Detection of Ischemic Heart Disease
JoãoJoão V. VitolaV. Vitola
CardiologistaCardiologista e e MMéédicodico Nuclear Nuclear Quanta Quanta DiagnosticoDiagnostico NuclearNuclear
Curitiba Curitiba -- BrasilBrasil
DISCLOSURESDISCLOSURESHonorarium Honorarium –– Research and/or conferences in NCResearch and/or conferences in NCBMS, CVT, BMS, CVT, AstellasAstellas, IAEA, IAEARoyalties Royalties –– Publishers in the USAPublishers in the USASpringerSpringer--VerlagVerlag--Nuclear Cardiology and Correlative Imaging: a teaching file,Nuclear Cardiology and Correlative Imaging: a teaching file, NY, 2004NY, 2004Lippincott Williams & Wilkins, Lippincott Williams & Wilkins, -- Nuclear Medicine teaching FileNuclear Medicine teaching File, 2009, 2009
1- Antes de Iniciar o Exame Coletar Informações em uma Entrevista MedicaSintomas e FR: estimar probabilidade pré-testeAjuda a define protocolo de estresseDefine pergunta/necessidade do clinicoDiagnostico ? Prognostico ?Arteria culpada ?Viabilidade ? Fx VE ?
1- Antes de Iniciar o Exame Coletar Informações em uma Entrevista MedicaSintomas e FR: estimar probabilidade pré-testeAjuda a define protocolo de estresseDefine pergunta/necessidade do clinicoDiagnostico ? Prognostico ?Arteria culpada ?Viabilidade ? Fx VE ?
2- Prova de esforçoEstima capacidade funcionalInformações adicionais com valor Diagnostico e PrognosticoCalculo Duke ScoreNova probabilidade pós teste de esforço e pré – teste imagemDefine momento ideal da imagem 15’ vs 30’ vs 60’
Coleta sistemática deInformaçõespara banco de dados~= 25.000 casos
1- Antes de Iniciar o Exame Coletar Informações em uma Entrevista MedicaSintomas e FR: estimar probabilidade pré-testeAjuda a define protocolo de estresseDefine pergunta/necessidade do clinicoDiagnostico ? Prognostico ?Arteria culpada ?Viabilidade ? Fx VE ?
2- Prova de esforçoEstima capacidade funcionalAlguma informação Diagnostico e PrognosticoDuke ScoreNova probabilidade pós teste de esforço e pré – teste imagemDefine momento ideal da imagem 15’ vs 30’ vs 60’
3- Análise de imagem perfusão e função
4 - Relatório Final (1 + 2 + 3) Considerar as informações de 1 e 2 na analise (leitura mais especifica ou mais sensível)
Mujer 61 a
TCE 80 % + DA 100% proximal, CX ok, CD ok.
MultipleMultiple PresentationsPresentations ofof CAD CAD leadingleadingto to HardHard CardiacCardiac EventsEvents
•• ObstructiveObstructive diseasedisease: : criticalcritical lesionslesions, , affectingaffectingvascular reserve, vascular reserve, severesevere ischemiaischemia -- arrythmiasarrythmias
•• CAD CAD unstableunstable plaques plaques -- eventsevents
•• CAD CAD withoutwithout significantsignificant lesionslesions –– ““Normal Normal CoronariesCoronaries byby AngiographyAngiography””endothelialendothelial dxdx, , autonomicautonomic dxdx ~ ~ spasmspasm ~ AMI ~ AMI
Elderly female, stressful event, anterior STEMI“ normal ” epicardial vessels
99mTc- MIBI at Rest
Villaroel A, Vitola J, Stier A, Dippe T, Cunha C. Expert Rev. Cardiovasc. Ther., 7 (7) 2009
123 MIBG at Rest
90% are womenusual post menopausalWhy ?
MultipleMultiple PresentationsPresentations ofof CAD CAD leadingleadingto to HardHard CardiacCardiac EventsEvents
•• ObstructiveObstructive diseasedisease: : criticalcritical lesionslesions, , affectingaffectingvascular reserve, vascular reserve, severesevere ischemiaischemia –– ventricular ventricular arrythmiasarrythmias ((speciallyspecially ifif LV LV dysfunctiondysfunction))
Female, 54 yo, Atypical CP, referred for MIBI3 min after low workload exercise
Middle Age Women undergoing investigation of suspected CAD in Brazil
Ischemia Induced Cardiac ArrestWould probably be fatal outside hospital/clinic
OUTCOME – Successful CPR, Cath (3 V disease)Surgical revascularization, ALIVE AND WELL
Imagem Não Invasiva em DCV
Funcional (Nuclear e FFR) vs Anatomia (QCA)
*
New Gold Standard - coronary flow reserve
50% = Não “significativa”
50% = Obstrução crítica
Teste de reserva de dilatação coronária
New Gold Standard - coronary flow reserve
Extent/Severity of Perfusion Defects
Risk*
*Adjusted or unadjustedSource: Klocke et al. J Am Coll Cardiol 2003.
Extent/Severity Extent/Severity –– Ischemia toIschemia to PredictsPredicts DeathDeath80 % RCA 80 % LAD
OMTPCI + OMTPCI + OMT
8.6% 8.1% 8.1%
(6.9%(6.9%--9.4%)9.4%)
8.2% 5.5% 5.5%
(4.7%(4.7%--6.3%)6.3%)
Tamanho da Àrea Isquêmica – Pacientes do COURAGE
0
1
2
3
4
5
6
7
0% 1-5 % 6-10 % 11-20% >20 %
Hachamovitch R et al, Circulation, 2003 DEFECT SIZE ON SPECT
MORTALITY(%)
Management based on ischemic burden by NUCLEAR
ConservativeRevasc
NO Benefit Benefit
0,3 0,5 0,8
2,72,3
2,92,4
4,2
0
1
2
3
4
5Cardiac DeathMI
Hachamovitch Circ 1998;97:535-543
MildlyAbnormal
Moderately Abnormal
Severely > 13Abnormal Normal < 4
2,946 884 455 898
Summed Stress Perfusion Score
Medical Therapy
Revascularization + Med Therapy
Post 1 stent LAD0% ischemia
53 yo maleAtypical chest pain
High Risk > 3%/ year Low Risk < 1%/year
stenting
Habibian R, Delbeke D, Martin W, Sandler M, Vitola JV Cardiovascular Imaging, in Nuclear Medicine Teaching File, 2009
020406080
100
014 YEARS EF < 35%
EF 35-49%EF > 50 %
SURVIVAL
LV Function LV Function –– An Important Predictor of DeathAn Important Predictor of Death
CIRCULATION 1983;68:939-950
Sudden Cardiac Death in patient with CAD and LV Dx
At age 57 yo anterior MI, treated with primary PTCA. At age 61 yo – had an MPI for risk stratificationAt age 63 yo - had sudden death while playing tennis.
24 months prior do sudden death
AKINESIAREMODELED LVLVEF 25 % (nl > 50%)EDV 235 ml (nl 101 ml) ESV 176 ml (nl 44 ml)
Sharir et al., Circulation 1999;100:1035-1042
↓ SMC
ThinfibrousCap
LargeLipidCore
↑Macrophages***
DANGERDANGER
UNSTABLE STABLE
UNSTABLE PLAQUES
CT, MRIIVUS
CT, MRIIVUS
FDG - PET
1818FF--FDG as a Marker of InflammationFDG as a Marker of Inflammation
Rudd JH et al. Circulation 2002;105:2708Rudd JH et al. Circulation 2002;105:2708--2711.2711.
•• Autoradiography from samples from carotid Autoradiography from samples from carotid endarterectomyendarterectomy confirm FDG confirm FDG uptake in uptake in macrophagemacrophage--richrich (marked with (marked with AbAb) areas of the plaque (silver ) areas of the plaque (silver stain).stain).
From Vitola JV et Delbeke From Vitola JV et Delbeke D (D (edseds): Nuclear ): Nuclear Cardiology and Cardiology and Correlative Imaging: A Correlative Imaging: A Teaching File. Springer Teaching File. Springer 20042004
FDG uptake FDG uptake along the along the aortic wallaortic wall
SimvastatinSimvastatin attenuates Plaque Inflammationattenuates Plaque InflammationEvaluation by FDG PETEvaluation by FDG PET•• 43 oncology patients with arterial FDG uptake were randomized to43 oncology patients with arterial FDG uptake were randomized to
receiving 3 months of receiving 3 months of simvastatinsimvastatin + diet or diet alone+ diet or diet alone
TaharaTahara N et al. JACC 2006;48 (9):1825N et al. JACC 2006;48 (9):1825--18311831
FDG uptake FDG uptake 1)1) Decreases in the Decreases in the
simvastatinsimvastatingroup but not group but not with diet alonewith diet alone
1818FF--FDG as a Marker of Inflammation in FDG as a Marker of Inflammation in the Coronary Arteriesthe Coronary Arteries
TaharaTahara N et al. J N et al. J NuclNucl Med 2009;50(3):331Med 2009;50(3):331--334334
71 year71 year--old oncology patient with coronary risk factorsold oncology patient with coronary risk factorsCoronary angiography: nonCoronary angiography: non--calcified plaques in left main and LADcalcified plaques in left main and LADFDG PET/CTA fusion: FDG uptake in plaque SUV 2.1FDG PET/CTA fusion: FDG uptake in plaque SUV 2.1
Research – plaque morphology
Documenting Response to Therapy in Vulnerable PlaquesDocumenting Response to Therapy in Vulnerable Plaques
Courtesy Nihon Hospital, Tokyo
8 MonthsStatin Therapy
Baseline
HIGH CALCIUM SCORE HIGH CALCIUM SCORE –– MARKER OF INCREASED MORTALITYMARKER OF INCREASED MORTALITY
Shaw LS et al. Radiology 2003;228:826Shaw LS et al. Radiology 2003;228:826--833833
Cohort > 10,000 asymptomatic patients Cohort > 10,000 asymptomatic patients
15 - 46% SPECT abnormalHe ZX et al. Circulation 2000;101:244He ZX et al. Circulation 2000;101:244--251.251.Berman DS et al. J Am Berman DS et al. J Am CollColl CardiolCardiol 2004;44:9232004;44:923--930.930.
ATHEROSCLEROSIS – QUANTITATIONISCHEMIA QUANTITATION
INTEGRATION
Strengh of CT – High Negative Predictive Values
AHA: NPV > 95% ~ may avoid invasive angiography
Source: Budoff - AHA - Assessment of CAD by cardiac computed tomography. Circulation. 2006 Oct 17;114(16):1761-91. Achenbach Computed tomography coronary angiography. JACC 2006; Nov 21;48(10):1919-28.
• Evidence favors use of CTA in patients with equivocal ischemia provoking tests
WhatWhat informationinformation shouldshould wewe bebe lookinglooking for for to to changechange managementmanagement andand resultresult in in betterbetterpatientpatient outcomeoutcome iin n a a costcost effectiveeffective wayway ??
• ANATOMY / ATHEROSCLEROSIS ? • PERFUSION / ISCHEMIA ?• LV FUNCTION / LVEF + VOLUMES ?• COMBINATION OF ALL THE ABOVE ?
It depends highly on who is my patient .....
Adel Allam – EgyptAmalia Peix – Cuba
Annare Ellmann – South AfricaBon Nang Lee – Malaysia
C. Siritara - ThailandFelix Keng – Singapore
Fernando Mut- (Co-chairman) - UruguayGianmario Sambucetti – Italy
Gregory Thomas – USAJoão V. Vitola (Chairman) - Brazil
Kevin Allman – AustraliaLeslee Shaw – USA
Maurizio Dondi - IAEA - AustriaMarla Kiess – CanadaPilar Orellana – Chile
Raffaele Giubbini – SwitzerlandSalaheddine Bouyoucef – Algeria
Zuo – Xiang He – China
UN UN headquartersheadquarters, , ViennaVienna, Austria, 2008, Austria, 2008
Adel AllamEgito Samuel WannEUA
Alexandria, junho 2009CardioAlexPanArab Cardiologia Intervencionista 2009
Evidência de Aterosclerose
Aterosclerose da Vida Moderna Aterosclerose - Egito Antigo - 1500 AC
JAMA, 2009