Hybrid Imaging Improving Nuclear Cardiology Practice · PDF fileDISCLOSURES Honorarium –...
Transcript of Hybrid Imaging Improving Nuclear Cardiology Practice · PDF fileDISCLOSURES Honorarium –...
DISCLOSURES
Honorarium – Research and Conferences in Nuclear Cardiology
BMS, CVT, Astellas, Pgx Health/Forest laboratories, Lantheus Medical Imaging International Atomic Energy Agency
Royalties – Publications in Nuclear Cardiology Springer-Verlag-Nuclear Cardiology and Correlative Imaging: a teaching file, NY, 2004 Lippincott Williams & Wilkins, - Nuclear Medicine teaching File, 2009
João V. Vitola, MD, PhD
Cardiologist and Nuclear Medicine Physician
Quanta Diagnostico Nuclear
Curitiba - Brazil
Hybrid Imaging Improving Nuclear Cardiology Practice
The Achilles Heel
Recognizing and Correcting for NC Artifacts Reducing false positive rate as much as possible
Improving Nuclear Cardiology Practice
HW Strauss, BL Zaret, ND Martin,
HP Wells, Jr, and MD Flamm, Jr
Noninvasive evaluation of
regional myocardial perfusion
with potassium 43. Technique in
patients with exercise-induced
transient myocardial ischemia
Radiology 1973 108: 85-90
Nuclear Cardiology in 1973 and in 2012
Look at the global picture – who is my patient ? Estimate the pre test probability of disease
The Achilles Heel
Patient Centered Imaging and Quality
1- Medical history – talk to the patient
Estimation of pre test probability – symptoms, risk factors Interview needed to better define ideal stress protocols Needed to define which question clinician wants to answer Diagnosis ? Prognosis ? Culprit artery ? Viability? Function ?
2- Stress data
Estimate functional capacity Some Diagnostic and Prognostic info Duke Score (time – 5 x ST mm – 4 x angina) New pre test probability before imaging Define ideal for post stress imaging 15’ vs 30’ vs 60’
3- Imaging analysis
4 –Final report (1+2+ 3)
Consider info from history and stress test for image interpretation (more sensitive or specific reading – consider artifacts)
Improving Nuclear Cardiology Practice Patient Centered Imaging and Quality
Medical team should participate actively Decide best type of stress – keep good quality control, systematically review image before releasing patient, verify acquisition / processing (preferably process yourself), decide when to do additional images (delayed), reacquire in prone if needed, repeat study if necessary (inadequate IV injection/SQ) - Look for motion, evaluate statistics, body habitus (attenuation), history / rest ECG (prior MI ? LBBB/PCM ?)
The Achilles Heel
How to Recognize and to Correct for NC Artifacts
case
70 yo Man HTN, Disl BMI 34 Atypical Pain Duke score -1
Prone Imaging
case
SPECT 99mTc-MIBI -stress-rest
No history of CAD Atypical Chest Pain Question 1 What is your interpretation ? A - Silent Inferior MI B – Inferior MI, LAD ischemia C – Diaphragmatic attenuation D – Inferior MI, Dilated LV E – Not sure, need more data
SPECT 99mTc-MIBI -stress-rest
No history of CAD Atypical Chest Pain Question 1 What is your interpretation ? A - Silent Inferior MI B – Inferior MI, LAD ischemia C – Diafragmatic attenuation D – Dilated LV, Inferior MI E – Not sure, need more data
Question 2
What could be helpful to differentiate a true defect and diaphragmatic attenuation in this patient ?
A- Prone Imaging
B- Attenuation correction
C – Rest ECG and TMT results
D- Gated SPECT
E – All of the above
Question 2
What could be helpful to differentiate a true defect and diaphragmatic attenuation in this patient ?
A- Prone Imaging
B- Attenuation correction
C – Rest ECG and TMT results
D- Gated SPECT
E – All of the above
PET 82Rb
Courtesy of J. Machac-Mt Sinai, NY
Attenuation Correction using PET- CT
SPECT 99mTc-MIBI
• Use LV Function data - Gated SPECT
– Wall motion and thickening at rest and after stress
What can we do to overcome the problem ?
Gated Tc-99m SPECT improving specificity in women
67.2
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Tl-201
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Gated
Taillefer et al JACC 1997;29:69-77
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Supine NC
Supine NC/Prone
Supine NC/AC
All
Malkerneker D et al. J Nucl Cardiol 2007
Prone + AC on SPECT-CT – reduce number of equivocal studies
Camera Time Consuming !!!
Before and After Attenuation Correction
Before
Before
Before
After
After
After
Before
Before
Before
After
After
After
Before and After Attenuation Correction
SPECT-CT Imaging (No Attenuation Correction)
SPECT-CT Imaging (After Attenuation Correction)
Relevant questions in 2012
What information do we need to manage our patient ?
Is new imaging technology reducing CV mortality ?
Is technology translating in cost effective care ?
Have we already maximize extracting the information from
basic techology ?
Vitola JV
Vitola JV, Shaw L, Allam A, Peix A et al JNC, 2009
Worldwide Utilization of MPI– Underutilized in Many Nations
High Moderate – High Moderate Moderate – Low Low Inexistent Limited info
Having both information from Nuclear (physiology) and CT (Anatomy) : competition and / or cooperation ?
• Cooperation increasing – both are non-invasive – Roles being defined for calcium score and anatomy by CT
• Potential for competition: – For pratical purposes CT excludes CAD (high NPV, low PPV)
– A negative CT implies no nuclear on follow up (including nuclear after + TMT)
– Acute chest pain in ER
Calcium Score – long term prognosis
Diagnosis of CAD
Secondary Prevention
Plaques/Obstruction – continue
investigation
Ischemic burden
Prognosis – 1 - 2 years
Need to revascularize
Eixo Curto
Eixo Longo Vertical
Eixo Longo Horizontal
Cortes Tomográficos-Referência
QUANTA Diagnostico Nuclear
75 yo women, no history of CAD – mild antero-septal ischemia ?
Good Chance for Contribution and Feedback to NC
Negative CT: Mibi showed microvascular ischemia ? Breast attenuation ?
Negative MPI but very “advanced” atherosclerosis No revascularization but aggressive secondary prevention
Man, 57 yo, HTN, Dyslipidemia, Obese and sedentary Denies DM , Family hx, Smoking Asymptomatic on check up
Calcium score 2037 LAD 962 LCX 194 RCA 881
Calcium score 2037 LAD 962 LCX 194 RCA 881
Calcium score 2037 LAD 962 LCX 194 RCA 881
Berman DS et al. J Nucl Med 2006:47:1107-1118.
Calcium Score Superior Compared to Framingham Score
Framingham Risk Score
Man, 57 yo, HTN, Dyslipidemia, Obese and sedentary Denies DM , Family hx, Smoking Asymptomatic
CCS 2037
In asymptomatic patients with CCS > 400, what is the probability of a positive SPECT ?
A : < 10% B : 10 – 20% C : 20-30% D : 30-40% E : 40-50%
A : < 10% B : 10 – 20% C : 20-30% D : 30-40% E : 40-50%
In asymptomatic patients with CCS > 400, what is the probability of a positive SPECT ?
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Cortes Tomográficos-Referência
Deliver the highest possible quality NC imaging AC using SPECT CT can help Identify your value and recognize your limitations Nuclear and CT – there is more room for cooperation than competition
Conclusions
Thank you