Cardiac CT and Nuclear Cardiology in Stable CAD Director, Cardiac ... · Nuclear Cardiology and Cardiac CT • CT coronary calcium: effective – Class IIa ACC/AHA prevention guidelines

1

Contemporary Best Practice: How to Integrate Cardiac CT and Nuclear Cardiology in Stable CAD

Daniel S. Berman, MDDirector, Cardiac Imaging

Department of Imaging andCedars-Sinai Heart Institute

Professor of MedicineDavid Geffen School of Medicine at UCLA

CSMC2013

• Identify patient in need for specific therapy

Noninvasive Imaging in CAD Changing Problems for Imaging

– Prevention– Diagnosis– Guiding management

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• Identify patient in need for specific therapy

Noninvasive Imaging in CAD Changing Problems for Imaging

– Prevention– Diagnosis– Guiding management

• Contain rising costs

Cardiac CTStrengths• Non-contrast: proven role of CAC for prevention• Contrast: CCTA

– Highest sensitivity and specificity for CAD

– Strong prognostic value– Potential for comprehensive cardiac assessment

– Function, perfusion, infarct, plaque

WeaknessesD l l ifi d l di ti• Densely calcified plaques: nondiagnostic

• Dependence on low HR and regular rhythm• Iodinated contrast

3

Myocardial Perfusion SPECT/PET Strengths

• High technical success rate

• Objective measurements of perfusion and function

• Documented for risk-stratification/management

• Validated for myocardial viability

• Promising new PET tracer in phase II

Limitations

N d i f l h l i *• No detection of early atherosclerosis*

• Frequently underestimates extent of ischemia/CAD

*unless hybrid with routine coronary calcium scanning

Pre-test likelihood of CAD

Selection of Imaging Tests in Evaluation of Symptomatic Patients with Suspected CAD

CTA Stress SPECT/PET

Low- to High-Intermediate (15-85%)Intermediate to High (50-100%)

Low

CAC CTA Stress SPECT/PETCAC

4

Nuclear Cardiology and Cardiac CT

• Asymptomatic Prevention

• Symptomatic Diagnosis• Symptomatic Diagnosis

• Known disease Intervention

Coronary Calcium as a Predictor of Coronary Events in Four Racial or Ethnic Groups

Unadjusted Kaplan–Meier Survival for

Coronary Events by CAC Scores Categories

n=6722, 38.6% white,

CD or MI

27.6% black, 21.9% Hispanic, and 11.9% Chinese. FU 3.9 yrs.

Detrano et al. NEJM 2008;358:1336-45

Any cor event

5

Comparison of Novel Risk Markers for Improvement in Cardiovascular Risk-Assessment in Intermediate-Risk Subjects

Yeboah JAMA 2012 - MESA

Cardiovascular Events with Minimal vs Absent Coronary Calcification: The Multi-Ethnic Study of

Atherosclerosis (MESA)

Budoff et al. Am Heart J 2009;158:554-61

3415 CAC=0, 508 CAC=1-10, FU 4.1 yrs, 28 all CHD events (MI, cardiac death, resuscitatied cardiac arrest, angina and probable angina with revasc.) and 16 hard events

6

SHAPE: Screening for Heart Attack Prevention and EradicationNaghavi, et al Am J Cardiol July 2006

CAC Severity Predicts Stress-Induced Scintigraphic Ischemia

326 M, 85 F, age 58 ±10 yrs, SPECT in median 17 days

4650(%)

*

11.310

20

30

40

norm

al S

PE

CT

He et al, Circulation 2000;101:244-51

0 0 2.60

0 1-10 11-100 101-399

≥400

Abn

CACS

n = 37 n = 19 n = 76 n = 142 n = 137 *p<0.001

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Ischemia ≥5% Ischemia ≥10%

Frequency of Ischemia on Myocardial Perfusion SPECT by Coronary Artery Calcium (CAC) Category

19.9%

8.9%

5.2%

8.6%

5%

10%

15%

20%

25% *

*

*p<0.0001 for trend for Ischemia 5%, Ischemia 10%

0%2.4%1.6%

0.4% 0% 0.5%2.1% 2.4%

0%

5%

CAC=0(n=250)

1-9 (n=49)

10-99 (n=207)

100-399(n=290)

400-999(n=248)

≥1000(n=151)

Berman et al, JACC 2004;44:923-30

Screening for Subclinical Atherosclerosis


• CT coronary calcium: effective– Class IIa ACC/AHA prevention guidelines (2010)

• Coronary CTA: uncertain role at present

• Limited role for nuclear cardiology

• Stress imaging documented as useful for guiding management when CCS is high (~10%)

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ACC N ti l C di l D t R i t

Patel et al. NEJM 2010;362:886-95

• ACC National Cardiovascular Data Registry • 397,954 patients with elective cath (663 hospitals)• 37.6% had obstructive CAD (>70% stenosis)

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Patel et al. NEJM 2010;362:886-95



Patel et al. NEJM 2010;362:886-95


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Coronary CTA

Sensitivity and specificity: 95%/90%• Sensitivity and specificity: ~ 95%/90%• Higher than all other modalities

–Per patient–Per vessel

Per segment–Per segment

Coronary CTA



Per segment–Per segment • Very unlikely to miss high risk disease

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Coronary CTA



Per segment–Per segment • Very unlikely to miss high risk disease• Very high negative predictive value for

events

Prognostic value of CCTA is widely generalizable

CONFIRM Registry: Coronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter Registry (James K. Min, PI)

v.1. CONFIRM, 9.1.10 v.2. CONFIRM, expected 2.15.10

• Dynamic registry of >32,000 consecutive patients undergoing CCTA

• V.1. 12-centers in 6 countries (US, Canada, Germany, Switzerland, Italy, and S. Korea), Database lock 09/10 – Derivation Cohort

• V.2. 6 add’l sites (Miami, California, Vancouver, New York, Innsbruck, Seoul) – Validation Cohort

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Normal

Non-Obstructivep<0.0001

Prognostic Value of CCTA CAD Extent / Severity23,854 patients w/o known CAD (57+13 years), 2.3 year f/u

1-Vessel CAD

p<0.0001

2-Vessel CAD

p<0.001

3-Vessel/Left Main

Surv

ival

Pro

babi

lity

3 Vessel/Left Main p<0.0001

Survival Time (Years)Source: Min et al. J Am Coll Cardiol 2011

Normal

Non-Obstructivep<0.0001

Prognostic Value of CCTA CAD Extent / Severity23,854 patients w/o known CAD (57+13 years), 2.3 year f/u

1-Vessel CAD

p<0.0001

2-Vessel CAD

p<0.001

3-Vessel/Left Main

Surv

ival

Pro

babi

lity

3 Vessel/Left Main p<0.0001

Survival Time (Years)

• Warranty period of normal scan: likely ~ 10 years

Source: Min et al. J Am Coll Cardiol 2011

13

Comparison of observed Ob-CAD prevalence in MEN to probabilities based on DFC and CASS

80

100%

)Observed prevalence DFC and CASS

0

20

40

60

-39

-39

-49

-49

-59

-59

-69

-69

70+

-39

-39

-49

-49

-59

-59

-69

-69

70+

-39

-39

-49

-49

-59

-59

-69

-69

70+

Pre

vale

nce

(%

Victor Cheng, Circ 2011

30-

30-

40-

40-

50-

50-

60-

60- 7

30-

30-

40-

40-

50-

50-

60-

60- 7

30-

30-

40-

40-

50-

50-

60-

60- 7

Age (years)Nonanginal Chest Pain Atypical Angina Typical Angina



CTA

Low- to High-Intermediate (15-85%)

CTA

Prediction: In SYMPTOMATIC patients:• CCTA will become a common initial test in intermediate likelihood of CAD: • ~10% will need further (ischemia) testing

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Low (< 15%)

Symptomatic

Intermediate (15%-85%) High (>85%)

CTA y p

1° Prevention 2° Prevention Catheterization +/- Revasc.

SOB

HUDPET 55 M

Cholesterol, FH early CAD

Rest ECG: LBBB

Referred for SPECT MPI

No walk adenosine

15

Hudpet 51 M

Hudpet 51 M

16

HUDPET 55 M #3321-1784

CCTA: normal coronary arteries, CCS 6, HR 63, LVEF 55%63, LVEF 55%


Low (< 15%)

Symptomatic


CTA

NL

y p


17

RR, a 66y old male

Proximal and mid LAD severe stenosisRR, a 66y old male

18

Cath done 2 days later…

RR, a 66y old male

Non-Invasive Detection of Coronary Artery Disease in Patients with Left Bundle Branch Block using 64-

Slice Computed Tomography

Ghostine et al. JACC Vo.44, No. 10, 2006:1929-34

19

Non-Invasive Detection of Coronary Artery Disease in Patients with Left Bundle Branch Block using 64-

Slice Computed Tomography

97% sensitivity (28/29); 95% specificity (35/37



Low (< 15%)

Symptomatic


CTA

NL

y p

ABNL*

*C i i l i


*Critical stenosis

20

SAGMAN 67 M #3311-1670

Reason for test: atypical chest pain

Risk factors: hypertension cholesterolRisk factors: hypertension, cholesterol

Medications: statin, beta blocker

Resting ECG: RBBB

SAGMAN 67 M #3311-1670

CCTA: LAD prox: nondiagnostic (calcium), D1 and D2 50-69%, CCS 1212, LVEF 64%, HR 57

LM/LAD/LCX LAD RCA

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Which of the following would be appropriate?:

1. Invasive coronary angiography

2. Stress ECG

3. Myocardial perfusion imaging

4. Stress echo

5. Coronary CTA

.



2. Stress ECG


4. Stress echo

5. Coronary CTA

.

22

SAGMAN 67 M #3311-1670

Reason for test: uninterpretable coronary CTA

Results of exercise:Duration: 8:30 HR reserve: 89%HR: 144 (94% MPHR) BP: 162/102 170/94Clinical response: nonischemicECG response: nonischemicECG response: nonischemic

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50-69% LAD Stenoses with Normal SPECT-MPI

Stress

A C

Rest

B DD

Tamarappoo, et al JNC 2010

50-69% First Diagonal Stenosis with Ischemia on SPECT-MPI

Diagonal

Stress

A

Rest

CLAD

B D


24

CCTA Stenosis Severity by CCTA vs Prevalence of ischemia by SPECT-MPI

100

20

40

60

80

Pre

vale

nce

(%

) (p

t)

p = 0.001

0

20

0-24 25-49 50-69 70-89 90-100% without ischemia by SPECT-MPI

P

% Luminal stenosis by CCTA

(153)

(45)

(34) (24) (27)



Low (< 15%)

Symptomatic


CTA

NL

y p

ABNL*


*No critical stenosis

25


Low (< 15%)

Symptomatic


CTA

NL

y p

EquivABNL*

2° Prevention Catheterization +/- Revasc.1° Prevention


Patient Management Following Coronary CT Angiography

• “negative” study: clear• negative study: clear– No plaque: assurance

– Non-obstructive plaque: prevention

• “positive” or uninterpretable study: not clear

26

Need for Ischemia Testing after CCTAMost Common Circumstances

B d li i (50 69%)• Borderline stenosis (50-69%)

• Non-diagnostic CCTA– Dense coronary calcium

– Other artifact (motion, arrhythmia)

M di l b id• Myocardial bridge

• Anomalous coronary artery


Low (< 15%)

Symptomatic



NL

y p

EquivABNL*



27


Low (< 15%)

Symptomatic



NL

y p

EquivABNL*







28

Coronary CTA is not useful in many settings

CCTA MPICCTA MPI

• High CAC - +

• Renal failure - +

• Prior MI - +

• Arrhythmia +• Arrhythmia - +

• Stents <3 mm - +

• Obese - +

• Men and women

S d A

SPECT: Risk Increases as a Function of Stress Perfusion Abnormality

Data from over 50,000 patients

• Sx and Asx

• Diabetics

• Obese

• Renal Failure

• Arrhythmia

• Elderly

Ris

k*

• Elderly

• Known CAD– MI

– PCI

– CABG

Extent/Severity of Perfusion Defects*Adjusted or unadjusted

Guidelines for Clinical Use of Cardiac Radionuclide Imaging 2003

29

Rat

io 56

M di l R*

Adjusted† Risk of Cardiac Death vs MPS ischemiaRevascularization vs Medical Rx

†Adjusted for predictorsof revascularization as well as

log

Haz

ard

R2

34

Medical Rx

Revasc*

*p<0 001

clinical, hx, stress SPECT data

01

% Myocardium Ischemic0 12.5% 25% 32.5% 50%

p<0.001

Hachamovitch, et al Circulation 2003

34

ard

Adjusted Risk of Cardiac Death vs EF and Ischemia

Revascularization vs Medical Rx

Revasc Hachamovitch, et alJ Nucl Cardiol 2006;13:768-78

01

2lo

g R

elat

ive

Haz

a

Revascularization:All levels of ischemia

Medical Rx: % ischemic

30%

-2-1

Gated SPECT EF

0%

10%

20%

0 20% 40% 60% 80% 100%

change in risk with revasc

30

dica

l The

rapy

)1.50

1.75

2.00

1.49

Therapeutic Benefit among Patients with <10% Myo Fixed

n = 11,880FU 8.73.3 yrs

Haz

ard

Rat

io

ascu

lari

zati

on v

s. M

ed

0 50

0.75

1.00

1.25

0.700.80

0.95

1.10

1.28

(Ear

ly R

ev

0.00

0.25

0.50

0 5 10 15 20 25Hachamovitch et al. EHJ 2011

Ischemia on MPI Predicts Benefit from Revascularization

• Elderly Circulation 2010• Elderly Circulation 2010

• Prior revascularization EHJ 2010

• Prior MI EHJ 2011

Hachamovitch, et al

31

Underestimation of the Extent of CAD by Underestimation of the Extent of CAD by SPECT MPISPECT MPI

Berman et al, Berman et al, J Nucl Cardiol 2007;14:521J Nucl Cardiol 2007;14:521--88

101 consecutive stress MPS pts with LM CAD (50% stenosis)

Myocardial Perfusion SPECTRole in Guiding Patient Management

LimitationsLimitations• Cannot detect early atherosclerosis• May underestimate extent of ischemia/CAD

CAC scanning and ancillary high risk findingshelp identify high risk patient

32

STRESS

REST

STRESS

REST

CAC 1463 (97th %)

33


Low (< 15%) Intermediate (15%-85%) High (>85%)

Stress SPECT/PET




No/minimalischemia(<5%)**

Mild-Moderate ischemia(5-10%)

Extensive ischemia(>10%)

Stress SPECT/PET


34






Stress SPECT/PET







Stress SPECT/PET


ancillary high risk markers?

35






Stress SPECT/PET

Consider ICA





Mild-Moderate ischemia

(5-10%)**


Stress SPECT/PETCTA/CCS

Equivocal/Discordant


36

ISCHEMIA Trial

International Study of Comparative H lth Eff ti ith M di lHealth Effectiveness with Medical

and Invasive Approaches

Study Chair: Judith HochmanP i i l I i D id MPrincipal Investigator: David Maron

Sponsor: NHLBI; Submitted: February 2010

>10% Ischemia*LVEF >35%

Blinded CCTA to

ISCHEMIA Trial

RANDOMIZE

Blinded CCTA to R/0 LM, NCA

• 8,000 stable CAD patients• 3-6 yr. F/U

Cath(Revasc+ OMT)

No Cath(OMT)

• 3-6 yr. F/U*SPECT, PET, echo, CMR

Core lab verification

37





Low


Noninvasive Imaging for CADSuspected CAD


Intermediate to High (50-100%)

CAC + Ischemia Testing

38

Noninvasive Imaging for CADKnown CAD

Need to consider revascularization



• Extensive data supports:• the extent of ischemic myocardium (stress)• the extent of dysfunctional but viable myocardium (SPECT, echo, PET, CMR)

• Little data supports the application of coronary CTA in this setting

39



• Extensive data supports:• the extent of ischemic myocardium (stress)• the extent of dysfunctional but viable myocardium (SPECT, echo, PET, CMR)


Thank you very much

40



2. Coronary CTA

3. Stress echo

4. No testing

.



2. Coronary CTA

3. Stress echo

4. No testing

.

41

SWIMIC 58 M #3021-1618

CCTA: LAD, LCX & RCA <25%, LA enlargement, LVEF 76%, CCS 154, HR 68

PET

42

DAMJAC 64 y/o M Sx: atypical chest pain Risk Factors: DM, BP, cholesterol Rest ECG: non‐specific ST‐T wave abnl. Rb‐82 PET requested

DAMJAC (Rb-PET 4/2/2010)

43



2. Coronary CTA

3. Stress echo

4. No testing

.



2. Coronary CTA

3. Stress echo

4. No testing

.

44

DAMJAC (Rb-PET 4/2/2010)

DAMJAC (CCTA 4/5/2010)

45



46

Teaching PointCCTA after Equivocal or Discordant Stress

MPI results• When clinical uncertainty exists after MPI• When clinical uncertainty exists after MPI

in patients without known CAD, coronary CTA can be used to effectively triage re: invasive coronary angiography






Stress SPECT/PET

? CCTA, cath if highrisk suspected



47

SOB

HUDPET 55 M


Rest ECG: LBBB


No walk adenosine

Hudpet 51 M

48

Hudpet 51 M



2. Coronary CTA

3. Stress echo

4. No testing

.

49



2. Coronary CTA

3. Stress echo

4. No testing

HUDPET 55 M #3321-1784


50

RR, a 66y old male with ATA; LBBB No CAD risk factors


RR, a 66y old male

51


Non‐Invasive Detection of Coronary Artery Disease in Patients with Left Bundle Branch Block using 64‐Slice

Computed Tomography


52


Computed Tomography



Atypical angina recent onset

ROSROB 66 yo M

Risk factors: hypertension, diabetes (oral agents)

Rest ECG: LBBB


No walk adenosine

53

RR, a 66y old male

ROSROB (SPECT 8/10/2009)

54



2. Coronary CTA

3. Stress echo

4. No testing

.



2. Coronary CTA

3. Stress echo

4. No testing

55

MAYCAR 51 F #3211-1651

Sx and Reason for test: typical chest painHx: no known CADRisk factors: noneResting ECG: NormalResults of exercise:

Duration: 7:30 HR reserve: 94%HR: 162 (96% MPHR) BP: 135/70 190/70Clinical response: nonischemicECG response: ischemic (-2.1 mm H V5,

-2.4 mm H III, -2.5 mm H AVF)

MAYCAR 51 F #3211-1651

56

MAYCAR 51 F #3211-1651ST MB

REST MB

ST MB

REST MB

ST MB

REST MB

ST MB

REST MB

MAYCAR 51 F #3211-1651

CCTA: normal

LAD LCX RCA

57


80

100%

)Observed prevalence DFC and CASS

0

20

40

60

-39

-39

-49

-49

-59

-59

-69

-69

70+

-39

-39

-49

-49

-59

-59

-69

-69

70+

-39

-39

-49

-49

-59

-59

-69

-69

70+

Pre

vale

nce

(%

Victor Cheng, Circulation 2011

30-

30-

40-

40-

50-

50-

60-

60- 7

30-

30-

40-

40-

50-

50-

60-

60- 7

30-

30-

40-

40-

50-

50-

60-

60- 7



80

100

%)

Observed prevalence DFC and CASS

0

20

40

60

-39

-39

-49

-49

-59

-59

-69

-69

70+

-39

-39

-49

-49

-59

-59

-69

-69

70+

-39

-39

-49

-49

-59

-59

-69

-69

70+

Pre

vale

nce

(%

30-

30-

40-

40-

50-

50-

60-

60- 7

30-

30-

40-

40-

50-

50-

60-

60- 7

30-

30-

40-

40-

50-

50-

60-

60- 7


Victor Cheng, Circulation 2011

58

ZAITAS 64 M #3421-1619

Sx and Reason for test: shortness of breath and atypical chest pain

Hx: Prior MI (1992)Risk factors: BPResting ECG: nonspecific T wave abnormalities


1. Stress MPI

2. Coronary CTA

3. Stress echo

4. No testing

.

59


1. Stress MPI

2. Coronary CTA

3. Stress echo

4. No testing

.

ZAITAS 64 M #3421-1619

Results of adenosine stress:HR: 63 83 HR ratio = 1.32 BP: not achievedClinical response: non-ischemicECG response: ischemic (-1.3 mm H II)

60

ZAITAS 64 M 4/19/07 #3421-1619

ST MIBI

REST Tl

ST MIBI

REST Tl

ST MIBI

REST Tl

ST MIBI

REST Tl

ZAITAS 64 M 4/19/07 #3421-1619

CCTA: LAD 70-89% mid, RCA 100% mid, CCS 965, LVEF 53%, HR 73

LAD RCA

61

ZAITAS 64 M 4/30/07 #3421-1619

Cath:

LAD 70% mid & distalLAD 70% mid & distal

RCA 100% mid (stent)

Known CAD/ CHF

Nuclear Cardiology and Cardiac CTComplementary Roles


•Extensive data supports SPECT/PET:• the extent of ischemic myocardium (stress)

h f d f i l b i bl di• the extent of dysfunctional but viable myocardium• MIBG

62

Teaching Point“Complementary Tests”

• When the first test is definitive and matches• When the first test is definitive and matches the clinical setting, the second test is generally not justified.

Asymptomatic (imaging for prevention) • Coronary calcium scanning

Nuclear Cardiology and Cardiac CTComplementary Roles

Symptomatic (imaging for diagnosis/intervention)• Selection of Initial Test Depends on CAD Likelihood

Limiting symptoms: Direct catheterizationLower likelihood: favors CTA firstHigher likelihood: favors ischemia testing first

Indications for Sequential Imaginginitial test + clinical evaluation not definitive

63

• Thank you• Thank you

Spectrum of CAD

Risk Factors Symptoms Known Disease

CTA

NL


64

SOB

HUDPET 55 M


Rest ECG: LBBB


No walk adenosine

Hudpet 51 M

65

Hudpet 51 M

HUDPET 55 M #3321-1784


66



2. Coronary CTA

3. Stress echo

4. No testing

.



2. Coronary CTA

3. Stress echo

4. No testing

67

RR, a 66y old male


RR, a 66y old male

68



Computed Tomography


69


Computed Tomography



Spectrum of CAD


CTA

NL ABNL*

*C i i l i


*Critical stenosis

70

Spectrum of CAD


CTA Ischemia Testing

NL EquivABNL*



SAGMAN 67 M 10/2/07 #3311-1670

Atypical chest pain; hypertension; cholesterolMedications: Statin, beta blocker

LM/LAD/LCX LAD RCA

71

10091 91 88 94100%

PPV NPV

Predictive Value by Five Studies for CTA to Detect Ischemia with MPI Perfusion

2944 39 3231

0

20

40

60

80

0Hacker2005

Rispler2007

Di Carli2006

Schiuf2006

Hacker2006

N = 25 37 110 114 36

Hachamovitch et al. JNC 2007;14:634-44

72

Relationship between Stenosis Severity by CCTA and Ischemia on SPECT MPI

Tamarappoo et al, J Nucl Card 2010;17:791-802

Need for Ischemia Testing after CCTAMost Common Circumstances

B d li i (50 69%)

Symptomatic patient

• Borderline stenosis (50-69%)

• Non-diagnostic CCTA– Dense coronary calcium

– Other artifact (motion, arrhythmia)

M di l b id• Myocardial bridge

• Anomalous coronary artery

73

Spectrum of CAD


Limitingsymptoms

2° Prevention1° Prevention Catheterization +/- Revasc.

• Men and women

S d A

SPECT: Risk Increases as a Function of Stress Perfusion Abnormality

Data from over 50,000 patients

• Sx and Asx

• Diabetics

• Obese

• Renal Failure

• Arrhythmia

• Elderly

Ris

k*

• Elderly

• Known CAD– MI

– PCI

– CABG

Extent/Severity of Perfusion Defects*Adjusted or unadjusted

Guidelines for Clinical Use of Cardiac Radionuclide Imaging 2003

74

tio C

D5

6

M di l R*

Ischemic on SPECT-MPI Predicts Benefit

Revascularization vs Medical Rx†Adjusted for predictorsof revascularization as well as

log

Haz

ard

Rat

23

4

Medical Rx

Revasc*

*p<0 001

clinical, hx, stress SPECT data

01

% Myocardium Ischemic0 12.5% 25% 32.5% 50%

p<0.001

Hachamovitch, et al. Circulation 2003

dica

l The

rapy

)

1.50

1.75

2.00

1.49

Therapeutic Benefit among Patients with <10% Myo Fixed

n = 11,880FU 8.73.3 yrs

Haz

ard

Rat

io

ascu

lari

zati

on v

s. M

ed

0 50

0.75

1.00

1.25

0.700.80

0.95

1.10

1.28

(Ear

ly R

ev

0.00

0.25

0.50

0 5 10 15 20 25Hachamovitch et al. EHJ 2011

75

Ischemia on MPI Predicts Benefit from Revascularization

• Elderly Circulation 2010• Elderly Circulation 2010

• Prior revascularization EHJ 2011

• Prior MI EHJ 2011

Hachamovitch, et al

Spectrum of CAD





Ischemia Testing


76

ISCHEMIA Trial

International Study of Comparative H l h Eff i i h M di lHealth Effectiveness with Medical

and Invasive Approaches

Study Chair: Judith HochmanP i i l I i D id MPrincipal Investigator: David Maron

Sponsor: NHLBI; Submitted: February 2010

>10% Ischemia*LVEF >35%

Blinded CCTA to

ISCHEMIA Trial

RANDOMIZE

Blinded CCTA to R/0 LM, NCA

• 8,000 stable CAD patients• 3-6 yr. F/U

Cath(Revasc+ OMT)

No Cath(OMT)

• 3-6 yr. F/U*SPECT, PET, echo, CMR

Core lab verification

77

Spectrum of CAD


Mild-Moderate ischemia

(5-10%)**


CTA/CCS

Equivocal/Discordant

Ischemia Testing


CCTA After Inconclusive Stress Testing:To establish added Dx value of CCTA, and

prognostic value for intermediate-term events

Inconclusive or non-diagnostic stress imaging tests (n=199)

CCTA• Obstructive CAD, but not stress test parameters, predictive of MACE•MDs planned ICA in 125 (63.0%), but performed in

l 32 (16%) ft CCTA

No CAD (n=93) No events

CAD18 underwent TVR

Source:Abidov et al. JNC 2009

>2 yr f/uonly 32 (16%) after CCTA

78

Utilization of Two Studies Covered by Medicare

Percent CCTA vs SPECT-MPI

• Overall: ~2.5%

• CSMC: ~5%

Utilization of Two Studies Covered by Medicare

Percent CCTA vs SPECT-MPI

• Overall: ~2.5%

• CSMC: ~5%

Still has not caught on!

79

Coronary CTA is not useful in many settings

CCTA MPICCTA MPI

• High CAC - +

• Renal failure - +

• Prior MI - +

• Arrhythmia +• Arrhythmia - +

• Stents <3 mm - +

• Obese - +

For the Symptomatic Patient, a Calcium Score and a Stress Test Could Be More Useful than a Coronary CT

Angiogram


Intermediate to High (50-100%)

Stress SPECT/PET+CAC

80

Cardiac imaging in the symptomatic patient guides therapy

• Does the patient have ischemia?• Does the patient have ischemia?– Should beta blockers and nitrates be

initiated?

– Should revascularization be considered?

• Are aggressive preventive measures warranted?

Myocardial Perfusion SPECT/PET Role in Guiding Patient Management

Li it tiLimitations• Relative quantitation

– May miss highest risk disease (balanced reduction)

– May underestimate extent of ischemia/CAD

C t d t t l th l i• Cannot detect early atherosclerosis

81

Underestimation of the Extent of CAD by Underestimation of the Extent of CAD by SPECT MPISPECT MPI

Berman et al, Berman et al, J Nucl Cardiol 2007;14:521J Nucl Cardiol 2007;14:521--88

101 consecutive stress MPS pts with LM CAD (50% stenosis)

• TID

Non-perfusion High Risk Variableson SPECT/PET MPI

• TID

• Increased lung uptake

• Increased RV uptake

• Stress-induced wall motion abnormality

• Fall in LVEF >5%

• Reduced EF (<40%)

82

• TID

Non-perfusion High Risk Variableson SPECT/PET MPI

• TID

• Increased lung uptake

• Increased RV uptake

• Stress-induced wall motion abnormality

• Fall in LVEF >5%

• Reduced EF (<40%)

• High CAC Score

CAC score 76 ischemic MPS studies1,119 normal MPS

Distribution of CAC Scores in Patients with Normal MPS and Patients with Ischemic MPS

0

1-9

10-99

100-399

5%

7%

0%

20%

22%

4%

18%

25% 100 399

400-999

> 1000

20%

29%

39%

25%

20%

11%

Berman et al, JACC, 2004

83

EISNER Trial: Conclusions

• CAC scanning led to improved risk factor filprofile

– greater reduction in systolic BP

– LDL cholesterol

– waist circumference

– weightweight

• Degree of risk factor modification increased as CAC score increased

Rozanski, et al: J Am Coll Cardiol 2011

Adding CAC to MPI Changes Therapy

• 760 patients having normal Rb-82 PET/CT

• 48% non-zero CAC

• <50% on statins at baseline

• Changes after CAC• Any medication p<0.001

Bybee et al JNC 2010

• Statin p<0.001

• Suggested OMT

84

RJ 75 F ATA/SOB, DM, no walk adeno

STRESS

REST

RJ 75 F ATA/SOB, DM, no walk adeno

STRESS

REST

REST

CAC 1463 (97th %)

85

FO 60 M ATA/SOB, AF, HF, no walk adeno

STRESS

REST

FO 60 M ATA/SOB, AF, HF, no walk adeno

STRESS

REST

REST

CAC 0

86

Symptomatic Patient with Suspected CAD


• Either CCTA or ischemic testing approaches are supported by data

• Coronary CTA: increasing role likely

• Ischemia testing: established; particularly useful in settings where CCTA likely to be nondiagnostic

• Ischemia testing + CAC when negative could become increasingly common





87


• Asymptomatic Prevention• Symptomatic DiagnosisSymptomatic Diagnosis• Known disease Intervention

– High likelihood/post cath/post MI– CHF/viability– Devices

• Implantable cardiac defibrillater (ICD)• Cardiac Resynchronization therapy (CRT)





88

Rest MIBI/FDG13% mismatch3% match

Increasing Benefit from Revascularization Is

Associated with Increasing Amounts of Myocardial

Hibernation (A Substudy of

182 (of 207) pts (complete data) with LVEF <35%

d i d PET

( ythe PARR-2 Trial )

Effect of Revascularization or Medical Therapy

randomized to PETFU 1 yr for cardiacdeath, MI, or cardiac repeat hospital stay; creat ↓ EF also risk predictors

D’Egidio et al. ACCImg2009;2:1060-8

89





Need to consider revascularization/devices

Noninvasive Imaging in CAD: Known Disease

•Data support stress/viability imaging:• the extent of ischemic myocardium• the extent of dysfunctional but viable myocardium (SPECT, echo, PET, CMR)

• Less data supports the application of coronary CTA in this setting

90





Low


Complementary test may be useful if initial test + clinical evaluation not definitive

91

AGHHAS 61 M #2300-7115

Atypical chest pain

No prior CAD

Risk factors: dyslipidemia, hypertension

ECG: normal

AGHHAS 61 M #2300-7115

Atypical chest pain, dyslipidemia, hypertension

92

AGHHAS 61 M #2300-7115

Atypical chest pain, dyslipidemia, hypertension

CCTA: critical proximal LAD stenosis

Which of the following would be appropriate?


2. Stress ECG


4. Stress echo

.

93

Which of the following would be appropriate?


2. Stress ECG


4. Stress echo

.

AGHHAS 61 M #2300-7115

CATH results

LAD: subtotal occluded

Disposition: stent to LAD

94





Low


Documents

Cardiac CT and Nuclear Cardiology in Stable CAD Director, Cardiac ... · Nuclear Cardiology and Cardiac CT • CT coronary calcium: effective – Class IIa ACC/AHA prevention guidelines