Anatomically and Functionally Significant Coronary Artery Disease A 69-year-old man with attacks of atypical anginal pain. A, CT showed significant LAD and RCA stenoses with only mild stenosis in the LCx. B, Hybrid images with normal stress PET perfusion (absolute scale, 0 to 3.5 ml g -1 min -1 ). Normal perfusion is >2.5 ml g -1 min -1 (yellow or red). C, ICA with quantitative analysis and FFR. Despite anatomically significant narrowing of the LAD and borderline changes in the RCA, FFR was normal in both vessels, indicating functionally nonsignificant disease. Kajander S, et al. (Circulation. 2010;122: )
22 Cardiac Positron Emission Tomography/Computed Tomography Imaging Accurately Detects Anatomically and Functionally Significant Coronary Artery Disease A 57-year-old man with atypical chest pain during exertion. A, CT reconstructions show significant stenoses in the LAD, RCA, and a small intermediate branch (IM). LCx was nonstenosed. Yellow dotted line denotes motion artifacts in the RCA. B, Hybrid volumerendered image. Stress myocardial perfusion was reduced only in the area supplied by the LAD. C, ICA with quantitative analysis showed significant 73% luminal narrowing in the LAD. Other vessels were not stenosed. Kajander S, et al. (Circulation. 2010;122: )
23 Cardiac Positron Emission Tomography/Computed Tomography Imaging Accurately Detects Anatomically and Functionally Significant Coronary Artery Disease A 63-year-old man with positive family history. Good performance, atypical chest pain, and 2-mm ST depression in the ECG at the exercise test. In hybrid images, stress myocardial perfusion was reduced in most regions (green and blue). However, both CT and ICA showed normal coronary arteries, indicating possible microvascular disease. Kajander S, et al. (Circulation. 2010;122: )
24 Stress/rest myocardial perfusion scintigraphy in patients without significant coronary artery disease Death rate MACE rate Adamu U et al. (J Nucl Cardiol 2009)
25 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery >20% perfusion defect by myocardial perfusion stress imaging when viable myocardium is present in the region of intended revascularization Glenn N. Levine et al - L. David Hillis et al (JACC Vol. 58, No. 24, December 6, 2011:000 00)
26 Guidelines on myocardial revascularization Wijns W et al. (European Heart Journal (2010) 31, )
27 PATIENT MANAGEMENT AFTER NONINVASIVE CARDIAC IMAGING Results From SPARC (Study of Myocardial Perfusion and Coronary Anatomy Imaging Roles in Coronary Artery Disease) A noninvasive procedure, the results of which have no impact on subsequent management, must be considered an inappropriate study; the current study suggests that a significant amount of inappropriate noninvasive procedures are currently performed ( ) Hachamovitch R, et al. (J Am Coll Cardiol 2012;59:462 74)
28 MSCT Versus MPI in an Intermediate Likelihood of CAD 10% MSCT Normal MSCT Obstructively diseased MPI Normal MPI Abnormal 50% 50% 90% Schuijf et al. (JACC 2006;48: )
29 Combined non-invasive anatomical and functional assessment with MSCT and MRI for the detection of significant coronary artery disease in patients with an intermediate pre-test likelihood J. M. van Werkhoven (Heart : )
30 Intracoronary Doppler Assessment of Moderate Coronary Artery Disease CFVR < 1.7 CFVR 1.7 Pos Tl % 11% Neg Tl % 89% r = 88% Heller et al. (Circulation 1997)
31 PCI of Functionally Nonsignificant Stenosis Pijls et al. (JACC 2007;49: )
32 PCI of Functionally Nonsignificant Stenosis Pijls et al. (JACC 2007;49: )
33 Fractional Flow Reserve vs. Angiography for Guiding PCI Tonino PA et al. (N Engl J Med 2009;360:213-24)
34 Fractional Flow Reserve versus Angiography for Guiding Percutaneous Coronary Intervention Tonino PA et al. (N Engl J Med 2009;360:213-24)
35 Fractional Flow Reserve Versus Angiography for Guiding Percutaneous Coronary Intervention in Patients With Multivessel Coronary Artery Disease Nico H. J. Pijls et al (J Am Coll Cardiol 2010;56:177 84)
36 Fractional Flow Reserve Versus Angiography for Guiding Percutaneous Coronary Intervention in Patients With Multivessel Coronary Artery Disease Nico H. J. Pijls et al (J Am Coll Cardiol 2010;56:177 84)
37 A Randomized Trial of Therapies for Type 2 Diabetes and Coronary Artery Disease The BARI 2D Study Group (N Engl J Med 2009;360: )
38 A Randomized Trial of Therapies for Type 2 Diabetes and Coronary Artery Disease The BARI 2D Study Group (N Engl J Med 2009;360: )
39 Optimal Medical Therapy with or without PCI for Stable Coronary Disease Boden WE et al. (N Engl J Med 2007;356: )
40 Optimal Medical Therapy With or Without Percutaneous Coronary Intervention to Reduce Ischemic Burden 0% 39.3% Shaw et al. (Circulation. 2008;117: )
41 No. of patients No. of patients Prognostic Value of Myocardial Perfusion Scintigraphy to Guide Therapeutic Decision Making % MT (No. 794) 400 MPS1 350 MPS MPS negative - 52% MPS severe % RT (No. 548) - 86% MPS1 MPS MPS negative MPS severe Nudi F et al, personal data on file
42 Coronary Revascularization % Hard Event Rate The Economic Consequences of Available Diagnostic and Prognostic Strategies for the Evaluation of Stable Angina p< Death MI Direct Catheterization (n=5423) Initial stress perfusion imaging (n=5826) Shaw LJ et al. (J Am Coll Cardiol 1999)
43 Nuclear Cardiology and Molecular Imaging Myocardial Perfusion Ventricular Function and Remodeling Myocardial Viability Mechanical Dyssynchrony Neurotransmission Integrity
44 Metabolism-Perfusion Mismatch Perfusion Contractility Viability
45 Hibernating Myocardium (Technetium tetrofosmin)
46 Hibernating Myocardium (Thallium-201)
47 Increasing Benefit From Revascularization Is Associated With Increasing Amounts of Myocardial Hibernation - A Substudy of the PARR-2 Trial PARR-2 Investigators (J Am Coll Cardiol Img 2009;2:1060 8)
48 Prognostic Value of Myocardial Perfusion Scintigraphy to Guide Therapeutic Decision Making 40% 35% Clinical AMI: % 25% 20% 15% 10% 5% 0% NEG m L ML M MS S (2943) (576) (785) (656) (793) (757) (1290) Myocardial Perfusion Scintigraphy Nudi F et al, personal data on file
49 Necrotic Myocardium pre- and post- Revascularization % Reversible Irreversible
50 Annual Rate of Death Hibernating Myocardium 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% 3.2 Revascularized Viable Non-Viable 6.2 Medical Therapy NO Allman et al. (JACC 2002)
51 Increasing Benefit From Revascularization Is Associated With Increasing Amounts of Myocardial Hibernation - A Substudy of the PARR-2 Trial PARR-2 Investigators (J Am Coll Cardiol Img 2009;2:1060 8)
52 Long-term Survival of patients with Coronary Artery Disease and Left Ventricular Dysfunction: implications for the role of myocardial viability assessment in management decisions Di Carli et al. (J Thorac Cardiovasc Surg 1998)
53 No Difference in Cardiac Event-Free Survival Between PET-guided and SPECT-guided Patient Management MT RT Siebelink HJ et al. (J Am Coll Cardiol 2001;37:81 8)
54 VIABLE INNERVATION MISMATCH H / M 1.46 H / M 1.56 Washout > 26%
55 PERFUSION INNERVATION MISMATCH
56 Assessment of neurotransmission integrity (Iodine123 metaiodobenzylguanidine MIBG) Prediction of response to medical therapy Prediction of death Prediction of sudden cardiac death Selection of CHF patients for implantable defibrillators
57 Dysinnervated but viable myocardium in ischemic heart disease Fallavolita J A and Canty J M (JNC nov/dec 2010)
58 Cardiac Sympathetic Imaging With mibg in Heart Failure I. Carrió, P.G. Camici (JACC Img 2010;3;92-100)
59 Cardiac Sympathetic Imaging With mibg in Heart Failure I. Carrió, P.G. Camici (JACC Img 2010;3;92-100)
60 ADMIRE-HF Study AdreView Myocardial Imaging for Risk Evaluation in Heart Failure Jacobson A F et al. (JACC 2010;55: )
61 Nuclear Imaging in Cardiac Resynchronization Therapy Henneman M M et al (J Nucl Med 2007; 48: )
62 Phase Analysis of Gated Myocardial Perfusion SPECT Compared With Tissue Doppler Imaging for the Assessment of Left Ventricular Dyssynchrony Henneman MM et al. (J Am Coll Cardiol, 2007; 49: )
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