Current Applications of Cardiac Imaging
NUCLEAR MEDICINE
International Conference on Integrated Medical Imagingin Cardiovascular Diseases – 2013
Paola Smanio MD, PhDProfessor of Cardiology and Nuclear Medicine
Director of the Nuclear Medicine and PET/CT CenterDante Pazzanese Heart Institute - São Paulo Brazil
Fleury Medical Center - São Paulo Brazil
NON-INVASIVE DIAGNOSTIC METHODS
ECG
EXERCISE STRESS TEST
ECHOCARDIOGRAM
CALCIUM SCORING
CORONARY TOMOGRAPHY
MAGNETIC RESSONANCE IMAGING
NUCLEAR MEDICINE
- SPECT
-PET
- MIBG- 123I
- 67GALLIUM
- MUGA
DIAGNOSTIC ESTRATEGY
AVAILABILITY
GUIDELINES/APPROPRIATNESS CRITERIA
CLINICAL EXPERTISE
OBJECTIVE OF THE STUDY AND PRETEST LIKELIHOOD
CHARACTERISTICS OF THE METHOD X PATIENT (asthma, acoustic window,
limitation to exercise)
SINGLE METHOD X ASSOCIATION OF METHODS
FISIOLOGY
ANATOMY
ERA OF MULTIMODALITY OF DIAGNOSTIC TESTS
IMPACT IN OUTCOME
HELPING CLINICAL DECISION
EVIDENCE BASED
INDIVIDUALITY
BENEFIT
COST
RADIATION
EVALUATION OF PATIENTS WITH SUSPECT CAD
ASSESSMENT OF THE HIGH RISK PATIENT:
MULTIVESSEL, DIABETIC, RENAL FAILURE
ASSESSMENT OF WOMEM
ASSESSMENT OF ATHLETES AND FOR EXERCISE
PRESCRIPTION
ASSESSMENT OF ELDERLY
RISK STRATIFICATION
PREOPERATIVE RISK ASSESSMENT FOR NON-CARDIAC
SURGERY
CURRENT APPLICATIONS
Braunwald Heart Disease 2008. Nuclear Cardiology. Practical Applications. Gary Heller and Robert Hendel 2 ed.C
EVALUATION OF SUBCLINICAL ATHEROSCLEROSIS
EVALUATION OF ISCHEMIA THERAPIES IN PATIENTS WITH
CAD: MEDICAL, REVASCULARIZATION
ACUTE REST MPI IN THE EMERGENCY DEPARTMENT
RADIONUCLIDE IMAGING IN HEART FAILURE
- ASSESSMENT OF MYOCARDIAL VIABILITY
- ETIOLOGY OF LV DISFUNCTION
- PROGNOSIS : MIBG -123I
- EVALUATION OF SYNCHRONY OF LV CONTRACTION
SPECT X PET IMAGING
EVIDENCE BASED
Author year radionuclide Technique Sens(%) Specif(%)
Wackers 1995 Tálio-201 planar 78 74
Santana-Boado 1997 MIBI Ex/SPECT 91 90
Iskandrian 1996 MIBI Adeno/SPECT 90 94
Miller 1997 MIBI Ajustado ‘bias” 91 71
Ficaro 2000 MIBI SPECT-CA 93 88
HENDEL 2000 MIBI Gated-SPECT 94 93
Ficaro 2001 MIBI Gated+ CA/prono 93 98
Gould 2001 Rubidium/NH3 PET 95 100
Tamaki 2002 NH3/FDG PET 98 100
Oklocke AHA/ACC Guidelines.2003
0
20
40
60
80
100
Exe Adeno Dipi Dobuta
SensibEspec
*Leppo. J Nucl Cardiol 1996
STRESS TEST X ACURACYstress agent and intensity
0102030405060708090
100
%
CPM ECG ANGINA
85%70%
Heller G et al. Am J Cardiol 1991;68-569.
0,85 (0,6-1,2)
5,9 (4,6-8,5)
2,3 (1,8-3,9 Y)69.6551994-2003
LOW RISKHIGH RISKFOLLOW UPNº PATIENTSYEAR
MPI –ASSESSMENT OF RISK IN THE POPULATION
Shaw L and Iskandrian JNCardiol 2004 -PROGNOSTIC VALUE OF GATED MYOCARDIAL PERFUSION SPECT
MPI – PATIENTS WITH KNOWN CAD
YEARS Nº STUDIES Nº PATIENTS FOLLOW UP NL MPI ABNL MPI
1994-2001 13 16.000 28 months 0-1,3 % 2,0-14,3 %
RISK STRATIFICATION
15-Year outcome after normal exercise 99mTc-sestamibi myocardial perfusion imaging:What is the duration of low risk after a normal scan?
Schinkel AFL et al. J Nucl Cardiol 2012;19:901-6
Conclusion. Patients withsuspected or known CADand normal exercise99mTc-sestamibi MPIhave a favorable 15-yearprognosis.
Follow-up should be closerin patients with knownCAD, and/or havingclinical and exerciseparameters indicatinghigher risk status.
Patients with known CAD and a normal SPECT MPI study have a
favorable long-term prognosis.
The annualized cardiac mortality and/or non-fatal M I was 1,2%.
The inability to perform exercise test was associated with an
impaired outcome.
Independent predictors to cardiac death and non-fatal MI were
Diabetes and rate-pressure product at peak stress.
Value of myocardial perfusion imaging in the assessment of ischemia in asymptomatic renal
disease patients before dialysis
Smanio P. et al. ICNC 2013 and submitted Arq.Brasil.Cardiol.
123 p
DIAGNOSTIC VALUE OF MPI BEFORE RENAL TRANSPLANT
128
22
ISCHEMIA NORMAL
Vankataraman R and Iskandrian A. Am J Cardiol2008.102(11):1451.
170 P
(75%)
Wild S. Diabetes care 27:1047-1053,2004
Global Prevalence of DiabetesEstimates for the year 2000 and projections for 2030
0
20
40
60
80
100
120
140
160
180
20-44 45-64 >65
20002030
2000 2030
Country DM (million) Country DM (million)
1 India 31,7 India 70,9
2 China 20,8 China 42,3
3 USA 17,7 USA 30,3
4 Indonesia 8,4 Indonesia 21,3
5 Japan 6,8 Pakistan 13,9
6 Pakistan 5,2 Brazil 11,3
7 Russia 4,6 Bangladesh 11,1
8 Brazil 4,6 Japan 8,9
9 Italy 4,3 Philippines 7,8
10 Bangladesh 3,2 Egypt 6,7
32,7%67,3%
Com DACSem DAC
PREVALENCE OF SIGNIFICANT CAD INASYMPTOMATIC DIABETIC WOMEN
34 P104 P
Smanio P. Arq Bras Cardiol 2007 Nov;89(5):263-9, 290-7.
ETT MPI
SENSIT 44,1% 94,1%
(43% < 85% MPHR)
SPECIF 61,4% 92,4%
( 37,5% – ECG BASAL: abnormal ST)
25% DM already have CAD at the moment of Diabetes diagnostic
HIGH RISK X INCLUIDING ASYMPTOMATIC
DIAD – 14 CENTERS, VOLUNTEERS22%- abnormal SPECT …6% severe!!!
Wackers F. Diabetes care 2007.Wackers et al, 2004 Diabetes Care 27: 1954
WOMEN MORTALITY
AHA/ACC/ASNC. (USA, 2003) Mortality in Women
MEN 50.102 (58%)WOMEN 36.679 (42%)TOTAL 86.679
DEATHS PER 1.000.000 INHABITANTS FOR CAD CAUSE - BRAZIL 2004
Brazilian Health Secretary of State. SEADE 2004
Women are lesser investigated
1st manifestation = MI or cardiac death
start + older, atypical symptoms = worst prognosis
physiopathology, manifestation, diagnosis
Early investigation is very important
WOMEN AND CAD
Mosca L. Circulation 2004.
617068
77
0
20
40
60
80
100
Sensitivity Specificity
womenmen
STRESS TEST X WOMEN
Kwok et al. Am J Cardiol. 1995; 83: 660-6
%
EXERCISE STRESS TEST X MPIWOMEN
67 68
88 87
0
20
40
60
80
100
TERGO GATED-SPECT
SENS ESPEC
• Mieres J.Am J Cardiol 2007;99:1096-1099
CARDIAC MORTALITY IN DIABETIC MEN AND WOMEN BASED IN THE RESULTS OF SPECT
0123456789
Normal Mildly Abn Mildly Abn Severe Abn
Car
diac
Mor
talit
y MenWomen
Berman et al, 2003JACC 41: 1125
NO DIFFERENCE TO NON-DIABETICS
MPI IN ELDERLY
ATTENTION
• CAROTID STENOSIS
• ATRIO-VENTRICULAR BLOCK
• FEW SYMPTOMS ARE MENTIONED
• INTERATION WITH OTHER DRUGS
• ABNORMAL EKG
• 3412p – 616 > 70ª
• MPI was considered a safe test
• Hashimoto A. J Nucl Cardiol 1999:8;512
DIAGNOSTIC ACURACY IN ELDERLY >80Y
8795
8375
83
0102030405060708090
100
SENS ESPEC NORMALCYRATE
50%70%
• Wang J Nucl Cardiol. Sept. 1995
Causes of Sudden Death in Athletes
1: 100 000 athletes normal/year
< 35 years > 35 years
CAD Ocasional 80%
HCM 26%
Anomalous coronary 14%
RV arrythmogenicdysplasia
3% (USA),22% (Italy)
Myocarditis 6%
Aneurism Rupture(Marfan)
3%
Aortic Stenosis 3%
Dilated Cardiomyopathy 2%
Electrics Syndromes Rare
Comotio cordis Rare (USA)
Miocardial bridge 4%
N H Prakken, B K Velthuis. Br J Sports Med 2009;43:677–684
CHALLENGES OF THE
ATHLETE ‘S HEART
Myocardial perfusion imaging in the evaluation of multivessel disease patients
Siqueira M, Vieira Neto E, Kelendjian J, Smanio P. Arq. Bras. Cardiol. 2011;97(3):194-8
68 p with documented CAD
MPI within 7 days after angiography
MULTIVESSEL AND LM SIGNIFICANT DISEASE
101 p, NO PREVIOUS MI
Berman D et al. J Nucl Cardiol 2007;14:521-8
02468
1012141618
VOLUNT ASSINT
CAC>1000
J Nucl Cardiol Dez 2010Rozanski A e cols. JACC 200749:1352-1361
SUBCLINICAL ATHEROSCLEROSIS
FAMILY HISTORY OF PREMATURE
CAD
HIGH RISK WORK: pilots, firemen,
policemen
DIABETIC
CHRONIC RENAL FAILURE
LOW FUNCTIONAL CAPACITY
CAC > 400
VASCULAR DISEASE
ERECTILE DISFUNCTION
AUTOIMMUNE DISEASE, AIDS
PRESURGICAL RISK ASSESSMENT
J Nucl Cardiol 2008;15:e6-19.
New Cardiac Scanners in Clinical Use
Dynamic SPECT(D-SPECT)
James A. Patton, PhD, Vanderbilt U., SNM 2006
Discovery NM 530
Garcia EV, Faber TL, Esteves FP.J Nucl Med. 2011 Feb;52(2):210-7.
New systems surround thepatient’s heart with detectorand acquire all angles at once.
STRESS ONLY16,854 consecutive patients who had a normal gated stress SPECT study and were followed for a median of 4.5 years-AMI/mortality
Mahmariam J. J Nucl Cardiol 2010;17:529–35.
RADIONUCLIDE IMAGING OF CARDIAC AUTONOMIC INNERVATION
Cardiac autonomic function plays a crucial role in
the health and disease
Contributing specifically to indicate clinical
deterioration and poor prognosis.
Increased global cardiac uptake appears to have a
high negative predictive value in terms of cardiac
events (deaths and arrhythmias) and may have a
role in guiding therapy
Helping to better select pts unresponsive to
conventional medical therapies that would benefit
from devices therapies such as: ICD, CRT, LAVD
or cardiac transplantation
Ji S Y and Travin MI . J Nucl cardiol 2010
J Nucl Cardiol 2008;15:127-36. J Nucl Med 2009; 50:718–725
J Nucl Cardiol 2011;18:685–94.
At baseline, CRT responders showed a significantly larger histogrambandwidth (94°± 23° vs. 68°± 21°, P < 0.01) and a larger phase SD
(26 °± 6° vs. 18°± 5°, P<0.01) than did nonresponders
ADVANTAGES OFRb-82 PET/CT vs SPECT
Better efficiency Faster examLesser exposure dose Less attenuation artifactsBetter spatial resolution and contrastReal time ejection fraction Measurement of coronary flow reserve
Quantification of regional myocardial blood flow (ml/min/g)