EvidenceEvidence--based Nuclear Cardiology:based Nuclear Cardiology:Imaging of CADImaging of CAD

The ESC documentThe ESC document

Technical Meeting on:Technical Meeting on:““Current Role of Nuclear Cardiology in the Current Role of Nuclear Cardiology in the

Management of Cardiac DiseasesManagement of Cardiac Diseases””Vienna, 5Vienna, 5--9 May 20089 May 2008

Vienna International CentreVienna International Centre

�� Diagnosis of obstructive CAD in pts. with intermediate preDiagnosis of obstructive CAD in pts. with intermediate pre--test probability:test probability:•• Sensitivity = 87%Sensitivity = 87%•• Specificity = 73% (referraSpecificity = 73% (referral bias)l bias)•• Specificity using Normalcy Rate = 91%Specificity using Normalcy Rate = 91%Evidence: Evidence: Class I, Level BClass I, Level B Issuing body: ESC, ACC/AHAIssuing body: ESC, ACC/AHA

�� Additional comments:Additional comments:•• Gated SPECTGated SPECT•• Attenuation correctionAttenuation correction•• Scatter correctionScatter correction

……increase the accuracy of MPSincrease the accuracy of MPS

�� MPS as primary diagnostic test:MPS as primary diagnostic test:•• Women with diabetesWomen with diabetes•• Anticipated poor exercise performanceAnticipated poor exercise performance•• Inability to exerciseInability to exercise•• Abnormal resting ECGAbnormal resting ECG�� MPS as secondary diagnostic test:MPS as secondary diagnostic test:

•• Women (alternative)Women (alternative)•• NonNon--diagnostic ECGdiagnostic ECG•• Unexpected ECG resultsUnexpected ECG results•• Intermediate Duke Treadmill ScoreIntermediate Duke Treadmill Score

Recommendations for MPS in patients with suspected or knownCAD according to current clinical guidelines Recommendations for MPS in patients with suspected or knownRecommendations for MPS in patients with suspected or knownCAD according to current clinical guidelines CAD according to current clinical guidelines

Clinical scenario Recommendation Issuing bodyClinical scenario Recommendation Issuing body Class LevelClass Level

Chronic chest painChronic chest pain Diagnosis of CAD in pts. Diagnosis of CAD in pts. w. intermediate prew. intermediate pre--testtestlikelihood:likelihood:Unable to exercise Unable to exercise ESC I B ESC I B Abnormal resting ECG Abnormal resting ECG ACC/AHA I BACC/AHA I B

Identification of targetIdentification of targetcoronary lesions coronary lesions ESC ACC/AHA I BESC ACC/AHA I BAssessment Assessment hemodynamichemodynamicsignificance of knownsignificance of knowncoronary lesions coronary lesions ESC ACC/AHA I BESC ACC/AHA I BEvaluation post PCI/CABG Evaluation post PCI/CABG ESC ACC/AHA I B ESC ACC/AHA I B

Recommendations for MPS in patients with suspected or knownCAD according to current clinical guidelines Recommendations for MPS in patients with suspected or knownRecommendations for MPS in patients with suspected or knownCAD according to current clinical guidelines CAD according to current clinical guidelines

Clinical scenario Recommendation Issuing bodyClinical scenario Recommendation Issuing body Class LevelClass Level

Acute chest pain Acute chest pain Detection resting ischemia ESC ACC/AHA Detection resting ischemia ESC ACC/AHA IIbIIb IIaIIa BBDetection resting ischemiaDetection resting ischemiain low/intermediate risk in low/intermediate risk pts. after UA/NSTEMI pts. after UA/NSTEMI ESC ACC/AHA I B ESC ACC/AHA I B Detection ischemia in pts.Detection ischemia in pts.w. uncertain diagnosis w. uncertain diagnosis ESC ACC/AHA I AESC ACC/AHA I AAssessment of infarct sizeAssessment of infarct sizeand myocardium at riskand myocardium at riskafter STEMI after STEMI ESC ACC/AHA I BESC ACC/AHA I B

Recommendations for MPS in patients with suspected or knownCAD according to current clinical guidelines Recommendations for MPS in patients with suspected or knownRecommendations for MPS in patients with suspected or knownCAD according to current clinical guidelines CAD according to current clinical guidelines

Clinical scenario Recommendation Issuing bodyClinical scenario Recommendation Issuing body Class LevelClass Level

PrePre--operative operative Risk stratification before Risk stratification before risk assessmentrisk assessment elective nonelective non--cardiac surgery ACC/AHA I Ccardiac surgery ACC/AHA I C

Heart failureHeart failure Detection of ischemia andDetection of ischemia andviability assessment viability assessment ACC/AHA ACC/AHA IIaIIa BB

ESC study group ESC study group report report

Diagnosis of CAD Diagnosis of CAD ACC/AHA ACC/AHA IIbIIb CC

�� Normal MPS in pts. with Normal MPS in pts. with interminterm./high likelihood of CAD predicts very ./high likelihood of CAD predicts very low event ratelow event rate ((≤≤1%/yr), yielding 1%/yr), yielding NPVNPV≥≥99%.99%.�� Even in pts. with risk factors, Even in pts. with risk factors, low event rate extend for low event rate extend for ≥≥2 yrs.2 yrs.�� Abnormal MPS in pts. with Abnormal MPS in pts. with interminterm./high likelihood of CAD ./high likelihood of CAD increasesincreases

annualized event rate x7annualized event rate x7, with risk 3, with risk 3--7% according to severity of defects.7% according to severity of defects.�� LVEF postLVEF post--stress or stress or EDV EDV ≥≥70 ml70 ml indicate adverse outcome indicate adverse outcome even ifeven if

perfusion is normal or nearperfusion is normal or near--normal.normal.�� Gated SPECT provides Gated SPECT provides additional prognostic infoadditional prognostic info over clinical, ECG andover clinical, ECG and

CA data, for the general population, following ACS, and afteCA data, for the general population, following ACS, and after revasc.r revasc.�� Markers of Markers of LV dysfunctionLV dysfunction are more predictive of are more predictive of deathdeath, markers of, markers of

ischemiaischemia are more predictive of are more predictive of nonnon--fatal cardiac eventsfatal cardiac events (angina, IM). (angina, IM).

�� Resting MPS to exclude ACS in pts. with chest pain and nonResting MPS to exclude ACS in pts. with chest pain and non--diagdiag. ECG. . ECG. Evidence: Evidence: Class II aClass II a--b, Level Bb, Level B Issuing body: ESC, ACC/AHAIssuing body: ESC, ACC/AHA�� Risk stratification in pts. with otherwise low/Risk stratification in pts. with otherwise low/interminterm. risk after UA/NSTEMI. risk after UA/NSTEMI

Evidence: Evidence: Class I, Level BClass I, Level B Issuing body: ESC, ACC/AHAIssuing body: ESC, ACC/AHA�� Selectively in pts. unable to exercise, inconclusive stress ECGSelectively in pts. unable to exercise, inconclusive stress ECG, women., women.

Evidence: Evidence: Class I, Level AClass I, Level A Issuing body: ESC, ACC/AHAIssuing body: ESC, ACC/AHA�� Assessment of infarct size and Assessment of infarct size and myocmyoc. at risk after uncomplicated STEMI:. at risk after uncomplicated STEMI:

•• STEMI with STEMI with thrombolyticthrombolytic therapy, before CA.therapy, before CA.•• STEMI with preserved LV function, STEMI with preserved LV function, uninterpretableuninterpretable ECG.ECG.

Evidence: Evidence: Class I, Level BClass I, Level B Issuing body: ESC, ACC/AHAIssuing body: ESC, ACC/AHA

�� Risk stratification before elective nonRisk stratification before elective non--cardiac surgery:cardiac surgery:•• Intermediate clinical predictors of cardiac risk + poor ex. tolIntermediate clinical predictors of cardiac risk + poor ex. toleranceerance•• Intermediate clinical predictors + high surgical riskIntermediate clinical predictors + high surgical risk•• High surgical risk + poor ex. tolerance regardless of clinical High surgical risk + poor ex. tolerance regardless of clinical predictorspredictorsEvidence: Evidence: Class I, Level CClass I, Level C Issuing body: ACC/AHAIssuing body: ACC/AHA

�� Additional comments:Additional comments:•• Information derived from MPS should also be used forInformation derived from MPS should also be used forsubsequent cardiac management of patients after surgery.subsequent cardiac management of patients after surgery.

�� Assessment of viability in the initial evaluation of pts. with Assessment of viability in the initial evaluation of pts. with heart failure,heart failure,known CAD, and no angina.known CAD, and no angina.Evidence: Evidence: Class Class IIaIIa, Level B, Level B Issuing body: ACC/AHAIssuing body: ACC/AHA�� Diagnosis of CAD in pts. with symptomatic LV dysfunction.Diagnosis of CAD in pts. with symptomatic LV dysfunction.

Evidence: Evidence: Class Class IIbIIb, Level C, Level C Issuing body: ACC/AHAIssuing body: ACC/AHA

�� Additional comments:Additional comments:•• Dysfunctional, viable myocardium associated with poor prognosisDysfunctional, viable myocardium associated with poor prognosis..•• This can be reversed with appropriate intervention (revasculariThis can be reversed with appropriate intervention (revascularization).zation).•• European guidelines for chronic heart failure do not address thEuropean guidelines for chronic heart failure do not address the issuee issuebut ESC has made recommendations.but ESC has made recommendations.

�� In pts. with stable angina and intermediate preIn pts. with stable angina and intermediate pre--test prob. of CAD, test prob. of CAD, MPSMPSis more costis more cost--effective than effective than sECGsECG and CA.and CA.�� MPSMPS--led management results in led management results in 2323--41% cost savings41% cost savings compared withcompared with

direct CA.direct CA.�� Normal Normal sECGsECG does not preventdoes not prevent additional diagnostic testing.additional diagnostic testing.�� Normal MPS is a Normal MPS is a strong deterrentstrong deterrent of additional investigations.of additional investigations.�� In pts. with known CAD, MPS leads to In pts. with known CAD, MPS leads to significant savingssignificant savings by limitingby limiting

costly procedures to those with highcostly procedures to those with high--risk scans.risk scans.�� Greatest costGreatest cost--effectiveness in womeneffectiveness in women, resulting in reduction of normal , resulting in reduction of normal

CA and increase in the detection of CA and increase in the detection of multivesselmultivessel disease.disease.

�� MPS has a MPS has a high NP accuracyhigh NP accuracy for ruling out ACS and future cardiac eventsfor ruling out ACS and future cardiac eventsin pts. with chest pain, nonin pts. with chest pain, non--diagnostic ECG and negative enzymes.diagnostic ECG and negative enzymes.�� MPS can MPS can reduce costsreduce costs by avoiding unnecessary admissions withoutby avoiding unnecessary admissions without

compromising patient outcome.compromising patient outcome.�� MPSMPS--guided chest pain workguided chest pain work--up up decreases the rate of hospitalization.decreases the rate of hospitalization.�� MPS MPS influence triage decisionsinfluence triage decisions and lower the threshold for earlyand lower the threshold for early

discharge of pts. with lowdischarge of pts. with low--risk scans.risk scans.�� MPS may be particularly costMPS may be particularly cost--effective in special subgroups like effective in special subgroups like diabetics.diabetics.

�� Effective doses of different diagnostic procedures:Effective doses of different diagnostic procedures:•• 11--day MPS (day MPS (99m99mTc, 1600Tc, 1600--2000 2000 MBqMBq, 43, 43--54 54 mCimCi) = ) = 1212--20 20 mSvmSv..•• 22--day MPS (day MPS (99m99mTc, 1200Tc, 1200--1800 1800 MBqMBq, 32, 32--48 48 mCimCi) = ) = 4.54.5--9 9 mSvmSv..•• StressStress--redistredist. (. (201201Tl, 74Tl, 74--111 111 MBqMBq, 2, 2--3 3 mCimCi) = ) = 12.912.9--19.5 19.5 mSvmSv..•• StressStress--redist.redist.--reinjreinj. (. (201201Tl, + 37 Tl, + 37 MBqMBq, 1 , 1 mCimCi) = ) = + 6.5 + 6.5 mSvmSv..•• Catheterization coronary angiography = Catheterization coronary angiography = 22--6 6 mSvmSv..•• MultiMulti--slice CT angiography = slice CT angiography = 66--15 15 mSvmSv..�� Comments:Comments:

•• Additional lifetime risk of fatal cancer: Additional lifetime risk of fatal cancer: 0.04% / 0.04% / SvSv in young/middle aged.in young/middle aged.•• In elderly pts. risk is balanced by delay in event vs. life expIn elderly pts. risk is balanced by delay in event vs. life expectancy.ectancy.

Br J Br J CardiolCardiol 20072007

�� Complication rates of stress tests (death, IM, sustained VT):Complication rates of stress tests (death, IM, sustained VT):•• Dynamic exercise = 1.2 / 10,000.Dynamic exercise = 1.2 / 10,000.•• DypiridamoleDypiridamole = 3.5 / 10,000.= 3.5 / 10,000.•• DobutamineDobutamine = 29.8 / 10,000.= 29.8 / 10,000.

�� Comments:Comments:•• For For dypiridamoledypiridamole, complication rate is low even shortly after an, complication rate is low even shortly after anuncomplicated MI (<3 days).uncomplicated MI (<3 days).

�� MPS has MPS has proven a safe and highly costproven a safe and highly cost--effectiveeffective strategy for thestrategy for theearly detection of obstructive CAD in symptomatic individualearly detection of obstructive CAD in symptomatic individuals.s.�� It is powerful to It is powerful to stratify patientsstratify patients according to their risk of cardiacaccording to their risk of cardiac

death or nonfatal MI.death or nonfatal MI.�� It assists It assists clinical decisionclinical decision--makingmaking with regard to medical treatmentwith regard to medical treatment

or intervention.or intervention.�� MPS is successfully integrated in several MPS is successfully integrated in several guidelines for clinicalguidelines for clinical

practicepractice in cardiology.in cardiology.

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Rate of utilization of MPS in 2003 (studies/1000)Rate of utilization of MPS in 2003 (studies/1000)

Sources: NICE, 2003 Sources: NICE, 2003 –– Amersham Health, 2003 Amersham Health, 2003 –– SUBIMN, 2003SUBIMN, 2003

0.80.83.03.0 3.03.02.82.81.91.9 2.42.4

7.87.8

20.320.3

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Sources: NICE, 2003 Sources: NICE, 2003 –– Amersham Health, 2003 Amersham Health, 2003 –– SUBIMN, 2003SUBIMN, 2003

Growth of MPS utilization between 1998Growth of MPS utilization between 1998--20022002

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5.15.1

16.916.9 18.618.615.815.8

11.011.014.214.2

26.726.7

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8080

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MPS vs. stress EchocardiographyMPS vs. stress Echocardiography

MPSMPSMPS

DipiDipi DipiDipiDipiDipi DobuDobuDobuDobu DobuDobuExerExer ExerExer ExerExer

SensitivitySensitivity SpecificitySpecificity AccuracyAccuracy

ECHOECHOECHO

HeadHead--toto--head comparison head comparison –– 23 studies 23 studies –– 1,421 pts. in total.1,421 pts. in total.

8787

6868

8888 8585 8282 76769090 9191

777789898585 8888 8383

73738181 8484 8383 8181

00

2020

4040

6060

8080

100100

MPS vs. stress EchocardiographyMPS vs. stress Echocardiography

MPSMPSMPS

DipiDipi DipiDipiDipiDipi DobuDobuDobuDobu DobuDobuExerExer ExerExer ExerExer

SensitivitySensitivity SpecificitySpecificity AccuracyAccuracy

ECHOECHOECHO

HeadHead--to head comparison to head comparison –– 23 studies 23 studies –– 1,421 pts. in total.1,421 pts. in total.

8787

6868

8888 8585 8282 76769090 9191

777789898585 8888 8383

73738181 8484 8383 8181

General situation and trends of MPSGeneral situation and trends of MPS

•• The technique is The technique is growing in all countriesgrowing in all countries, at different pace., at different pace.•• Still Still underutilizedunderutilized as compared to the USA.as compared to the USA.•• SPECT is the ruleSPECT is the rule, planar imaging almost disappearing., planar imaging almost disappearing.•• PharmacologicPharmacologic stressstress is increasing.is increasing.•• Attenuation correctionAttenuation correction rarely applied.rarely applied.•• Gated SPECTGated SPECT increasing but still less than desired. increasing but still less than desired.

Thank you