The use of Cardiac The use of Cardiac CT and MRI in CT and MRI in

Clinical PracticeClinical PracticeMatthew W. Martinez, MDMatthew W. Martinez, MD

Assistant Professor of MedicineAssistant Professor of Medicine

LVPG - Lehigh Valley Heart LVPG - Lehigh Valley Heart SpecialistsSpecialists

Lehigh Valley Health NetworkLehigh Valley Health Network

Oct. 3, 2009Oct. 3, 2009

DISCLOSUREDISCLOSURERelevant Financial Relationship(s)Relevant Financial Relationship(s)

NoneNone

Off Label UsageOff Label UsageNoneNone

Learning ObjectivesLearning Objectives

Review basics of cardiac MRI and Review basics of cardiac MRI and CTACTA

Review utility of cardiac CT and MRI Review utility of cardiac CT and MRI in clinical practicein clinical practice

Clinical casesClinical cases

EchoEchoSPECTSPECT

PETPET MRIMRI

NoninvasiveNoninvasive Tests for the Tests for the Diagnosis of Coronary Diagnosis of Coronary

Artery DiseaseArtery DiseaseTMETTMET

CTCT

Cardiac MRICardiac MRI

Black-Blood (Spin-Echo) White-Blood

SSFP

Still Images

Morphology

Edema

Cine Imaging

Morphology and function

Delayed Enhancement

Still Images

Delayed Enhancement

SSFP = 2D echo = 2D echo

Delayed Enhancement-Delayed Enhancement-MRIMRI Images obtained 10-15 Images obtained 10-15

minutes post-contrast minutes post-contrast (Gd)(Gd)

Normal myocardium – Normal myocardium – Black *Black *

Necrosis/scarring/Necrosis/scarring/inflammation – inflammation – Hyperenhanced Hyperenhanced

Image in Press – Nature of Clinical Practice

Infarct size by MRI Infarct size by MRI Delayed EnhancementDelayed Enhancement

Abundance of Abundance of validation data in validation data in animal modelsanimal models

Dog with near-Dog with near-transmural infarcttransmural infarct

Visible on SPECT and Visible on SPECT and DE-MRIDE-MRI

3 dogs with 3 dogs with subendocardial subendocardial infarctsinfarcts

Visible on DE-MRI onlyVisible on DE-MRI only

CP1302151-4

Hyperenhancement PatternsHyperenhancement Patterns

Subendocardial infarctSubendocardial infarct

Transmural infarctTransmural infarct

IschemicIschemic

Mid-wall HEMid-wall HE

Epicardial HEEpicardial HE

NonischemicNonischemic

• Idiopathic dilated cardiomyopathy

• Myocarditis

• Idiopathic dilated cardiomyopathy

• Myocarditis

• Hypertrophiccardiomyopathy

• Right ventricularpressure overload

• Hypertrophiccardiomyopathy

• Right ventricularpressure overload

• Sarcoidosis

• Myocarditis

• Anderson–Fabry disease

• Sarcoidosis

• Myocarditis

• Anderson–Fabry disease

Shah DJ et al: Magnetic resonance of myocardial viabilityShah DJ et al: Magnetic resonance of myocardial viability

Mass RV Function

Cardiomyopathies

Cardiac MRICardiac MRI

LVEFLVEF LV massLV mass Wall MotionWall Motion LV ESVLV ESV LV EDVLV EDV LV stroke LV stroke

volumevolume

RV ESVRV ESV RV EDVRV EDV RV Stroke RV Stroke

volumevolume RVEFRVEF

FunctionalFunctional AnalysisAnalysis

Infarct Infarct identificationidentification

Infarct sizeInfarct size ViabilityViability

Tissue Tissue characterizationcharacterization

CP1210291-8

ImagingImaging

Evaluation of Chest PainEvaluation of Chest Pain

Unstable Hemodynamics and Complications

Unstable Hemodynamics and Complications

PrognosisViability

PrognosisViability

FunctionInfarct sizeFunction

Infarct sizeACS

Cardiac MRICardiac MRI

LVEFLVEF LV massLV mass Wall MotionWall Motion LV ESVLV ESV LV EDVLV EDV LV stroke LV stroke

volumevolume

RV ESVRV ESV RV EDVRV EDV RV Stroke RV Stroke

volumevolume RVEFRVEF

FunctionalFunctional AnalysisAnalysis

Infarct Infarct identificationidentification

Infarct sizeInfarct size ViabilityViability PrognosisPrognosis

Tissue Tissue characterizationcharacterization

Case 1Case 157-year-old woman57-year-old woman

Sudden onset of Sudden onset of achy, continuous, achy, continuous, substernal, 8/10 substernal, 8/10 chest painchest pain

Radiating to backRadiating to back Pain came on at Pain came on at

restrest

Cardiac Risk Cardiac Risk FactorsFactors

Never SmokerNever Smoker Hyperlipidemia Hyperlipidemia

(untreated)(untreated) Sedentery LifestyleSedentery Lifestyle

Troponin – 0.56, 0.5 (3h), 0.36 (6h)

EchocardiogramEchocardiogram

Cardiac CatheterizationCardiac Catheterization

Cardiac CatheterizationCardiac Catheterization

Cardiac MRICardiac MRI

Cardiac MRICardiac MRI

Acute MI

Importance of Importance of unrecognized Myocardial unrecognized Myocardial

scarscar Aim: Assess the prognostic Aim: Assess the prognostic

significance of unrecognized significance of unrecognized myocardial scar by MRI in patients myocardial scar by MRI in patients without a history of MIwithout a history of MI

195 patients without known prior 195 patients without known prior MIMI

1) Pts with unknown status of CAD 1) Pts with unknown status of CAD referred for assessment of LV fxn, referred for assessment of LV fxn, scarscar

2) Pts with angiographic CAD 2) Pts with angiographic CAD referred for prediction of referred for prediction of segmental wall motion after segmental wall motion after revascularization (22)revascularization (22)

16 month follow-up16 month follow-upCirculation,

2006

Case Presentation 2Case Presentation 2 History of Present IllnessHistory of Present Illness

46 year old man presents to ED, 6:30 AM with 46 year old man presents to ED, 6:30 AM with 10/10 chest pain10/10 chest pain Began 4:30 AM - Radiated to left armBegan 4:30 AM - Radiated to left arm No SOB, no n/vNo SOB, no n/v Feeling ill with episodic CP over past 2 weeksFeeling ill with episodic CP over past 2 weeks

Past Medical HistoryPast Medical History Hyperlipidemia at Hyperlipidemia at

health fairhealth fair

MedicationsMedications nonenone

Social HistorySocial History 30 pack year history, 30 pack year history,

currently smokes 1 currently smokes 1 pack/weekpack/week

Initial ECGInitial ECG

Angiography ResultsAngiography Results

Troponin Elevation:Troponin Elevation:Baseline 0.44 3 hr 0.48 6 hr 0.49Baseline 0.44 3 hr 0.48 6 hr 0.49

Cardiac MRICardiac MRI

Delayed EnhancementDelayed Enhancement

Myocarditis

Etiologies of Elevations of Etiologies of Elevations of Cardiac TroponinsCardiac Troponins

Plaque rupture Plaque rupture mediated necrosismediated necrosis STEMISTEMI nSTEMInSTEMI

Alterations in Alterations in coronary vasomotor coronary vasomotor tonetone Coronary spasmCoronary spasm Subarachnoid Subarachnoid

hemorrhagehemorrhage Intracranial Intracranial

hemorrhagehemorrhage Apical Ballooning Apical Ballooning

SyndromeSyndrome Transplant Transplant

vasculopathyvasculopathy

Sub-endocardial Sub-endocardial myocyte necrosismyocyte necrosis CHFCHF Hypertensive crisisHypertensive crisis Acute pulmonary Acute pulmonary

embolismembolism Tachycardia-mediated – Tachycardia-mediated –

CHF, Pressure overload CHF, Pressure overload Volume-Pressure overload Volume-Pressure overload

(renal failure, CHF, (renal failure, CHF, fluid fluid resuscitation)resuscitation)

AnemiaAnemia HypotensionHypotension Aortic Stenosis and / or Aortic Stenosis and / or

RegurgitationRegurgitation Hypertrophic Hypertrophic

CardiomyopathyCardiomyopathy Amyloid heart diseaseAmyloid heart disease

Problem Solving ToolProblem Solving Tool Troponin is extremely sensitive for Troponin is extremely sensitive for

detecting myocardial cell necrosisdetecting myocardial cell necrosis

9-14% of patients who present with ACS 9-14% of patients who present with ACS will have normal or non-significant disease will have normal or non-significant disease on coronary angiographyon coronary angiography

This cohort of patients have been shown to This cohort of patients have been shown to have a poorer prognosis; potentially from have a poorer prognosis; potentially from clinical uncertaintyclinical uncertainty (TACTICS-TIMI-18)(TACTICS-TIMI-18)

Development of CTDevelopment of CTDevelopment of CTDevelopment of CT

2000 2010 2015

DSCTDSCT128-slice128-slice

20092009

MDCTMDCT320-slice320-slice

20082008

MDCTMDCT4-slice4-slice

19981998

MDCTMDCT16-slice16-slice

20022002

MDCTMDCT40-slice40-slice

20052005

DSCTDSCT64-slice64-slice

20062006

MDCTMDCT8-slice8-slice

20012001

MDCTMDCT64-slice64-slice

20042004

CT ScanningMinimallyInvasive

Angiography

Nuclear Cardiac ImagingNuclear Cardiac ImagingDiagnostic AccuracyDiagnostic Accuracy

Imaging Imaging ModalityModality

# of # of StudieStudie

ssPatientPatient

ss Sen. (%)Sen. (%)Spec. Spec. (%)(%)

AccuracAccuracyy

SPECT 99mTc* > 45> 45 ~7,000~7,000 83-8683-86 73-7573-75 83-86%83-86%

CTA* >20>20 ~2,000~2,000 83-9483-94 77-9277-92 89-9289-92

“GOLD” Standard - Angiography

MDCT in Clinical MDCT in Clinical PracticePractice

A Clinician’s ViewpointA Clinician’s Viewpoint

Gold StandardGold Standard Anomalous coronary vesselsAnomalous coronary vessels Coronary fistula, aneurysmsCoronary fistula, aneurysms

Coronary DiseaseCoronary Disease Great for ruling out CADGreat for ruling out CAD OK (but not great) for disease severityOK (but not great) for disease severity

High High ProbabilityProbability

Intermediate Intermediate ProbabilityProbability

Low Low ProbabilityProbability

• Typical chest painTypical chest pain

• ECG changes & cardiac enzyme elevationECG changes & cardiac enzyme elevation

• Personal history of CADPersonal history of CAD

““Definite” signs of CAD:Definite” signs of CAD:

Patient PopulationPatient Population

High High ProbabilityProbability

Intermediate Intermediate ProbabilityProbability

Low Low ProbabilityProbability

• Atypical chest painAtypical chest pain

• Discordant symptoms & stress test resultsDiscordant symptoms & stress test results

High risk factors & negative stress testHigh risk factors & negative stress test

Low risk factors & positive stress testLow risk factors & positive stress test

• Patient reluctant to have a cathPatient reluctant to have a cath

““Indeterminate” signs of CAD:Indeterminate” signs of CAD:

Patient PopulationPatient Population

High High ProbabilityProbability

Intermediate Intermediate ProbabilityProbability

Low Low ProbabilityProbability

Patient PopulationPatient Population

CTACTA

High High ProbabilityProbability

Intermediate Intermediate ProbabilityProbability

Low Low ProbabilityProbability

• “ “Worried well”Worried well”

““Doubtful” signs of CAD:Doubtful” signs of CAD:

Patient PopulationPatient Population

High High ProbabilityProbability

Intermediate Intermediate ProbabilityProbability

Low Low ProbabilityProbability

Patient PopulationPatient Population

? CTA ?? CTA ?

High High ProbabilityProbability

Intermediate Intermediate ProbabilityProbability

Low Low ProbabilityProbability

Patient PopulationPatient Population

? CTA ?? CTA ?CTACTA

HistoryHistory 49yr female previously healthy 49yr female previously healthy 6+ months of dyspnea on exertion 6+ months of dyspnea on exertion No personal history of No personal history of

hyperlipidemia, HTN, CAD, smoking, hyperlipidemia, HTN, CAD, smoking, and family history and family history

Currently on no cardiac medicationsCurrently on no cardiac medications BMI = 36.BMI = 36.

HistoryHistory

Exercise Time: 7.3 minutesExercise Time: 7.3 minutes Test was stopped due to dyspnea and leg Test was stopped due to dyspnea and leg

fatiguefatigue 32,736 (SBP x HR)32,736 (SBP x HR) Stress Echo with an area of anterior ischemia Stress Echo with an area of anterior ischemia

was noted from mid to the basewas noted from mid to the base ECG was negativeECG was negative

Appropriateness for CTAppropriateness for CT

References supporting the use of References supporting the use of coronary CTA following equivocal coronary CTA following equivocal

exercise sestamibiexercise sestamibi Schuijf, J., et. al, “Relationship between Noninvasive Coronary Schuijf, J., et. al, “Relationship between Noninvasive Coronary

Angiography with Multi-slice Computed Tomography and Angiography with Multi-slice Computed Tomography and Myocardial Perfusion Imaging” Myocardial Perfusion Imaging” Journal of the American College of Journal of the American College of CardiologyCardiology; December 19, 2006.; December 19, 2006.

Rubinstein, R., et. al, “Usefulness of 64-slice multidetector Rubinstein, R., et. al, “Usefulness of 64-slice multidetector computed tomography in diagnostic triage of patients with chest computed tomography in diagnostic triage of patients with chest pain and negative or nondiagnostic exercise stress test result” pain and negative or nondiagnostic exercise stress test result” American Journal of CardiologyAmerican Journal of Cardiology 2007; 99: 925-929. 2007; 99: 925-929.

Danciu, S., et. al, “Usefulness of multislice computed tomography Danciu, S., et. al, “Usefulness of multislice computed tomography coronary angiography to identify patients with abnormal myocardial coronary angiography to identify patients with abnormal myocardial perfusion stress in whom diagnostic catheterization could be perfusion stress in whom diagnostic catheterization could be avoided” avoided” American Journal of CardiologyAmerican Journal of Cardiology 2007; 100: 1605-1608. 2007; 100: 1605-1608.

Dewey, M., et. al, “Head-to-head comparison of multislice computed Dewey, M., et. al, “Head-to-head comparison of multislice computed tomography and exercise electrocardiography for diagnosis of tomography and exercise electrocardiography for diagnosis of coronary artery disease” coronary artery disease” European Heart JournalEuropean Heart Journal 2007; 28: 2485- 2007; 28: 2485-2490.2490.

55 y/o womanSubsternal chest discomfort 2 mosEmotion and sometimes exertion

Today 10 min chest and back pain at rest ED

PostmenopausalPrior smoker >15 yrs ago

No FHNo medsMild HTN

Case 2 –chest painCase 2 –chest pain

Exam: no murmurBP 142/88

Troponin: <.01Creat: 0.8

Acute chest painWhat do you want to know?

ProbabilityCAD

Risk of acute event

Low/inter

High Angio

LowIntermediate

What to Do?What to Do?Sestamibi

Stress Echo

Coronary CTA

CTA vs Standard of Care CTA vs Standard of Care in Chest Painin Chest Pain

Goldstein JACC 2007 49:863-71

Chest painLow risk197 pts

Standard care

Normal Nondiag Severe

MSCT

Stress Nucs

Stress Nucs

HOME HOMEAngio

Goldstein JACC 2007 49:863-71

CTA – 67% normal and discharged9% severe CAD cath24% needed further eval

Length of stay: lowered by 43%12.5 hrs vs 22.1 hrs

Cost of care: lowered by 15%$1586 vs $1872

ConclusionsConclusions

Cardiac MRI Cardiac MRI EF, ESV, EDV, RV function, infarct EF, ESV, EDV, RV function, infarct

sizesize ICM vs DCMICM vs DCM ACSACS

Cardiac CTCardiac CT Excellent for exclusion of CAD in low to Excellent for exclusion of CAD in low to

intermediate riskintermediate risk ED patients, “equivocal stress test”ED patients, “equivocal stress test”

THANK YOU!THANK YOU!