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