DECLARATION OF CONFLICT OF INTEREST

Transcription

1 DECLARATION OF CONFLICT OF INTEREST

2 The additive prognostic value of myocardial perfusion defects, coronary flow reserve and wall motion abnormalities during dipyridamole contrast stress-echo: a prospective study Nicola Gaibazzi Fausto Rigo, Claudio Reverberi Parma University Hospital and Mestre Venice - Italy The presenter has received research grants from Bracco and GE-healthcare

3 Gould revisited ECG 30 years later >3 CFR WM ~ % 50% 70% 95% Behaviour of perfusion and wall motion during stress-echo with progressively increasing coronary stenosis. Perfusion abnormalities become apparent before wall motion abnormalities Stenosis grade Gould, Am J Cardiol 1974-Courtesy F.Rigo, modified

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5 Incremental accuracy of combined contrast myocardial perfusion&wm analysis over WM for CAD detection is mainly due to much higher sensitivity, with relatively smaller decrease in specificity 400 pts, all undergoing clinically indicated angiography Dip 0.84mg/kg/6min 70 pts undergoing clinically indicated angiography, Exercise-Low Dip Moir S, Haluska BA, Jenkins C, Fathi R, Marwick TH. Circulation Aug 31;110(9): Gaibazzi N, Rigo F, Reverberi C. J Am Soc Echocardiogr. 2010;23:

6 Pharmacologic Stressecho Sensitivity & Feasibility for detection of CAD>50% from published literature The addition of contrast makes: 1) accurate wall motion analysis feasible in almost 100% of pts 2) it allows for myocardial perfusion analysis in the vast majority of pts 3) coronary Doppler LAD imaging becomes also more feasible Wall motion+perfusion Sens~90-95% Total Feasibility remains 95% (lower for perfusion) LVO wall motion Sens~75%-----Higher(~95%) Feasibility Specificity Standard wall motion Sensitivity~70%-----Feasibility ~80% in unselected population

7 Normal flash-replenishment sequence at stress: either triggered or realtime At stress, when flow increases up to 4 times, the microbubbles take up to seconds to refill the ultrasound beam elevation (4mm) after they have been cleared by repeated high frequency high-mi impulses (flash) 4-chamber Endsystolic triggering: 1 endsystolic image per cycle 4-chamber 4-chamber 2-chamber Real-time imaging: Endsystolic triggering: 1 endsystolic image per cycle Endsystolic triggering: 1 endsystolic image per cycle

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9 MP abnormal only

10 Incremental value of combined contrast WM&myocardial perfusion over wall motion for cardiac prognosis Contrast Stress-Echocardiography Predicts Hard Cardiac Events in Patients with Suspected Acute Coronary Syndrome but nondiagnostic Electrocardiogram and Normal 12-hour Troponin. Tsutsui JM, Elhendy A, Anderson JR, Xie F, McGrain AC, Porter TR. Prognostic value of dobutamine stress myocardial contrast perfusion echocardiography. Circulation Sep 6;112(10): Gaibazzi N, Reverberi C, Senior R. Contrast Stress-Echocardiography Predicts Hard Cardiac Events in Patients with Suspected Acute Coronary Syndrome but nondiagnostic Electrocardiogram and Normal 12-hour Troponin. JASE 2011 in press

11 Wall Motion-contrast LVO settings Myocardial perfusion Original ESC abstract submitted describing data on first 419 pts, from 2 centers Enrollment January 2009 until March 2010 Last follow-up Dec combined events -16 hard events CFR-LAD with contrast without contrast with contrast

12 Final data: StressechoParmaAndriaMestre: SPAM study Enrollment January March 2011 Patients were included at the University Hospital in Parma, Italy (n 470); Umberto I Hospital in Mestre-Venice, Italy (n 161) and Andria Hospital in Andria, Bari, Italy (n 121). Median follow-up 495 days (1st quartile, 245 days; 3rd quartile, 659 days) 85 Test driven revascularizations(<90 days) censored at time of the procedure Inclusion criteria: (i) stable chest pain syndrome (ii) absence of absolute contraindications to dipyridamole (iii) absence of known allergy to sulphonamyde containing products Exclusion criteria were: (i) inadequate acoustic window (ii) severe valvular or congenital heart disease (iii) suspected pregnancy (iiii), significant comorbidity reducing life expectancy to less than 1 year; Death, non-fatal myocardial infarction (MI) and unstable angina requiring urgent revascularization were registered as clinical events. 19 Hard events, 48 total cardiac events

13 StressechoParmaAndriaMestre: SPAM study Total cardiac events-univariable Cox models HR CI95% P-value Harrell' s C CI95% Demographics/cardiac risk factors BASELINE CHARACTERISTICS Patients number 718 Age, ys±sd 65±11 interquartile range Gender M/F 442/276 Risk factors and patient history, Hypertension 485 (68) Hypercholesterolaemia 422 (59) Smoking habit 168 (23) Diabetes mellitus 200 (28) Family history of CAD 238 (33) Reduced ejection fraction, LVEF <50% 172 (24) Known CAD 226 (31) Previous myocardial infarction 135 (19) Previous revascularization 221 (31) Contrast-StressEcho Pts with reversible WMA 129 (18) Pts with CFR-LAD <2 275 (38) Pts with reversible MPD 198 (27) Pts with reversible WMA and CFR-LAD<2 83 (12) Pts with reversible WMA or CFR-LAD<2 321 (45) Pts with reversible WMA or CFR-LAD<2 or reversible MPD 351 (49) Age Gender Family History of CAD Smoking Habit Hypercholesterolemia Diabetes Mellitus Hypertension Obesity CV history PreviosMI/knowCAD/any revasc Previous MI Previous PCI/CABG Therapy at the time of stress-test ASA Beta Blockers ACE Statins Stress-echo Reduced EF CFR LAD< Pos. Ind. WM Pos. Perf. MPD Pos. Ind. WM or CFR LAD<

14 EUROECHO CONGRESS - COPENHAGEN - TEACHING COURSE 2010

15 Combined Cardiac events-multivariable Cox models Model 3-Clinical+ Model 1-Clinical Parameters Model 2-Clinical +WMA combined WMA+CFR p- p- HR CI95% P-value HR CI95% HR CI 95% value value Model 4-Clinical+MPD HR CI 95% p- value Hypercolesrolemia Diabetes Mellitus Prev.MI or Known CAD or revascularization Reversible WMA Reversible WMA/CFR < Reversible MPD AIC Harrell's C ( ) ( ) ( ) ( ) Clin.Param. Clin.Param.+WMA+CFR<2 P-value for Harr. C diff. 0,023 Clin.Param. Clin.Param.+MPD P-value for Harr. C diff. <0.001 Clin.Param.+WMA+CFR<2 Clin.Param.+MPD P-value for Harr. C diff. 0,09 NRI P-value Clin.+WMA+CFR vs Clin. 0,001 NRI P-value Clin.+MPA vs Clin. 0,009 NRI P-value Clin.+MPD vs Clin+WMA CFR 0,859

16 Model comparison (combined events) Clinical+WMA vs Clinical+WMA+CFR<2 Clinical+WMA vs Clinical+MPD AUC Clin.Param.+WMA 0.676( ) Clin.Param.+WMA+CFR< ( ) P-value for AUC diff. 0,078 Clin.Param.+WMA Clin.Param.+WMA+CFR<2 NRI P-value for Harr. C diff. P-value 0,187 Clin.+WMA+CFR vs Clin.+WMA <0.01 AUC Clin.Param.+WMA 0.676( ) Clin.Param.+MPD 0.768( ) P-value for AUC diff. 0,003 Clin.Param.+WMA Clin.Param.+MPD P-value for Harr. C diff. 0,002 NRI P-value Clin.+MPD vs Clin.+WMA 0,009

17 Final Remarks: Both WM+CFR-LAD and MP are prognostically useful for risk stratification on top of clinical variables Both may be useful on top of clinical variables and stress-echo WM analysis, although in our study this is more clearly demonstrated for MP rather than WM+CFR-LAD, probably for insufficient sample numerosity/follow-up time, given the low event-rate. Although these data seem to suggest that MP is superior compared to WM-CFR-LAD, statistically there is no significant difference between the multivariable model substituting one with the other as the additional stratifying parameter on top of other available data. It looks like either MP or WM+CFR-LAD should definitely be added to WM for risk stratification, depending on the center preference, contrast availability and on which is best acquired in the specific patient.