aprilia, 13 ottobre 2012

Diagnostica nella

cardiopatia ischemica:

confronto tra scintigrafia e ecostress

Francesco Nudi e Marco Giovagnoni

Aprilia, 13 ottobre 2012

Nuclear Cardiology and Molecular Imaging

Myocardial Perfusion

Myocardial Viability

Ventricular Function and Remodeling

Neurotransmission Integrity

Mechanical Dyssynchrony

High-Speed Myocardial Perfusion Imaging:

Dawn of a New Era in Nuclear Cardiology?

energy

resolution

count

sensitivities

spatial

resolution

Anger cameras 9-10% 0.5-0.7 Kcps 9-11 mm

CZT cameras

5.7% 2.2-4.7 Kcps 4.3-4.9 mm

HIGHER IMAGE CONTRAST

FEWER SCATTERED GAMMA RAYS

DUAL ISOTOPE IMAGING

ACQUISITION TIME <3 MINUTES

SIGNIFICANT DOSE REDUCTION (<3 mSv)

REDUCED MOTION ARTIFACTS

FIRST PASS STUDIES

CORONARY FLOW RESERVE

MULTIVESSEL DISEASE

MYOCARDIAL MASS

RV INFARCTION

MORE ACCURATE EF

HYBRID SPECT/CT

Bonow RO (JACC 2008)

Stress Thallium-201/Rest Technetium-99m

Sequential Dual Isotope High-Speed Myocardial Perfusion Imaging

Berman et al. (JACC Img 2009;2:273– 82)

SPECT Imaging

Risk Assessment Using SPECT Imaging

Spatial Resolution

Assessment of the Functional Severity of Coronary-artery Stenoses

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1V 2V 3V

MPS NEG

MPS POS

n. of vessels

Nudi F et al, personal data on file

EXCLUSION CRITERIA:

EDV>130

Previous RT

SM-Coro > 12 months

Stenosis < 70%

(269) (188) (150) (20) (4) (3)

Myo

ca

rdia

l P

erf

us

ion

Sc

inti

gra

ph

y

Treadmill Exercise Produces Larger Perfusion Defects Than

Dipyridamole Stress N-13 Ammonia PET

Chow B.J.W. et al., JACC 2006

2008

Pre-Percutaneous Coronary Intervention

2009

Post-Percutaneous Coronary Intervention


0%

10%

20%

30%

40%

50%

60%

MPS POS

ET NEG

ET NV

ET POS

4548

1823

2609


n = 8980

EXCLUSION CRITERIA

Previous MI

Previous RT

Kajander S, et al. (Circulation. 2010;122:603-613)

Cardiac Positron Emission Tomography/Computed Tomography Imaging Accurately

Detects Anatomically and Functionally Significant Coronary Artery Disease


A 69-year-old man with attacks of atypical anginal

pain. A, CT showed significant LAD and RCA

stenoses with only mild stenosis in the LCx.

B, Hybrid images with normal stress PET perfusion

(absolute scale, 0 to 3.5 mL g-1 min-1). Normal

perfusion is >2.5 mL g-1 min-1 (yellow or red). C, ICA

with quantitative analysis and FFR.

Despite anatomically significant narrowing of the

LAD and borderline changes in the RCA, FFR was

normal in both vessels, indicating functionally

nonsignificant disease.




A 57-year-old man with atypical chest pain

during exertion. A, CT reconstructions show

significant stenoses in the LAD, RCA, and a

small intermediate branch (IM). LCx was

nonstenosed. Yellow dotted line denotes motion

artifacts in the RCA. B, Hybrid volumerendered

image. Stress myocardial perfusion was reduced

only in the area supplied by the LAD. C, ICA with

quantitative analysis showed significant 73%

luminal narrowing in the LAD. Other vessels

were not stenosed.




A 63-year-old man with positive family history. Good performance, atypical chest pain,

and 2-mm ST depression in the ECG at the exercise test. In hybrid images, stress

myocardial perfusion was reduced in most regions (green and blue). However, both CT

and ICA showed normal coronary arteries, indicating possible microvascular disease.



Stress/rest myocardial perfusion scintigraphy in patients without

significant coronary artery disease

Adamu U et al. (J Nucl Cardiol 2009)

Death rate

MACE rate

Glenn N. Levine et al - L. David Hillis et al (JACC Vol. 58, No. 24, 2011 - December 6, 2011:000–00)

2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention

2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery

“…>20% perfusion defect by myocardial

perfusion stress imaging”

“…when viable myocardium is present in

the region of intended revascularization”

Guidelines on myocardial revascularization

Wijns W et al. (European Heart Journal (2010) 31, 2501–2555)

Hachamovitch R, et al. (J Am Coll Cardiol 2012;59:462–74)

“A noninvasive procedure, the results of which have no impact on subsequent management,

must be considered an inappropriate study; the current study suggests that a significant

amount of inappropriate noninvasive procedures are currently performed” (…)

PATIENT MANAGEMENT AFTER NONINVASIVE CARDIAC IMAGING

Results From SPARC (Study of Myocardial Perfusion and Coronary Anatomy

Imaging Roles in Coronary Artery Disease)

MSCT Normal

90%

10%

MSCT Versus MPI in an Intermediate Likelihood of CAD

MSCT Obstructively diseased

50%50%

MPI Normal

MPI Abnormal

Schuijf et al. (JACC 2006;48:2508 –14)

J. M. van Werkhoven (Heart 2010 96: 425-431)

Combined non-invasive anatomical and functional assessment with MSCT

and MRI for the detection of significant coronary artery disease in patients

with an intermediate pre-test likelihood

89% 11% CFVR 1.7

13% 87% CFVR < 1.7

Neg Tl-201 Pos Tl-201

r = 88%

Intracoronary Doppler Assessment of Moderate Coronary

Artery Disease

Heller et al. (Circulation 1997)

PCI of Functionally Nonsignificant Stenosis

Pijls et al. (JACC 2007;49:2105–11)

Fractional Flow Reserve vs. Angiography for Guiding PCI

Tonino PA et al. (N Engl J Med 2009;360:213-24)

Fractional Flow Reserve versus Angiography

for Guiding Percutaneous Coronary Intervention

Tonino PA et al. (N Engl J Med 2009;360:213-24)

Fractional Flow Reserve Versus Angiography for Guiding Percutaneous

Coronary Intervention in Patients With Multivessel Coronary Artery Disease

Nico H. J. Pijls et al (J Am Coll Cardiol 2010;56:177–84)

Nico H. J. Pijls et al (J Am Coll Cardiol 2010;56:177–84)

Fractional Flow Reserve Versus Angiography for Guiding Percutaneous

Coronary Intervention in Patients With Multivessel Coronary Artery Disease

A Randomized Trial of Therapies for Type 2 Diabetes and

Coronary Artery Disease

The BARI 2D Study Group (N Engl J Med 2009;360:2503-15)

Optimal Medical Therapy with or without PCI for Stable Coronary Disease

Boden WE et al. (N Engl J Med 2007;356:1503-16)

Optimal Medical Therapy With or Without Percutaneous

Coronary Intervention to Reduce Ischemic Burden

Shaw et al. (Circulation. 2008;117:1283-1291)

0%

39.3%

0

50

100

150

200

250

300

350

400

450

500

MPS negative MPS severe

MPS1

MPS2

Prognostic Value of Myocardial Perfusion Scintigraphy to Guide

Therapeutic Decision Making


No

. o

f p

ati

en

ts

MT (No. 794)

- 52%

- 7%

0

20

40

60

80

100

120

140

160

180

200

MPS negative MPS severe

MPS1

MPS2

RT (No. 548)

No

. o

f p

ati

en

ts

- 86% + 450%

The Economic Consequences of Available Diagnostic

and Prognostic Strategies for the Evaluation of Stable Angina

0

1

2

3

4

5

Death MI

Ha

rd E

ve

nt

Ra

te

0

10

20

30

40

50

60

70

80

Co

ron

ary

Re

va

sc

ula

riza

tio

n %

Direct Catheterization (n=5423)

Initial stress perfusion imaging (n=5826)

Shaw LJ et al. (J Am Coll Cardiol 1999)

p<0.0001

Nuclear Cardiology and Molecular Imaging

Myocardial Perfusion

Myocardial Viability

Ventricular Function and Remodeling

Neurotransmission Integrity

Mechanical Dyssynchrony

Metabolism-Perfusion Mismatch

Perfusion Contractility Viability

Hibernating Myocardium (Technetium tetrofosmin)

Hibernating Myocardium (Thallium-201)

Increasing Benefit From Revascularization Is Associated With Increasing

Amounts of Myocardial Hibernation - A Substudy of the PARR-2 Trial

PARR-2 Investigators (J Am Coll Cardiol Img 2009;2:1060–8)

0%

5%

10%

15%

20%

25%

30%

35%

40%

NEG m L ML M MS S

(2943) (576) (656) (757) (1290)

Clinical AMI: 7800

Prognostic Value of Myocardial Perfusion Scintigraphy to Guide

Therapeutic Decision Making


Myocardial Perfusion Scintigraphy

(785) (793)

Necrotic Myocardium pre- and post- Revascularization

0

10

20

30

40

50

60

70

80

90

100

Reversible

Irreversible

%

Hibernating Myocardium

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

Revascularized Medical Therapy

Viable

Non-Viable

Allman et al. (JACC 2002)

An

nu

al

Rate

of

Death

3.2

7.7

16.0

6.2

NO. 3088

Increasing Benefit From Revascularization Is Associated With Increasing

Amounts of Myocardial Hibernation - A Substudy of the PARR-2 Trial

PARR-2 Investigators (J Am Coll Cardiol Img 2009;2:1060–8)

Long-term Survival of patients with Coronary Artery Disease and Left

Ventricular Dysfunction: implications for the role of myocardial viability

assessment in management decisions

Di Carli et al. (J Thorac Cardiovasc Surg 1998)

No Difference in Cardiac Event-Free Survival Between

PET-guided and SPECT-guided Patient Management

Siebelink HJ et al. (J Am Coll Cardiol 2001;37:81– 8)

MT

RT

VIABLE – INNERVATION MISMATCH

H / M 1.46

H / M 1.56

Washout > 26%

PERFUSION – INNERVATION MISMATCH

Assessment of neurotransmission integrity

(Iodine123 – metaiodobenzylguanidine MIBG)

Prediction of response to medical therapy

Prediction of death

Prediction of sudden cardiac death

Selection of CHF patients for implantable defibrillators

Dysinnervated but viable myocardium in ischemic heart disease

Fallavolita J A and Canty J M (JNC nov/dec 2010)

I. Carrió, P.G. Camici (JACC Img 2010;3;92-100)

Cardiac Sympathetic Imaging With mIBG in Heart Failure

ADMIRE-HF Study

AdreView Myocardial Imaging for Risk Evaluation in Heart Failure

Jacobson A F et al. (JACC 2010;55:2212-21)

Nuclear Imaging in Cardiac Resynchronization Therapy

Henneman M M et al (J Nucl Med 2007; 48:2001-2010)

Phase Analysis of Gated Myocardial Perfusion SPECT

Compared With Tissue Doppler Imaging for the Assessment of

Left Ventricular Dyssynchrony

Henneman MM et al. (J Am Coll Cardiol, 2007; 49:1708-1714)

aprilia, 13 ottobre 2012

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