Cardiac Imaging: Yesterday, Today and Tomorrow ... Cardiac Imaging: Yesterday, Today and Tomorrow Matthew

  • View
    0

  • Download
    0

Embed Size (px)

Text of Cardiac Imaging: Yesterday, Today and Tomorrow ... Cardiac Imaging: Yesterday, Today and Tomorrow...

  • Cardiac Imaging: Yesterday, Today and Tomorrow

    Matthew J. Budoff, MD, FACC, FAHA Professor of Medicine

    Endowed Chair of Preventive Cardiology Harbor-UCLA Medical Center, Torrance CA

    Conflict of Interest: GE paid consultant

  • YESTERDAY

    • Functional Imaging constituted 95%+ of all work ups for CAD

    • Performance of nuclear, stress echo and ETT were adequate, as intermediate and high risk patients were being tested

    • LOW threshold to send to cardiac catherization

  • Sensitivity and Specificity of Non-invasive Tests for the Diagnosis of CAD*

    Sensitivity and Specificity of Non-invasive Tests for the Diagnosis of CAD*

    Diagnostic Test

    Sensitivity % (range)

    Specificity % (range)

    # Studies # Patients

    TMT 68 77 132 24,027

    Planar MPI 79 (70-94)

    73 (43-97)

    6 510

    SPECT 88 (73-98)

    77 (53-96)

    8 628

    Stress echo 76 (40-100)

    88 (80-95)

    10 1174

    * NEJM Vol. 344, No. 24 June 14, 2001

  • TODAY • More statins, preventive therapies,

    changing prevalence of obstructive disease

    • Less smoking, more diabetes, more women being studied

    • More COURAGE to treat medically

  • Rozanski JACC 2013

  • Rozanski Conclusions

    “CAC scanning, with or without treadmill exercise electrocardiography, could serve as potentially low-cost alternative to more expensive imaging tests for the initial workup of relatively lower-risk diagnostic patients.”

  • DATA TAKEN FROM “THE DAWN OF A NEW ERA - NON-INVASIVE CORONARY IMAGING” R. ERBEL HERZ 1996; 21, 75-77

    DIAGNOSTIC SENSITIVITY

    0% 20% 45% 60% 70% 90%

    INVASIVE MODALITIES

    STRESS ECG $300 STRESS ECHO $900

    PET SCANNING $2200 Coronary Calcium with CT $295

    NON-INVASIVE MODALITIES

    INTRAVASCULAR ULTRASOUND $3,000 CORONARY ANGIOGRAPHY $5,000

    STRESS THALLIUM $1600

    $150

  • The best predictor of a life threatening illness is the early

    manifestation of a life threatening illness

    Sir Geoffrey Rose Cardiac Epidemiologist

    Known for “The Rose Principle”

  • Coronary Artery Scanning

     SEVERE CALCIFICATION

  • Diagnostic accuracy Outcome • Schuijf JD et al. Am Coll Cardiol. 2006;19:2508-

    14.

    • Mollet NR et al. Eur Heart J. 2007;28:1872-8.

    • Dewey M et al. Eur Heart J. 2007;28:2485-90.

    • Ravapati G et al. Am J Cardiol. 2008:101;774-5.

    • Nieman K et al. Heart. 2009;95:1669-75.

    • Pundziute G et al. Coron Artery Dis. 2009;20:281- 7.

    • Øvrehus KA et al. Am J Cardiol. 2010;105:773-9.

    • Maffei E et al. Heart. 2010;96:1973-9.

    • Hamirani YS et al. J Comput Assist Tomogr. 2010;34:645-51.

    • Tandon V et al. Eur Hear J. 2012;33:776-82.

    • Weustink AC et al. Int J Cardiovasc Imaging.

    2012;28:675-84.

    • Min JK et al. Am J Cardiol. 2008;102:672-8.

    • Cheezum MK et al. J Cardiosvasc Comput Tomogr. 2011;5:101-9.

    • Shreibati JB et al. JAMA. 2011;306:2128-36.

    • Tandon V et al. Eur Hear J. 2012;33:776-82.

    • Hachamotvitch R et al. J Am Coll Cardiol. 2012;59:462-74.

    • Min JK et al. J Cardiovasc Comput Tomogr. 2012;6:274-83.

    • Nielsen LH et al. Eur Heart J Cardiovasc Imaging. 2013;14:449-55.

    CTA vs Functional Meta Analysis AHA 2013

  • Diagnostic accuracy - Nielson EHJI 2014

    Sensitivity: CCTA 98% vs. XECG 67%, (p < 0.001)

    Sensitivity: CCTA 99% vs. SPECT 73%, (p = 0.001)

    Specificity: CCTA 82% vs. XECG 46%, (p < 0.001)

    Specificity: CCTA 71 % vs. SPECT 48%, (p = 0.14)

  • Obstructive CAD at Cath: NCDR 2005-2007  376,430 pts without CAD/MI or prior PCI/CABG  Undergoing diagnostic cath to R/O CAD  59% of patients with positive stress tests had no obstructive CAD on

    invasive angio (False positive), 73% with equivocal test result

    Patel MR, Peterson ED, Dai D, Brennan JM, Redberg RF, Anderson HV, Brindis RG, Douglas PS. NEJM. 2010 Mar 11;362(10):886-95

  • SCCT 2015 14

    Non-Invasive Functional Testing Prior to Angiography

    Cury et al, JCCT 2014. Patel et al, Am Heart J 2014.

    CONVERSELY, 70% of all CCTA had obstructive disease, still 30% false positives

    Data from an analysis of more than 385,000 patients at over 1,100 US hospitals PATEL M NCDR AHJ 2014

    45% 44% 45% 45%

    Non-obstructive CADObstructive CAD

    SPECT Stress Echo Exercise Stress Test CMR

  • EVINCI STUDY Circ 2015

  • • So Anatomical Testing is more accurate than Functional Testing

    • What about CV outcomes?

  • CTA vs Functional Meta Analysis Myocardial infarction

    Nielson EHJI 2014

  • SPARC STUDY Hlatky JACC April 2014

    P

  • PROGNOSIS: Exercise Testing vs CTA

    Pontone JACC 2013

    “CTA may be a better diagnostic tool and may play a key role in prognostic stratification”

  • PROMISE NEJM 2015

  • PROMISE TRIAL

  • PROMISE TRIAL Primary Endpoint – Death, MI, and UA

    Coronary CTA: Obstructive CAD >70%

    C-Index: 0.72 (95% CI: 0.68, 0.77) 0.64 (95% CI: 0.59, 0.69) p=0.014

  • Net Reclassification Index (NRI)

    Reclassification is based on the change (continuous) in the estimated risk probability.

    Anatomical Testing Functional Testing

    FRS plus Test Results vs. FRS Alone

    Proportion of Events

    correctly Reclassified

    Proportion of Non-events correctly

    Reclassified

    NRI (95% Bootstrap CI)

    Proportion of Events

    correctly Reclassified

    Proportion of Non-events correctly

    Reclassified NRI (95%

    Bootstrap CI)

    Death/MI/UA 0.18 0.49 0.67 (0.49, 0.86) -0.37 0.76 0.40 (0.24, 0.56)

    CV death/MI/UA 0.32 0.55 0.88 (0.68, 1.00) -0.27 0.76 0.49 (0.31, 0.68)

    CV death/MI 0.41 0.07 0.47 (0.19, 0.74) -0.55 0.75 0.20 (0.02, 0.41)

  • PROMISE

    • Discriminatory ability of coronary CTA was significantly better than functional testing (c- index: 0.73 (95% CI: 0.69, 0.77) vs. 0.64 (95% CI: 0.59, 0.69); p=0.011).

    • Net Reclassification Index: CCTA 0.70 (95%: 0.52, 0.89) and Functional 0.40 (95%: 0.24, 0.56).

    • CCTA provided higher discrimination, reclassification and more robust event prediction

  • SCOT HEART Lancet 2015

    • 4,146 patients (mean age: 57 years, 56% male) who presented with chest pain due to suspected coronary artery disease

    • Changes in diagnosis occurred in 25% of patients receiving CTCA and only 1% of pts receiving standard protocol (P < .001).

    • after 3 years, the proportion of patients with events was reduced by 50% in the CTCA group (~2.5% vs ~1.7%, P = .015).

  • Future of Cardiac Imaging

    • More emphasis on early atherosclerosis and aggressive medical/lifestyle management

    • Less emphasis on obstruction and stenting • Continued decline, probably rapidly, of

    functional testing – concerns of cost, accuracy and radiation

  • So, We can Continue what we are doing….

    CT ANGIOGRAM = LARGE SOFT PLAQUE, INSTITUTE STATIN, ASPIRIN LIFESTYLE….

    Or with CTA We can do better!!

    FUNCTIONAL TEST RESULT = NORMAL STUDY, Reassure patient

  • • Superior test performance –  false negative test results/untreated CAD

    •  coronary events • Better detection of non-obstructive CAD

    • Improved preventive treatment and adherence

    – Longer ‘warranty’ period with fewer repeat tests •  hospitalizations during follow up

    Why is CTA-Superior?Why is CTA-Superior?

  • NICE ALGORITHM

  • Testing and Costs Go Down after implementation of NICE – BMJ

    2015

  • SYMPTOMATIC ALGORITHM

    Low Pretest Probability (0-50%)

    High Pretest Probability

    Intermediate Pretest Probability (50-80%)

  • UK NICE Guidelines 2016

    Where does Stress Nuclear and Stress Echocardiography fit into chest pain evalution in new guidelines?

  • What About FFR-CT?

    FFR 0.94

    FFRCT 0.93

    LAD stenosis 70-90%

    FFRCT Model

  • Per-Patient Diagnostic Performance vs. CT

    Nørgaard et al, JACC 2014: ePub ahead of print; DOI: 10.1016/j.jacc.2013. 11.043

    %

    CT (>50%) FFRCT (≤ 0.80)

    * * *

    *p

  • Platform Study – Douglas et al

    35

  • CONSERVE Trial – ESC 2016

  • CONSERVE RESULTS

  • CONSERVE

  • 0.9 mSv 1.3 mSv 2.0 mSv

    1.2 mSv

    1.3 mSv (interquartile range 0.8-1.9)

    Current CCTA dose is significantly reduced

    Source: Labounty, Leipsic, Earls, Min et al. AJC 2010

    Multicenter study of 449 patients undergoing CCTA after implementation of a standardized image acquisition