9/10/2013. September 12, pm. October 2010 through a generous grant provided by WAWA.

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September 12, 2013 6-9pm 9/10/2013 2 October 2010 through a generous grant provided by WAWA.

their risk as a part of primary prevention of heart disease.

1 September 12, pm 9/10/ October 2010 through a generous grant provided by WAWA. Goal has been to identify and risk stratify female patients at risk for heart disease in an effort to manage and minimize their risk as a part of primary prevention of heart disease. The goal is to also identify and treat heart disease early to prevent any future cardiac events in our female patients. W Center. Very diverse group of patients from as young as 30yrs to as old as 89yrs of age. 9/10/

Renee Bullock-Palmer, MD FACC FASNC FASE Director of Non-Invasive Cardiac Imaging Deborah Heart and Lung Center 9/10/2013 4 DOES THE PATIENT HAVE CHEST PAIN? a) Is it exertional? b) Is it substernal?

2 Renee Bullock-Palmer, MD FACC FASNC FASE Director of Non-Invasive Cardiac Imaging Deborah Heart and Lung Center 9/10/ DOES THE PATIENT HAVE CHEST PAIN? a) Is it exertional? b) Is it substernal? c) Is it relieved with NTG or rest <10mins? IS THE CHEST PAIN TYPICAL ANGINA (ALL THE DESCRIPTIVES ABOVE PRESENT) ATYPICAL ANGINA (2 OUT OF THE 3 DESCRIPTIVES ABOVE PRESENT) NON-ANGINAL (1 OR NONE OF THE DESCRIPTIVES PRESENT) 9/10/ Female patients may present with anginal equivalents such as exertional dyspnea resulting in reduced exercise capacity. These symptoms should also alert the physician to rule out coronary artery disease. This is particularly true for diabetic females who may not have the classic anginal symptoms. 9/10/

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This assessment is crucial in determining the BEST diagnostic path to take in diagnosing the presence of obstructive CAD.

in the patient presenting with angina or anginal equivalent, 9/10/2013 10 Relation between preand post-test probability.

Bayesian theory has shown that the value of non-invasive testing is greatest in patients with an intermediate pre-test probability of having CAD.

4 This assessment is crucial in determining the BEST diagnostic path to take in diagnosing the presence of obstructive CAD. The clinically assessed pre-test probability of CAD determines the type of test that should be ordered for the patient in determining the presence of obstructive CAD in the patient presenting with angina or anginal equivalent, 9/10/ Relation between preand post-test probability. Diagnostic accuracy improves with a test with a higher sensitivity and specificity. Bayesian theory has shown that the value of non-invasive testing is greatest in patients with an intermediate pre-test probability of having CAD. Assume certainty level. Very low pre-test probability (<5%): uncertainty will not be achieved. Low pre-test probability (5 10%): only certainty with a negative test result. Intermediate pre-test probability: (10 90%): certainty with a negative and positive test result. High pre-test probability: (>90%): only certainty with a positive test result 9/10/

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9/10/2013 22 A 68 year old female with a no prior cardiac history presented Cardiac Center with symptoms of a six month history of chest pressure, she had an unremarkable physical examination.

8 9/10/ A 68 year old female with a no prior cardiac history presented Cardiac Center with symptoms of a six month history of chest pressure, she had an unremarkable physical examination. She was referred for cardiac stress echocardiogram showed normal left ventricular size with normal left ventricular systolic wall motion, mildly elevated right atrial pressures but normal right side chamber size and function with no significant valve disease. 9/10/ She exercised via Bruce protocol for 10 minutes and 33 seconds achieving 12.8 METS, she achieved a peak heart rate of 160 bpm which was 105% age predicted maximum heart rate with mild chest pain and dyspnea towards the end of her exercise which was limiting. There were no ischemic EKG changes.. Her post exercise stress echo images revealed 9/10/

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10 9/10/ Patient was found to have a LCx to Right pulmonary artery fistula. She later went on to have a closure of this fistula with coil embolization. A few weeks later. 9/10/ /10/

11 Patients symptoms resolved and stress echo performed post interventions is as 9/10/ /10/ /10/

The fact that this fistula connected the high pressure arterial system in the coronary artery to the right pulmonary artery with a lower pressure likely explained this significant shunt through this

12 The fact that this fistula connected the high pressure arterial system in the coronary artery to the right pulmonary artery with a lower pressure likely explained this significant shunt through this fistula resulting in significant coronary steal thus resulting in ischemia that was detected in the LCx territory on stress echo. Patient achieved a good workload of 12.8 METS which is remarkable and indicates the importance of a symptom limited exercise stress test to maximize the sensitivity of stress echocardiography to detect ischemia rather than inappropriately stopping the treadmill exercise at target heart rate. Due to the lack of radiation with echocardiography we were able to perform a repeat stress echo to determine if coil embolization of the LCx to RPA fistula was successful in eliminating ischemia in the LCx territory without exposing the patient to any further ionizing radiation. 9/10/ y/o female with a h/o Dyslipidemia, Palpitations secondary to PVCs controlled with metoprolol succinate and a h/o obesity Cardiac Center as an initial visit with symptoms of chest pressure worsened with emotional distress and exertion. Also dyspnea on exertion. Had a suboptimal stress echo 2 years ago that showed no inducible wall motion abnormalities but was suboptimal due to technically limited views. Of note patient had chest pain with exercise on that study. Due to her presentation with typical angina and the fact that her last stress echo done 2 yrs ago was a technically limited suboptimal study she was referred directly for cardiac catheterization. Cardiac catheterization showed the following: 9/10/ /10/

9/10/2013 37 Patient had placement of a drug eluting stent to the LCx dyspnea on

13 9/10/ Patient had placement of a drug eluting stent to the LCx dyspnea on exertion resolved with improvement of her exercise capacity. 9/10/ /10/

ago and stress echo images were suboptimal.

14 In this case of progressive typical angina, there was a high level of suspicion for CAD especially as exercise had reproduced her symptoms of angina on her last stress echo 2 years ago and stress echo images were suboptimal. Due to high index of suspicion patient was sent directly for cardiac catheterization rather than non-invasive stress imaging. 9/10/ /10/

Dyspnea with limited exercise capacity <1 ½ block.

15 76 y/o female with PMHx of Gallstones and Cardiac Center with chest pain describes as gaseous in nature occasional pressure not relieved with Aspirin no clear relief with NTG. Dyspnea with limited exercise capacity <1 ½ block. Ex-tobacco smoker BP 152/72, LDL 146, HDL 57, BMI 39 NCEP ATP III risk calculated as: Calculated 10 year risk of 9%. Intermediate Pre-test probability 15

16 Patient had a pharmacological nuclear stress test with Lexiscan. Presence of chest pain 7/10 reversed with aminophylline and No EKG ischemic changes Medium to large reversible inferior/inferolateral defect from apex to base, suggestive of ischemia in the LCx. Normal wall motion and chamber size TID: 1.5 LVEF: 62% 16

Followed up since then and symptoms have resolved.

17 Severe 90% disease of the proximal portion of a very large OM1 Had successful drug eluting stent placement to the OM1 and placed on aspirin and plavix. Followed up since then and symptoms have resolved. She was placed on additional Metoprolol Succinate ER and Pravastatin for blood pressure and lipid management. 17

18 Although this was in a single coronary territory there were several high risk features if the scan that suggested the necessity of a coronary angiogram and PCI: Transient ischemic dilation (TID) suggesting a large area of jeopardized ischemic myocardium Large area of ischemia on the scan. The fact that pharmacologic stress ahd to be done as patient had poor exercise function secondary to her symptoms. 9/10/ year old female with history of hypertension and dyslipidemia presented to dyspnea on exertion. She was referred for nuclear stress testing and 2d echocardiogram. Intermediate Intermediate risk patient She was referred for nuclear stress testing and 2d echocardiogram. 9/10/

9/10/2013 55 Patient was found to have a large area of prior infarction in the LCx and

LV was very dilated with a LVEF of 15% with apical dyskinesis This was a diagnostic

19 9/10/ Patient was found to have a large area of prior infarction in the LCx and LAD territory with no evidence of peri-infarct ischemia. LV was very dilated with a LVEF of 15% with apical dyskinesis This was a diagnostic study as patient had no prior coronary evaluation of h/o AMI. In view of this she was referred for cardiac cath. Cath 19

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22 Severe triple vessel disease with critical LM disease. AAA 4.1cm Porcelain aorta and transverse aorta Significant PAD disease Patient was assessed by CT Surgery She was referred for viability study. 22

9/10/2013 67 9/10/2013 68 No significant viability in the

23 9/10/ /10/ No significant viability in the areas of infarction in the LAD and LCx territories. LVEF 23% 23

be high risk for surgery therefore patient had high risk

24 Due to lack of viability, LVEF 23%, and Renal disease (GFR of 35) as well as porcelain aorta, patient was thought to be high risk for surgery therefore patient had high risk PCI of LM with Impella support. medically/conservatively. 24

9/10/2013 74 Patient continues to do well in clinic, she had placement of a Biventricular Pacemaker with AICD in May 2013.

25 Patient was seen in clinic the following week and was doing remarkably better and her dyspnea had significantly decreased. 3 months later patient had a cardiac CT to assess patency of Left main stent. 9/10/ Patient continues to do well in clinic, she had placement of a Biventricular Pacemaker with AICD in May Currently on regimen of aspirin 81mg, clopidogrel 75mg, Coreg 12.5mg bid, Hydralazine 10mg tid, Imdur 30 mg, Lisinopril 5mg, Lasix 20 mg daily, Crestor 20 mg daily. 9/10/

26 In DIAGNOSTIC cases of widespread area of infarction especially in view of severely decreased LVEF, it is important to refer for cardiac cath even in the absence of ischemia. Viability with thallium is useful but remember Sn is ~80-85% and Sp is ~60%. Coronary CTA is appropriately useful for LM stent surveillance. 26

Sensitivity is 85-95% Specificity is 96-98% Negative predictive value is 93-100%.

but has other indications such as: Evaluation for anomalous origin of the coronary artery Evaluation

27 Sensitivity is 85-95% Specificity is 96-98% Negative predictive value is %. 9/10/ /10/ Coronary CTA is not only useful for detecting Coronary artery disease (CAD) but has other indications such as: Evaluation for anomalous origin of the coronary artery Evaluation of congenital heart disease as well as after placements of palliative shunts etc for congenital heart disease. 9/10/

exertion. She was referred for ECHO and Ex. Treadmill stress.

28 Cardiac Center with a h/o asthma, GERD and a hiatal hernia presented with a 6 month h/o left sided chest pressure radiating to the left arm and axilla as well as dyspnea on exertion. She was referred for ECHO and Ex. Treadmill stress. ECHO showed normal LV size and function, normal heart valve structure and function. 9/10/ /10/ /10/

9/10/2013 85 Patient had exercised for 8 mins., achieved 10.

29 9/10/ Patient had exercised for 8 mins., achieved 10.1 mets and reached a peak HR of 185bpm (98% MPHR). Patient had no angina but had dyspnea on exertion. Test was interpreted as being EQUIVOCAL for ischemia. Patient was referred for Cardiac CT due to persistent symptoms and equivocal result of Ex treadmill stress 9/10/ RA LA Ao PA RCA from LCC LMCA 9/10/

Patient was found to have an anomalous RCA arising from the left main coronary artery. Patient was managed on Toprol XL with adequate control of symptoms.

30 Patient was found to have an anomalous RCA arising from the left main coronary artery. Patient was managed on Toprol XL with adequate control of symptoms. Nuclear stress images done while on Metoprolol, patient exercised for 8 minutes achieved 10.1 METS with no angina or dyspnea and there were no ischemic EKG changes. Nuclear perfusion showed no evidence of myocardial ischemia or infarction. 9/10/ Usually the anomalous coronary takes an intramural course within the wall of the aorta and has a slit like opening which leads to obstruction especially at rapid heart rates. unroofing of the RCA from the Left main coronary sinus and re-implantation of the RCA into the right coronary sinus However medical management is first method of treatment with BetaBlockers or calcium channel blockers. Signs of worse prognosis would be presence of syncope especially with exertion, in these cases surgery should be strongly considered. 9/10/ y/o female with h/o HTN, DM type II, Hypothyridism, Dyslipidemia and h/o AVNRT s/p ablation of accessory pathway in February exertion with reduced exercise capacity to < 1 flight of stairs and with limitiation of her activities of daily living. Patient had a nuclear stress test done 1 year ago at another facility that reported normal myocardial perfusion with no evidence of myocardial ischemia or infarction. Patient had a complete evaluation by Pulmonary service and there was no discernible pulmonary etiology for her symptoms. Due to presence of disabling symptoms and an unremarkable nuclear stress test done 1 yr ago at another facility patient was referred for cardiac catheterization. 9/10/

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32 9/10/ /10/ RCA RA LMCA Ao PA LA 9/10/

Cardiac CT confirmed the presence of an anomalous LMCA arising from the right coronary cusp and coursing POSTERIORLY behind the aorta to branch into the LAD and LCx.

33 Cardiac CT confirmed the presence of an anomalous LMCA arising from the right coronary cusp and coursing POSTERIORLY behind the aorta to branch into the LAD and LCx. LAD showed severe proximal and mid CAD. There was moderate proximal RCA disease and severe disease in the RPDA and RPLB. Of note a 12 mm right breast mass was seen that was suspicious for right breast carcinoma. 9/10/ Patient had PCI with DES placed to the RPDA and RPLB branch 2 weeks later via the right radial artery approach. 2 weeks later she had PCI with DES of anomalous LM/proximal and mid LAD via the right radial artery approach with good angiographic result. Patient incidental finding in the right breast was diagnosed as carcinoma and patient had successful right breast lumpectomy and is currently on chemotherapy with anastrazole 1mg po daily and her LVEF has remained normal at >55% with normal wall motion. now able to perform all her activities of daily living without any limitations. Maintained on clopidogrel, aspirin, atorvastatin, lisinopril, furosemide and potassium supplementation. 9/10/ /10/

9/10/2013 10 0 9/10/2013 10 1 Diabetic females may not present with the classical anginal symptoms and there

presence of a normal non-invasive stress test, especially when done > 1 yr. ago.

34 9/10/ /10/ Diabetic females may not present with the classical anginal symptoms and there should be a high level of suspicion when these patient present with disabling exertional dyspnea even in the presence of a normal non-invasive stress test, especially when done > 1 yr. ago. With the help of our endovascular team at Deborah she was spared CABG with successful angiographic results with PCI. 9/10/

65% of diabetics die from heart disease or stroke 4.2 million American women have diabetes American Heart Association Centers for Disease Control and Prevention 10 Manson JE, et al.

35 65% of diabetics die from heart disease or stroke 4.2 million American women have diabetes American Heart Association Centers for Disease Control and Prevention 10 Manson JE, et al. Prevention of Myocardial 9/10/2013 Infarction Framingham Heart Study Women with diabetes mellitus are about 5 times more likely to have CAD vs. women without diabetes Women with diabetes are approximately twice as likely to have CAD compared to men with diabetes. Even if women had diabetes for <4 years, their risk of CAD was significantly elevated Kannel W. Am Heart J Manson J, et al. 9/10/2013 Arch Intern Med CAD mortality rates in diabetics, especially women, have not decreased to the same extent as those in the general population In a large patient population referred for coronary disease, diabetic women had the highest mortality rates Early detection is important and there should be a high level suspicion for the presence of CAD even in the absence of overt symptoms. Gu K, et al. JAMA Giri S, et al. 9/10/2013 Circulation

36 Relative Risk Age group Men Women In Adult Treatment Panel III, diabetes is regarded as a CAD risk equivalent; lowers LDL goal <100 mg/dl) Geiss LS, et al. Diabetes in America (2nd ed) Anomalous LM from the right coronary cusp is more benign when it takes a posterior course behind the aorta (retro-aortic) as compared to an interarterial course between the aorta and the main pulmonary artery which is associated with sudden cardiac death especially due to the valve-like/slit like opening of this anomaly and its course between the great vessels. This patient likely presented much later in life in her eighth decade due to the fact that she had the more benign POSTERIOR course. 9/10/ Cardiac CT can often times detect important incidental extracardiac findings such as breast CA as was the case in our patient. 9/10/

9/10/2013 10 9 CirculationJuly 1, 1997 vol. 96 no.

37 9/10/ CirculationJuly 1, 1997 vol. 96 no /10/ Circulation July 1, 1997 vol. 96 no /10/

Hence the design and enrollment in the national

38 Perform Truth is that the answer to this question in the cardiology community is essentially UNKNOWN. Hence the design and enrollment in the national prospective randomized trial THE PROMISE trial. Sponsored by the NIH. 38

39 Multi-center, randomized trial of 10,000 subjects Comparing the clinical effectiveness of imaging strategies, either anatomic (cardiac computed tomography, CT) or functional testing (exercise ECG, stress nuclear or stress echo) consistent with Performed in outpatient settings including acute and primary care and cardiology offices in ~250 sites in North America Time to first event (MACE) to include: Death Myocardial Infarction Unstable angina requiring hospitalization Major complications from cardiovascular procedures & testing: - Stroke - Bleeding - Anaphylaxis Renal Failure defined as requiring dialysis Deborah is one of the national sites of this landmark study. We are currently enrolling patients. Remember the inclusion criteria. New or worsening chest pain. years No prior evaluation for this episode of symptoms. 39

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Use of Nuclear Cardiology in Myocardial Viability Assessment and Introduction to PET and PET/CT for Advanced Users

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