SHA24/001002

What does Nuclear Cardiology provide in the Era of CTA. Khalid ALNemer MD,FRCPC,FACC,FASNC,FASCI,FSCCT Chairman of cardiac imaging working group SHA Clinical professor of cardiology ,KSU

Agenda 1.Declaration of Conflict of interests.

2.Welcome our colleauges‌.

3.Thanks to the organizing committee‌.

4.MPI,CTA: what,when,where?

5.Take home message

As of 2013 Functional imaging

Anatomical imaging

1.nuclear imaging 2.stress echocardiography 3.Stress CTA 4.stresss MRI

1.multislice CT (MSCT) 2.EBCT 3.Cath 4.MRA

What is the % of CTA significant stenosis are functionally significant?

50% JACC 2006,48(12):2508–14

Circulation. 2007;115:1464-1480

JACC 2006,48(12):2508–14

J Nucl Med 2005; 46:1294–1300

JACC 2006,47 (suppA):115A

26

0.29

JACC 2006,48(12):2508–14

Hybrid imaging‌.

JACC 2007, 49 (10): 1059-67

JACC Vol. 48, No. 11, 2006 :2324–39

Resting CT perfusion vs. MPI Visual analysis : sensitivity of 16% (24/152) specificity of 92% (393/428) positive predictive value of 40% (24/60) negative predictive value of 75% (392/520) in systole AJR Am J Roentgenol. 2013 Feb;200(2):337-42

Ccs: total atherosclerotic burden • Comparable to stress perfusion imaging but yet lack prognostic data on obstructive CAD. • More ischemia detected with high score • high SN, low SP( very high NPPV) • Is 100% SP for atheroma • Relation to obstructive CAD is modest.

CCS 1)Progression .

2) inter-test variability 3) changes in severity have prognostic relevance.

4) modification of cardiovascular risk factors modulates its progression .

CCS: Quick filter……

• in symptomatic pt, exclusion of measurable CCS >>>is aneffective filter before undertaking invasive diagnostic procedures or hospital admission.

CCS <100

>> (<2%) of abnormal MPI J Am Coll Cardiol 2004;44:923–30

>> (< 3%) of obstructiv CAD Circulation 2002;105:1791– 6.

Journal of Nuclear Cardiology 2007 Vol14, Number 3;272-4

simple fact:

an individual with (CCS 0) has no obstructive CAD.

Am J Cardiol 2004;93:1150 â&#x20AC;&#x201C;2

European Heart Journal (2006) 27, 713â&#x20AC;&#x201C;721

J Am Coll Cardiol 2004;44:923â&#x20AC;&#x201C;30

J Am Coll Cardiol 2004;44:923â&#x20AC;&#x201C;30

Journal of Nuclear Cardiology 2007 Vol14, Number 3;272-4

European Heart Journal (2006) 27, 713â&#x20AC;&#x201C;721

JACC 2007;49:378 – 402

J Am Coll Cardiol 2005;45:1494 â&#x20AC;&#x201C;504

Where these tests fit ?

CCS

CTA

MPI

0

50 Pretest likelihood

100

Anatomic testing vs. ischemia testing.

Pearls of wisdom : 1.Ccs is 1st in intermediate risk asymptomatic pts 2.MPI is still the 1st in intermediate risk symptomatic pts.

3.Any pt with CCS>/= 400 (?) should go for MPI not CTA .

4.CCS/CTA shouldnâ&#x20AC;&#x2122;t be used as general population screening in asymptomatic persons (even high risk ) 5.Every CTA should be preceeded by CCS if >400 >>>MPI

An appropriate imaging study ? â&#x20AC;˘ is one in which expected incremental informations + clinical judgement >>>negative consequences by sufficiently a wide margin for specific indications that the procedure is generally considered acceptable care and reasonable approach for the indications.

Hendel R.

Name that city?

Pt (100)

Achilles heels of different imaging techniques as of 2013

MPI

MSCT

CMR

Artifacts(motion, attenuation)

calcification

NSF

radiation

heart rate dependency

Lagging behind in coronary imaging

distinction between subendocardial and transmural perfusion defects

contrast nephropathy

Relatively Long duration

radiation

Published Data size <CT<MPI Agarophobia

motion artifact Metal artifacts

Metals parts (post cabg)

Perfusion/viability still reseach

Perfusion still research.

1/4 of coronary segemnts are not well visualized

Coronary anatomy

Functional significance of

Coronary anatomy still a

Adenosine-stress dynamic MPI with CTA With nuclear MPI results as a comparison: 0.85 sensitivity 0.92 Specificity 0.55 positive predictive value 0.98 negative predictive value

AJR Am J Roentgenol.2012 Mar;198(3):521-9

CTA+MPI for hemodynamically significant stenoses in patients with suspected coronary artery disease: a comparison with FFR

combined coronary CTA + CTP identifies patients with hemodynamically significant stenoses with >90% accuracy when compared with FFR.

JACC Cardiovasc Imaging.2012 Nov;5(11):1097-111

take home message â&#x20AC;˘ We should be interested in assessment of absolute myocardial blood flow (MBF) rather that relative regional distribution of radiotracer-uptake this will identify and characterize flow-limiting lesions and subclinical stages of functional and/or structural stages of CAD

Thank you .