Multimodality Imaging in Clinical Decision Making

João V. Vitola, MD, PhDJoão V. Vitola, MD, PhD

Cardiologist and Nuclear Medicine Physician Cardiologist and Nuclear Medicine Physician Quanta Diagnostico NuclearQuanta Diagnostico Nuclear

Curitiba Curitiba -- BrazilBrazil

DISCLOSURESDISCLOSURES

Honorarium Honorarium –– Research and Conferences in Nuclear CardiologyResearch and Conferences in Nuclear Cardiology

BMS, CVT, AstellasBMS, CVT, AstellasInternational Atomic Energy AgencyInternational Atomic Energy Agency

Royalties Royalties –– Publications in Nuclear CardiologyPublications in Nuclear Cardiologyyy gygy

SpringerSpringer--VerlagVerlag--Nuclear Cardiology and Correlative Imaging: a teaching file,Nuclear Cardiology and Correlative Imaging: a teaching file, NY, 2004NY, 2004

Lippincott Williams & Wilkins, Lippincott Williams & Wilkins, -- Nuclear Medicine teaching FileNuclear Medicine teaching File, 2009, 2009

Multiple Presentations of CAD leading Multiple Presentations of CAD leading to Hard Cardiac Eventsto Hard Cardiac Events

•• Obstructive disease: critical lesions, affecting Obstructive disease: critical lesions, affecting vascular reserve, severe ischemia vascular reserve, severe ischemia –– arrythmias arrythmias (specially if LV dysfunction)(specially if LV dysfunction)(specially if LV dysfunction)(specially if LV dysfunction)

Middle Age Women undergoing investigation of suspected CAD in Brazil

Female, 54 yo, Atypical CP, referred for MIBI

3 min after low workload exercise

Ischemia Induced Cardiac ArrestIschemia Induced Cardiac ArrestWould probably be fatal outside hospital/clinic

OUTCOME – Successful CPR Cath (3 V disease)OUTCOME Successful CPR, Cath (3 V disease)Surgical revascularization, ALIVE AND WELL

S dd C di D th i ti t ith CAD d LV DSudden 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 stratification

At age 63 yo - had sudden death while playing tennis.

24 months prior do sudden death

LVEF 25 %EDV 235 ml ESV 176 mlESV 176 ml

Sharir et al., Circulation 1999;100:1035-1042

Perfusion Defects Predict Events

12%E

8

10

EVEN

4

6TS-Y

0

2

NL Fib Isq Fib + Isq

YEAR NL Fib Isq Fib + Isq

JNM 2002;43:767-772

Multiple Presentations of CAD leading Multiple Presentations of CAD leading to Hard Cardiac Eventsto Hard Cardiac Events

•• Obstructive disease: critical lesions, affecting Obstructive disease: critical lesions, affecting vascular reserve, severe ischemia vascular reserve, severe ischemia -- arrythmiasarrythmias,, yy

•• CAD unstable plaquesCAD unstable plaques eventsevents•• CAD unstable plaques CAD unstable plaques -- eventsevents

LAD

73 yo male, typical anginaQCA 39.59 %,

RCA

Vitola J and Delbeke D, Nuclear Cardiology teaching file - Springer Verlag, 2004

StressDiDip

Rest

(ANATOMY VS PHYSIOLOGY)

StressDip

RestRest

Vitola J and Delbeke D, Nuclear Cardiology teaching file - Springer Verlag, 2004

IVUS

3 59 mmAREA LUM 10.1mm2

74 % STENOSIS2.15 mm3.59 mm

IVUS 74%

AREA LUM 3.9mm2

POSITIVE REMODELINGLARGE LIPID CORE

1818FF--FDG as a Marker of InflammationFDG as a Marker of Inflammation•• Autoradiography from samples from carotid endarterectomy confirm FDGAutoradiography from samples from carotid endarterectomy confirm FDGAutoradiography from samples from carotid endarterectomy confirm FDG Autoradiography from samples from carotid endarterectomy confirm FDG

uptake in uptake in macrophagemacrophage--richrich (marked with Ab) areas of the plaque (silver (marked with Ab) areas of the plaque (silver stain).stain).

Rudd JH et al. Circulation 2002;105:2708Rudd JH et al. Circulation 2002;105:2708--2711.2711.

FDG uptake FDG uptake along the along the a o g t ea o g t eaortic wallaortic wall

From Vitola JV et DelbekeFrom Vitola JV et DelbekeFrom Vitola JV et Delbeke From Vitola JV et Delbeke D (eds): Nuclear D (eds): Nuclear Cardiology and Cardiology and Correlative Imaging: A Correlative Imaging: A T hi Fil S iT hi Fil S iTeaching File. Springer Teaching File. Springer 20042004

1818FF--FDG as a Marker of InflammationFDG as a Marker of InflammationStudy of 8 patients with recent carotid territory Study of 8 patients with recent carotid territory transient ischemic attackstransient ischemic attacks

demonstrated that demonstrated that FDG accumulation was 27% higher in symptomaticFDG accumulation was 27% higher in symptomaticlesions than contralateral asymptomatic lesions.lesions than contralateral asymptomatic lesions.

Rudd JH et al. Circulation 2002;105:2708Rudd JH et al. Circulation 2002;105:2708--2711.2711.

Simvastatin attenuates Plaque InflammationSimvastatin attenuates Plaque InflammationEvaluation by FDG PETEvaluation by FDG PETEvaluation by FDG PETEvaluation by FDG PET•• 43 oncology patients with arterial FDG uptake were randomized to 43 oncology patients with arterial FDG uptake were randomized to

receiving 3 months of simvastatin + diet or diet alonereceiving 3 months of simvastatin + diet or diet alonereceiving 3 months of simvastatin + diet or diet alonereceiving 3 months of simvastatin + diet or diet alone

FDG uptake FDG uptake )) hh1)1) Decreases in the Decreases in the

simvastatin simvastatin group but not group but not with diet alonewith diet alonewith diet alonewith diet alone

Tahara N et al. JACC 2006;48 (9):1825Tahara N et al. JACC 2006;48 (9):1825--18311831

1818FF--FDG as a Marker of Inflammation in FDG as a Marker of Inflammation in the Coronary Arteriesthe Coronary Arteriesthe Coronary Arteriesthe Coronary Arteries71 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 LADy g g p yy g g p y p qp qFDG PET/CTA fusion: FDG uptake in plaque SUV 2.1FDG PET/CTA fusion: FDG uptake in plaque SUV 2.1

Tahara N et al. J Nucl Med 2009;50(3):331Tahara N et al. J Nucl Med 2009;50(3):331--334334

Multiple Presentations of CAD leading Multiple Presentations of CAD leading to Hard Cardiac Eventsto Hard Cardiac Events

•• Obstructive disease: critical lesions, affecting Obstructive disease: critical lesions, affecting vascular reserve, severe ischemia vascular reserve, severe ischemia -- arrythmiasarrythmias,, yy

•• CAD unstable plaquesCAD unstable plaques eventsevents•• CAD unstable plaques CAD unstable plaques -- eventsevents

•• CAD without significant lesions CAD without significant lesions –– “Normal “Normal Coronaries by Angiography”Coronaries by Angiography”Coronaries by Angiography Coronaries by Angiography spasm ? endothelial dx ? autonomic dx ?spasm ? endothelial dx ? autonomic dx ?

Elderly female, stressful event, anterior STEMI“ normal ” epicardial vessels

99mTc- MIBI at Rest123 MIBG at Rest

90% are women

Villaroel A, Vitola J, Stier A, Dippe T, Cunha C. Expert Rev. Cardiovasc. Ther., 7 (7) 2009

usual post menopausalWhy ?

Multiple Presentations of CAD leading to Hard Multiple Presentations of CAD leading to Hard Cardiac EventsCardiac EventsCardiac EventsCardiac Events

ROLE OF MULTIMODALITY IMAGING IN 2009ROLE OF MULTIMODALITY IMAGING IN 2009ROLE OF MULTIMODALITY IMAGING IN 2009ROLE OF MULTIMODALITY IMAGING IN 2009

I i h l t b tt d t d CAD d i k tImaging helps to better understand CAD and risk assessment

Define high risk subgroups – who will benefit from revascularisation

Define low risk subgroups – who will benefit from prevention and medical therapy

What information should we be looking forWhat information should we be looking forWhat information should we be looking for What information should we be looking for to change management and result in better to change management and result in better

ti t t i t ff ti ?ti t t i t ff ti ?patient outcome in a cost effective way ?patient outcome in a cost effective way ?

• ANATOMY / ATHEROSCLEROSIS ? • PERFUSION / ISCHEMIA ?PERFUSION / ISCHEMIA ?• LV FUNCTION / LVEF + VOLUMES ?• COMBINATION OF ALL THE ABOVE ?

It depends highly on who is my patientIt depends highly on who is my patient .....

What investment is ideal (Prevention + Detection + Management) ?

Porter ME, Teisberg EO: Redefining Health Care Harvard Business School Press, 2006

IAEA IAEA –– International Atomic Energy Agency International Atomic Energy Agency UN headquarters, Vienna, Austria, 2008UN headquarters, Vienna, Austria, 2008

ParticipantsMaurizio Dondi - IAEA - AustriaFernando Mut- IAEA - Austria

João V. Vitola (Chairman) - Brazil

Adel Allam – EgyptAmalia Peix – Cuba

Annare Ellmann South AfricaAnnare Ellmann – South AfricaBon Nang Lee – Malaysia

C. Siritara - ThailandFelix Keng – Singapore

Gianmario Sambucetti – ItalyGregory Thomas – USA

Kevin Allman – AustraliaLeslee Shaw – USA

Marla Kiess – CanadaPilar Orellana – ChilePilar Orellana Chile

Raffaele Giubbini – SwitzerlandSalaheddine Bouyoucef – Algeria

Zuo – Xiang He – China

Nicol et al, JNC 2008

NON INVASIVE ANATOMYGOOD TO EXCLUDE CAD

CALCIUM SCORE - ATHEROSCLEROSIS

NON INVASIVE PHYSIOLOGYISCHEMIC BURDEN – LV FUNCTION

PROGNOSIS

Strengh of CT – High Negative Predictive Values

STRENGH OF NUCLEAR RISK ASSESSMENT - SEPARATING LOW RISK FROM HIGH RISK

Extent/Severity predicts deathExtent/Severity predicts death

Ris

k*R

Extent/Severity of Perfusion Defects*Adjusted or unadjusted

Source: Klocke et al. J Am Coll Cardiol 2003.

Management based on ischemic burden by NUCLEAR

7

NO Benefit Benefit

5

6

7Conservative

Revasc

3

4

5

MORTALITY(%)

1

2

00% 1-5 % 6-10 % 11-20% >20 %

Hachamovitch R et al, Circulation, 2003

DEFECT SIZE ON SPECT

Post 1 stent LAD0% ischemia

53 yo maleAtypical chest pain

stenting

High Risk > 3%/ year Low Risk < 1%/yearg y y

Habibian R, Delbeke D, Martin W, Sandler M, Vitola JV Cardiovascular Imaging, in Nuclear Medicine Teaching File, 2009

Management based on ischemic burden by NUCLEAR

7

NO Benefit Benefit

5

6

7Conservative

Revasc

3

4

5

MORTALITY(%)

1

2

00% 1-5 % 6-10 % 11-20% >20 %

Hachamovitch R et al, Circulation, 2003

DEFECT SIZE ON SPECT

ECONOMIC IMPLICATIONS OF REVASCULARISATIONWITHOUT SELECTING BASED ON ISCHEMIA

Leslee Shaw et al. JACC 1999;33:661-669

Shaw JACC 1999;33:661-669

Nuclear Cardiology – Underutilized in Many Nations

International Atomic Energy Agency work group in Nuclear Cardiology

HighModerate HighModerate – HighModerateModerate – LowLow

Vitola JV, Shaw L, Allam A et al (JACC, 2009, 53 (10), A289)

Inexistente

What is the utilization of Nuclear Cardiology in India ?

Only about 20 thousand SPECT / year / entire India 100 MPI/mo

Time to Stop and Think About Cardiac CareMultimodality Imaging Utilization in 2009

•• Utilization based on guidelines / Utilization based on guidelines / appropriateness criteria appropriateness criteria –– which which depend on clinical scenario depend on clinical scenario -- who is who is my patient ?my patient ?

•• Consider Cost Consider Cost –– Benefit Benefit –– Literature Literature Data on OutcomesData on Outcomes

•• Wide variation under and over Wide variation under and over utilization of technology utilization of technology –– Information Information essentialessential

•• Radiation exposure is increasing Radiation exposure is increasing ––ALARA, adequate indicationsALARA, adequate indications

•• Essential to rationalize investigation Essential to rationalize investigation and management and management –– cost effective waycost effective way

Thank you – I love Egypt !