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

CARDIOVASCULAR IMAGING

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

398.978 p Coronary Angiography

in 663 centers

only 149.739 (37,6%) with significant CAD

NUCLEAR MEDICINE

J Nucl Cardiol 2013

NUCLEAR MEDICINE

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

EVALUATION OF PATIENTS

WITH SUSPECT CAD

PRE TEST PROBABILITY - ASSESSMENT OF RISK

Braunwald Heart Disease 2008.

APPROPRIATED INDICATIONS

Hendel R et al. JACC 2009

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.

ASSESSMENT OF HIGH RISK PATIENTS

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%)

2000.Pts Hakeem et al. JNucl Cardiol junho 2011.

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 ASSOCIATED TO CARDIOPULMONARY

STRESS TEST

PREOPERATIVE RISK ASSESSMENT

FOR NON-CARDIAC SURGERY

PERISURGICAL RISK ASSESSMENT CLINICAL RISK x DP- MIBI RISK

Kenneth Brown J Nucl Cardiol. 2004

Hoeks S et al. J Nucl Cardiol 2007Caramelli B. Arq Bras Cardiol 207;88(5):e139-e178

RECOMENDATION

ASSESSMENT OF MULTIVESSEL DISEASE

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

JACC 2010J Nucl Cardiol 2005;12:145-7.

J N Cardiol. Dezembro 2010

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.

EVALUATION OF ISCHEMIA THERAPIES

IN PATIENTS WITH CAD:

MEDICAL, REVASCULARIZATION

REDUCTION OF ISCHEMIA WITH CLINICAL TREATMENT

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.

A2 Agents

Zoghbi and Iskandrian. JNCardiol. Fev 2012

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)

Patient EMS ‐Mibi   Courtesy Dr Meneghetti

Patient EMS ‐ Rubidium ‐82 Courtesy Dr Meneghetti

Patient EMS ‐ Rubidium – 82 –Cedars‐Sinai

PET -18FDG ASSESSMENT OF MYOCARDIAL VIABILITY

EIXO CURTO

EIXO HORIZONTAL

EIXO VERTICAL

TÁLIO REPOUSO

TÁLIO REINJEÇÃO

PET - 18FDG

PET Flurpiridaz F-18

FUTURE DIRECTIONS

INTEGRATION

INTEGRATION TECHNIQUES E SPECIALITIES

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