MD F A F C A C MAS A N S C

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1 Myocardial Perfusion Imaging and Coronary Calcium Scoring: Complimentary or Competitive David Wolinsky MD FACC MASNC Section Head Nuclear Cardiology, Cleveland Clinic Florida Immediate Past President, American Society Nuclear Cardiology Disclosures Speaker Astellas Pharma Consultant Astellas Pharma Steering Committee Adenosine Therapeutics Immediate Past President ASNC Discussion Anatomy vs Physiology Long term vs Short Term Risk Assessment Value of MPI The patient with very high Calcium ScoreAssessment Positive Family History Assessing Incidental Coronary Calcium PET Perfusion 1

2 Cardiac Testing What ;Why? The Value of Noninvasive Testing Traditional Determine cause of symptoms Diagnose disease Define treatment Risk Stratify Modern Paradigm Shaw JACC Imaging 2010 No One Pair of Shoes for ALL Occasions 2

3 Anatomic vs Functional Imaging Courtesy Leslee Shaw PhD Calcium Score vs MPI Calcium Score MPI Anatomic Test Defines atherosclerosis Long term risk associated with increasing CAC score Used in assessing Asymptomatic patients Combined with CCTA, PET,SPECT for symptomatic patients Guideline to medical therapy or further noninvasive testing Physiologic test Short term risk (2 yr) very low with negative test Risk stratifies symptomatic patients Gatekeeper to invasive studies Proven management chronic CAD Diagnostic Accuracy MPI Shaw Jl Nuc Card

4 Prognostic Value Normal MPI Shaw Jl Nuc Card 2012 Stress MPI and Risk Hachamovitch Jl Nuc Card 2005 Shaw Jl Nuc Card 2012 SPECT vs PET SPECT Readily available Extensive AUC Extensive Outcomes data based on stress results Data on Medical vs Revascularization therapy Exercise stress data Raw Spinning Data PET Less available, $$$$$ No specific AUC Limited outcomes data Only pharm stress Attenuation Correction Lower radiation Less training Coronary flow reserve Less likely to be covered by insurance 4

5 What is Interelationship Between MPI and Calcium Score Prognosis MPI Shaw JNC 2012 Multimodality AUC 5

6 Sequential Testing Relationship CAC and Ischemia Predominantly symptomatic pts Intermediate pretest risk Schenker et al Circulation. 2008;117: ) 6

7 Ability CAC to Predict Ischemia Risk Stratification- Hard Events Absolute Stratification by MPI Relative Stratification by CAC Schenker et al Conclusion PET can achieve effective risk stratification for major cardiac events with good discrimination between high and low risk patients in patients with intermediate pretest risk Two year risk stratification with MPI provides an appropriate warranty period for a normal scan and appropriate risk that justifies further therapy in abnormal scans (Await ISCHEMIA) CAC can define long term risk. It can help determine which is the most appropriate functional test to do. It may also help refine risk of subsequent testing 7

8 The Patient with Very High Calcium Score- Greater than 1000 Concern that with severe extensive coronary disease that stress testing would provoke balanced ischemia and false negative stress test Triple vessel disease vs left main CAD Ancillary markers ECG, TID may help LVG 47 yo male HTN, FHX, Active tobacco (30-40 pack- years), Poor diet, History carotid stenosis. On Pravachol Calcium Score 2057 SOB climbing 15 stairs. No chest Pain Normal ECG LVG Intermediate to high risk Referred for MPI 11.9 METS No chest pain. No ECG changes Normal Perfusion Rest stress study No TID Normal EF 8

9 LVG LVG What is His Risk? Pilot Study Nonconclusive Unusual Finding Relatively uncommon finding Yuoness Eur J Nucl Med Mol Imaging (2015) 42:

10 Does presence of Significant CAC modify risk of normal MPI CAC increases pretest likelihood of having ischemia (Baye s Theorem) Is their a difference in prognosis between patients followed with CAC and normal MPI and patients followed with normal MPI? Rozanski JACC Vol. 49, No. 12, 2007 : CAC did not modify MPI based risk Patients with CAC did not have increased risk with normal scan Presence of CAC did not change risk based on clinical and MPS alone Evaluation of the Patient with Postive Family History Doc. I want all the tests done. My best friend just died. My father had a heart attack at 58. I want everything. I have great insurance. They will cover everything. Do it all! 10

11 Family History CAD Framingham does not include +FHx FHx cannot be quantitated There is no data supporting advanced imaging stress testing in this population. Can CAC be a surrogate for +FHX and help determine high risk patients? Does CAC modify risk stratification of MPI in these patient? Family History CAD There is an asssociation between premature CAD and presence of CAC. CAC provides long term risk stratification. There is no data to suggest CAC modifies short short term mortality risk in these patients beyond the general population Many of these patient have too low a risk profile at time they are studied Nasir Circ Knapper and Shaw Heart 2016 PET Do it Right Bad PET is not a substitute for Bad SPECT PET is not a substitute for SPECT if the patient can exercise and has good imaging characteristics PET s true value is not improved images but coronary flow reserve (CFR) Doing CFR is not easy 11

12 PET Perfusion-Rb Courtesy Wael Jaber MD Abnormal PET Perfusion Courtesy Wael Jaber MD PET-CT Attenuation Correction 12

13 Coronary Flow Reserve 13

14 Reclassification with CFR Courtesy Leslee Shaw PhD 14

15 Summary SPECT and PET MPI are valuable tools for assessing coronary physiology and determining ischemic burden. They are most appropriately used in assessing intermediate to high risk symptomatic patients. CAC assesses the presence of preclinical atherosclerosis and long term risk Though often used in different populations, when combined in appropriate patients they are complementary to fine tune short term risk I have a simple view of Calcium Score- We Need Dr Nasir Segmental rest perfusion measurements ranged from 0.8 to 0.9 ml/min/g of tissue, while hyperemic measurements ranged from 3.1 to 3.3 ml/min/g of tissue. Myocardial perfusion reserve measurements ranged from 3.3 to 3.6. Thank you 15

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