Microsoft PowerPoint - Prof. NUDI 2009 ARCA

Microsoft PowerPoint - Prof. NUDI 2009 ARCA

VIII Congresso Regionale
A.R.C.A. Campania
L’imaging scintigrafico nella scelta terapeutica
Francesco Nudi
Madonna della Fiducia e
Madonna delle Grazie - Roma
Napoli, 09-10 ottobre 2009
Nuclear Cardiology and Molecular Imaging
Myocardial Perfusion
Myocardial Viability
Ventricular Function and Remodeling
Mechanical Dyssynchrony
Neurotransmission Integrity
Myocite apoptosis
Risk Assessment Using SPECT Imaging
Risk Assessment Using SPECT Imaging
Risk Assessment Using SPECT Imaging
Risk Assessment Using SPECT Imaging
Viable – Innervation Mismatch
H/M
1.46
H/M
1.56
Washout > 26%
Risk Assessment Using SPECT Imaging
Event Rate/yr
Risk Assessment Using SPECT Imaging
12.360 paz.
in 14 studi
8
6
7.4
4
0.6
2
0
Normal
Abnormal
SPECT Result
Iskander S, Iskandrian AS (JACC 1998)
Incremental Prognostic Value of Exercise Tc-99m Sestamibi SPECT
*
12
10.8
Event Rate (%)
10
* p<0.05
*
7.9
8
6
*
3.8
4
2
0
0.5
0.0
n=
601
157
Low
(<0.15)
440
0.0
266
90
Intermediate
(0.15--0.85)
(0.15
Post--ETT Likelihood of CAD
Post
Berman et al. (JACC 1995)
148
High
(>0.85)
Normal
Scan Results
Abnormal
Scan Results
Alcyone technology - Cadmium Zinc Telluride (CZT)
energy
resolution
count
sensitivities
spatial
resolution
9-10%
0.5-0.7 Kcps
9-11 mm
5.7%
2.2-4.7 Kcps
4.3-4.9 mm
Anger cameras
CZT cameras
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 CARDIAC IMAGING
Stress Tl-201/Rest Tc-99m High-Speed MPI
Berman et al. (J Am Coll Cardiol Img 2009;2:273– 82)
From vulnerable plaque to vulnerable patient
Risk Assessment Using SPECT Imaging
Perfusion
Viability
From Vulnerable Plaque to Vulnerable Patient
Naghavi et al. (Circulation 2003)
Does Coronary Flow Trump Coronary Anatomy?
K. Lance Gould (JAmColl Cardiol Img 2009;2:1009 –23)
PCI of Functionally Nonsignificant Stenosis
Pijls et al. (J Am Coll Cardiol 2007;49:2105–11)
PCI of Functionally Nonsignificant Stenosis
Pijls et al. (J Am Coll Cardiol 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 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)
On the Inappropriateness of Noninvasive Multidetector Computed
Tomography Coronary Angiography to Trigger Coronary
Revascularization: A Comparison With Invasive Angiography
Sarno et al. (J Am Coll Cardiol Intv 2009;2:550 –7)
On the Inappropriateness of Noninvasive Multidetector Computed
Tomography Coronary Angiography to Trigger Coronary
Revascularization: A Comparison With Invasive Angiography
Sarno et al. (J Am Coll Cardiol Intv 2009;2:550 –7)
Intracoronary Doppler Assessment of Moderate Coronary
Artery Disease
CFVR < 1.7
CFVR ≥ 1.7
Pos Tl-201
Neg Tl-201
87%
13%
11%
89%
r = 88%
Heller et al. (Circulation 1997)
Long-Term (10 years) Prognostic Value of a Normal Thallium-201 Myocardial
Exercise Scintigraphy in Patients with CAD Documented by Angiography
Pavin D. et al. (EHJ 1997)
MSCT Versus MPI in an Intermediate Likelihood of CAD
MSCT Abnormal
MSCT Normal
MSCT Obstructively diseased
10%
MPI Normal
MPI Abnormal
45%
50%
55%
90%
Schuijf et al. (J Am Coll Cardiol 2006;48:2508 –14)
50%
Outcomes After Calcium Scans and
Exercise Myocardial Perfusion Scintigraphy
Rozanski et al. (J Am Coll Cardiol 2007;49:1352–61
ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria
for Coronary Revascularization
Patel et al. (J Am Coll Cardiol 2009;53:530 –53)
Coronary Revascularization %
The Economic Consequences of Available Diagnostic
and Prognostic Strategies for the Evaluation of Stable Angina
Hard Event Rate
5
4
3
2
1
0
Death
80
70
60
50
p<0.0001
40
30
20
10
0
MI
Direct Catheterization (n=5423)
Initial stress perfusion imaging (n=5826)
Shaw LJ et al. (J Am Coll Cardiol 1999)
PCI Versus Medical Treatment: Meta-Analysis
Schömig et al. (J Am Coll Cardiol 2008;52: 894–904)
Aggressive lipid-lowering therapy compared with angioplasty
in stable coronary artery disease
AVERT
No. 341
FU 20m
MI 42%
EF >40%
Stent 28%
Bertam Pitt et al. (N Engl J Med 1999;341:70-6)
Medical Therapy for Reducing Myocardial Ischemia
INSPIRE
No. 205
FU 60m
MI 100%
EF>35%
Stent 67%
Mahmarian et al. (J Am Coll Cardiol 2006;48:2458–67)
Invasive Treatment Reduces Mortality in Diabetic Subjects
MASS II
DIABETICS
No. 408
FU 60m
MI 46%
EF>50%
Stent 68%
NON DIABETICS
Soares et al. (Circulation. 2006;114[suppl I]:I-420–I-424)
Percutaneous Coronary Interventions vs Drug Therapy
for Silent Ischemia
SWISSI II
No. 201
FU 122m
MI 100%
Stent 0%
Paul Erne; Andreas W. Schoenenberger; Dieter Burckhardt; et al. (JAMA. 2007;297(18):1985-1991)
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)
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
COURAGE
No. 2287
FU 64m
MI 38%
EF>30%
Stent 90%
Shaw et al. (Circulation. 2008;117:1283-1291)
Optimal Medical Therapy With or Without Percutaneous
Coronary Intervention to Reduce Ischemic Burden
[moderate to severe pretreatment ischemia]
26%
[TR 33,3% vs TM 18,9%]
65%
[TR 78% vs TM 52%%]
Shaw et al. (Circulation. 2008;117:1283-1291)
Optimal Medical Therapy With or Without Percutaneous
Coronary Intervention to Reduce Ischemic Burden
Shaw et al. (Circulation. 2008;117:1283-1291)
Prognostic Value of Myocardial Perfusion Scintigraphy to Guide
Therapeutic Decision Making
80%
EXCLUSION CRITERIA
Revascularization Therapy
70%
Clinical instability
EF < 40%
60%
Previous MI
50%
Previous RT
40%
30%
20%
10%
0%
(No. 6211)
negative
minimal
mild
moderate
severe
(3177)
(1659)
(224)
(704)
(447)
Myocardial Scintigraphy
Nudi F et al, personal data on file
Annual Rate of Death or Nonfatl Myocardial Infarction
Prognostic Value of Myocardial Perfusion Scintigraphy to Guide
Therapeutic Decision Making
1,0%
0,9%
0,8%
0,7%
0,6%
0,5%
0,4%
0,3%
0,2%
0,1%
0,0%
Medical Therapy (MT)
Revascularization Therapy (RT)
(5341)
(870)
Nudi F et al, personal data on file
10%
9%
MT (No. 5341)
8%
7%
6%
5%
4%
3%
2%
1%
0%
negative
minimal
(1532)
(3142)
mild
moderate
severe
(174)
(353)
(140)
Myocardial Scintigraphy
Nudi F et al, personal data on file
Prognostic Value of Myocardial Perfusion Scintigraphy to Guide
Therapeutic Decision Making
Annual Rate of Death or Nonfatl Myocardial Infarction
Annual Rate of Death or Nonfatl Myocardial Infarction
Prognostic Value of Myocardial Perfusion Scintigraphy to Guide
Therapeutic Decision Making
1,2%
RT (No. 870)
1,0%
0,8%
0,6%
0,4%
0,2%
0,0%
negative
minimal
mild
moderate
severe
(35)
(127)
(50)
(351)
(307)
Myocardial Scintigraphy
Nudi F et al, personal data on file
Does Coronary Flow Trump Coronary Anatomy?
K. Lance Gould (JAmColl Cardiol Img 2009;2:1009 –23)
Prognostic Value of Myocardial Perfusion Scintigraphy to Guide
Therapeutic Decision Making
250
RT (No. 548 - 63%)
SM1
SM2
No. of patients
200
150
100
50
0
negative
minimal
mild
moderate
Myocardial Scintigraphy
Nudi F et al, personal data on file
severe
Prognostic Value of Myocardial Perfusion Scintigraphy to Guide
Therapeutic Decision Making
500
450
No. of patients
400
MT (No. 794 – 15%)
350
SM1
SM2
300
250
200
150
100
50
0
negative
minimal
mild
moderate
severe
moderate
severe
3500
No. of patients
3000
MT (No. 5341)
2500
2000
1500
1000
500
0
negative
minimal
mild
Nudi F et al, personal data on file