The use of Cardiac CT and MRI in Clinical Practice

Size: px
Start display at page:

Download "The use of Cardiac CT and MRI in Clinical Practice"

Transcription

1 The use of Cardiac CT and MRI in Clinical Practice Matthew W. Martinez, MD Assistant Professor of Medicine LVPG - Lehigh Valley Heart Specialists Lehigh Valley Health Network Oct. 3, 2009

2 DISCLOSURE Relevant Financial Relationship(s) None Off Label Usage None

3 Learning Objectives Review basics of cardiac MRI and CTA Review utility of cardiac CT and MRI in clinical practice Clinical cases

4 Noninvasive Tests for the Diagnosis of Coronary Artery Disease TMET SPECT Echo PET CT MRI

5 Cardiac MRI Black-Blood (Spin-Echo) White-Blood SSFP Delayed Enhancement Still Images Morphology Edema Cine Imaging Morphology and function Still Images Delayed Enhancement

6 SSFP = 2D echo

7 Delayed Enhancement-MRI Images obtained minutes post-contrast (Gd( Gd) Normal myocardium Black * Necrosis/scarring/inflammation Hyperenhanced Image in Press Nature of Clinical Practice

8 Abundance of validation data in animal models Dog with near- transmural infarct Visible on SPECT and DE-MRI 3 dogs with subendocardial infarcts Visible on DE-MRI only Infarct size by MRI Delayed Enhancement CP

9 Hyperenhancement Patterns Ischemic Subendocardial infarct Nonischemic Mid-wall HE Epicardial HE Transmural infarct Idiopathic dilated cardiomyopathy Myocarditis Hypertrophic cardiomyopathy Right ventricular pressure overload Sarcoidosis Myocarditis Anderson Fabry disease Shah DJ et al: Magnetic resonance of myocardial viability

10 Mass RV Function Cardiomyopathies

11 Cardiac MRI Functional LVEF LV mass Wall Motion LV ESV LV EDV Analysis LV stroke volume RV ESV RV EDV RV Stroke volume RVEF Tissue characterization Infarct identification Infarct size Viability

12 Evaluation of Chest Pain Prognosis Viability Imaging ACS Function Infarct size Unstable Hemodynamics and Complications CP

13 Functional LVEF LV mass Wall Motion LV ESV LV EDV Analysis LV stroke volume Cardiac MRI RV ESV RV EDV RV Stroke volume RVEF Tissue characterization Infarct identification Infarct size Viability Prognosis

14 Case 1 57-year year-old woman Sudden onset of achy, continuous, substernal, 8/10 chest pain Radiating to back Pain came on at rest Cardiac Risk Factors Never Smoker Hyperlipidemia (untreated) Sedentery Lifestyle Troponin 0.56, 0.5 (3h), 0.36 (6h)

15 Echocardiogram

16 Cardiac Catheterization

17 Cardiac Catheterization

18

19 Cardiac MRI

20 Cardiac MRI Acute MI

21 Importance of unrecognized Myocardial scar Aim: Assess the prognostic significance of unrecognized myocardial scar by MRI in patients without a history of MI 195 patients without known prior MI 1) Pts with unknown status of CAD referred for assessment of LV fxn,, scar 2) Pts with angiographic CAD referred for prediction of segmental wall motion after revascularization (22) 16 month follow-up Circulation, 2006

22 Case Presentation 2 History of Present Illness 46 year old man presents to ED, 6:30 AM with 10/10 chest pain Began 4:30 AM - Radiated to left arm No SOB, no n/v Feeling ill with episodic CP over past 2 weeks Past Medical History Hyperlipidemia at health fair Medications none Social History 30 pack year history, currently smokes 1 pack/week

23 Initial ECG

24 Angiography Results Troponin Elevation: Baseline hr hr 0.49

25 Cardiac MRI

26 Delayed Enhancement Myocarditis

27 Etiologies of Elevations of Cardiac Plaque rupture mediated necrosis STEMI nstemi Alterations in coronary vasomotor tone Coronary spasm Subarachnoid hemorrhage Intracranial hemorrhage Apical Ballooning Syndrome Transplant vasculopathy Troponins Sub-endocardial myocyte necrosis CHF Hypertensive crisis Acute pulmonary embolism Tachycardia-mediated CHF, Pressure overload Volume-Pressure overload (renal failure, CHF, fluid resuscitation) Anemia Hypotension Aortic Stenosis and / or Regurgitation Hypertrophic Cardiomyopathy Amyloid heart disease

28 Problem Solving Tool Troponin is extremely sensitive for detecting myocardial cell necrosis 9-14% of patients who present with ACS will have normal or non-significant disease on coronary angiography This cohort of patients have been shown to have a poorer prognosis; potentially from clinical uncertainty (TACTICS-TIMI TIMI-18)

29

30 Development of CT MDCT 4-slice 1998 MDCT 16-slice 2002 MDCT 40-slice 2005 MDCT 320-slice 2008 DSCT 128-slice 2009 MDCT 8-slice 2001 MDCT 64-slice 2004 DSCT 64-slice

31

32 CT Scanning Minimally Invasive Angiography

33 Nuclear Cardiac Imaging Diagnostic Accuracy Imaging Modality # of Studies Patients Sen. (%) Spec. (%) Accuracy SPECT 99m Tc* > 45 ~7, % 86% CTA* >20 ~2, GOLD Standard - Angiography

34 MDCT in Clinical Practice A Clinician s s Viewpoint Gold Standard Anomalous coronary vessels Coronary fistula, aneurysms Coronary Disease Great for ruling out CAD OK (but not great) for disease severity

35 Patient Population High Probability Intermediate Probability Low Probability Definite signs of CAD: Typical chest pain ECG changes & cardiac enzyme elevation Personal history of CAD

36 Patient Population High Probability Intermediate Probability Low Probability Indeterminate signs of CAD: Atypical chest pain Discordant symptoms & stress test results High risk factors & negative stress test Low risk factors & positive stress test Patient reluctant to have a cath

37 Patient Population High Probability Intermediate Probability Low Probability CTA

38 Patient Population High Probability Intermediate Probability Low Probability Doubtful signs of CAD: Worried well

39 Patient Population High Probability Intermediate Probability Low Probability? CTA?

40 Patient Population High Probability Intermediate Probability Low Probability CTA? CTA?

41 History 49yr female previously healthy 6+ months of dyspnea on exertion No personal history of hyperlipidemia, HTN, CAD, smoking, and family history Currently on no cardiac medications BMI = 36.

42 History Exercise Time: 7.3 minutes Test was stopped due to dyspnea and leg fatigue 32,736 (SBP x HR) Stress Echo with an area of anterior ischemia was noted from mid to the base ECG was negative

43 Appropriateness for CT

44

45

46

47

48 References supporting the use of coronary CTA following equivocal exercise sestamibi Schuijf, J., et. al, Relationship between Noninvasive Coronary Angiography with Multi-slice Computed Tomography and Myocardial Perfusion Imaging Journal of the American College of Cardiology; ; December 19, Rubinstein, R., et. al, Usefulness of 64-slice multidetector computed tomography in diagnostic triage of patients with chest pain and negative or nondiagnostic exercise stress test result American Journal of Cardiology 2007; 99: Danciu, S., et. al, Usefulness of multislice computed tomography coronary angiography to identify patients with abnormal myocardial perfusion stress in whom diagnostic catheterization could be avoided American Journal of Cardiology 2007; 100: Dewey, M., et. al, Head-to-head comparison of multislice computed tomography and exercise electrocardiography for diagnosis of coronary onary artery disease European Heart Journal 2007; 28:

49 Case 2 chest pain 55 y/o woman Substernal chest discomfort 2 mos Emotion and sometimes exertion Today 10 min chest and back pain at rest ED Postmenopausal Prior smoker >15 yrs ago No FH No meds Mild HTN

50 Exam: no murmur BP 142/88 Troponin: <.01 Creat: 0.8

51 Acute chest pain What do you want to know? Risk of acute event High Angio Low/inter Probability CAD Low Intermediate

52 What to Do? Sestamibi Stress Echo Coronary CTA

53 CTA vs Standard of Care in Chest Pain Chest pain Low risk 197 pts MSCT Normal Nondiag Severe Standard care Stress Nucs Stress Nucs HOME Angio HOME Goldstein JACC :863-71

54 CTA 67% normal and discharged 9% severe CAD cath 24% needed further eval Length of stay: lowered by 43% 12.5 hrs vs 22.1 hrs Cost of care: lowered by 15% $1586 vs $1872 Goldstein JACC :863-71

55

56 Conclusions Cardiac MRI EF, ESV, EDV, RV function, infarct size ICM vs DCM ACS Cardiac CT Excellent for exclusion of CAD in low to intermediate risk ED patients, equivocal stress test

57 THANK YOU!

Advanced Imaging MRI and CTA

Advanced Imaging MRI and CTA Advanced Imaging MRI and CTA Who and why may benefit. Matthew W. Martinez, M.D. FACC Lehigh Valley Health Network Director, Cardiovascular Imaging Learning Objectives Review basics of CMR and CTA Review

More information

The Value of Stress MRI in Evaluation of Myocardial Ischemia

The Value of Stress MRI in Evaluation of Myocardial Ischemia The Value of Stress MRI in Evaluation of Myocardial Ischemia Dr. Saeed Al Sayari, MBBS, EBCR, MBA Department of Radiology and Nuclear Medicine Mafraq Hospital, Abu Dhabi United Arab Emirates Introduction

More information

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

Use of Nuclear Cardiology in Myocardial Viability Assessment and Introduction to PET and PET/CT for Advanced Users Use of Nuclear Cardiology in Myocardial Viability Assessment and Introduction to PET and PET/CT for Advanced Users February 1 5, 2011 University of Santo Tomas Hospital Angelo King A-V Auditorium Manila,

More information

1. LV function and remodeling. 2. Contribution of myocardial ischemia due to CAD, and

1. LV function and remodeling. 2. Contribution of myocardial ischemia due to CAD, and 1 The clinical syndrome of heart failure in adults is commonly associated with the etiologies of ischemic and non-ischemic dilated cardiomyopathy, hypertrophic cardiomyopathy, hypertensive heart disease,

More information

Case based learning: CMR in Heart Failure

Case based learning: CMR in Heart Failure Case based learning: CMR in Heart Failure Milind Y Desai, MD FACC FAHA FESC Associate Professor of Medicine Heart and Vascular Institute, Cleveland Clinic Cleveland, OH Disclosures: none Use of Gadolinium

More information

Current Indications for Cardiac MRI: What You See is What You Get?

Current Indications for Cardiac MRI: What You See is What You Get? Current Indications for Cardiac MRI: What You See is What You Get? Javier Ganame, MD, PhD, FASE No disclosures Cardiology Update, Niagara, Sept 24th, 2016 The Ideal Diagnostic Technique Easy to apply Accurate

More information

Cardiac MRI: Cardiomyopathy

Cardiac MRI: Cardiomyopathy Cardiac MRI: Cardiomyopathy Laura E. Heyneman, MD I do not have any relevant financial relationships with any commercial interests Cardiac MRI: Cardiomyopathy Laura E. Heyneman, MD Duke University Medical

More information

Cardiology for the Practitioner Advanced Cardiac Imaging: Worth the pretty pictures?

Cardiology for the Practitioner Advanced Cardiac Imaging: Worth the pretty pictures? Keenan Research Centre Li Ka Shing Knowledge Institute Cardiology for the Practitioner Advanced Cardiac Imaging: Worth the pretty pictures? Howard Leong-Poi, MD, FRCPC Associate Professor of Medicine St.

More information

Disclosures. GETTING TO THE HEART OF THE MATTER WITH MULTIMODALITY CARDIAC IMAGING Organ Review Meeting 25 September. Overview

Disclosures. GETTING TO THE HEART OF THE MATTER WITH MULTIMODALITY CARDIAC IMAGING Organ Review Meeting 25 September. Overview GETTING TO THE HEART OF THE MATTER WITH MULTIMODALITY CARDIAC IMAGING Organ Review Meeting 25 September Disclosures None relevant to this presentation Mini Pakkal Assistant Professor of Radiology University

More information

Rational use of imaging for viability evaluation

Rational use of imaging for viability evaluation EUROECHO and other imaging modalities 2011 Rational use of imaging for viability evaluation Luc A. Pierard, MD, PhD, FESC, FACC Professor of Medicine Head, Department of Cardiology, CHU Liège, Belgium

More information

EAE Teaching Course. Magnetic Resonance Imaging. Competitive or Complementary? Sofia, Bulgaria, 5-7 April F.E. Rademakers

EAE Teaching Course. Magnetic Resonance Imaging. Competitive or Complementary? Sofia, Bulgaria, 5-7 April F.E. Rademakers EAE Teaching Course Magnetic Resonance Imaging Competitive or Complementary? Sofia, Bulgaria, 5-7 April 2012 F.E. Rademakers Complementary? Of Course N Engl J Med 2012;366:54-63 Clinical relevance Treatment

More information

Newly Diagnosed Heart Failure patient: When to Order an MRI and Why

Newly Diagnosed Heart Failure patient: When to Order an MRI and Why Newly Diagnosed Heart Failure patient: When to Order an MRI and Why Jennifer Dickerson MD Assistant Professor of Clinical Internal Medicine Director, The Ohio State University Echocardiography Laboratory

More information

Pearls & Pitfalls in nuclear cardiology

Pearls & Pitfalls in nuclear cardiology Pearls & Pitfalls in nuclear cardiology Maythinee Chantadisai, MD., NM physician Division of Nuclear Medicine, Department of radiology, KCMH Principle of myocardial perfusion imaging (MPI) Radiotracer

More information

Choosing the Appropriate Stress Test: Brett C. Stoll, MD, FACC February 24, 2018

Choosing the Appropriate Stress Test: Brett C. Stoll, MD, FACC February 24, 2018 Choosing the Appropriate Stress Test: Brett C. Stoll, MD, FACC February 24, 2018 Choosing the Appropriate Stress Test: Does it Really Matter? Brett C. Stoll, MD, FACC February 24, 2018 Conflicts of Interest

More information

Current and Future Imaging Trends in Risk Stratification for CAD

Current and Future Imaging Trends in Risk Stratification for CAD Current and Future Imaging Trends in Risk Stratification for CAD Brian P. Griffin, MD FACC Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Disclosures: None Introduction

More information

Case based learning: CMR in Heart Failure

Case based learning: CMR in Heart Failure Case based learning: CMR in Heart Failure Milind Y Desai, MD FACC FAHA FESC Associate Professor of Medicine Heart and Vascular Institute, Cleveland Clinic Cleveland, OH Disclosures: none Use of Gadolinium

More information

Optimal testing for coronary artery disease in symptomatic and asymptomatic patients

Optimal testing for coronary artery disease in symptomatic and asymptomatic patients Optimal testing for coronary artery disease in symptomatic and asymptomatic patients Alexandre C Ferreira, MD Clinical Chief of Cardiology Jackson Health System Director, Interventional Cardiology Training

More information

Indications of Coronary Angiography Dr. Shaheer K. George, M.D Faculty of Medicine, Mansoura University 2014

Indications of Coronary Angiography Dr. Shaheer K. George, M.D Faculty of Medicine, Mansoura University 2014 Indications of Coronary Angiography Dr. Shaheer K. George, M.D Faculty of Medicine, Mansoura University 2014 Indications for cardiac catheterization Before a decision to perform an invasive procedure such

More information

Why Cardiac MRI? Presented by:

Why Cardiac MRI? Presented by: Why Cardiac MRI? Presented by: Lisa G. Carkner, MD, FACC 1 Disclosures I have no financial disclosures Objectives Review basic principles of Cardiac MRI. What patient characteristics do I need to consider

More information

Conflict Disclosures. Vermont Cardiac Network. Outline. Series Learning Objectives 4/27/2016. Scott E. Friedman April 28, 2016

Conflict Disclosures. Vermont Cardiac Network. Outline. Series Learning Objectives 4/27/2016. Scott E. Friedman April 28, 2016 Conflict Disclosures Vermont Cardiac Network The Speaker has reported no significant financial relationship with any companies whose product may be germane to the content of their presentations or who

More information

Cardiovascular Disorders Lecture 3 Coronar Artery Diseases

Cardiovascular Disorders Lecture 3 Coronar Artery Diseases Cardiovascular Disorders Lecture 3 Coronar Artery Diseases By Prof. El Sayed Abdel Fattah Eid Lecturer of Internal Medicine Delta University Coronary Heart Diseases It is the leading cause of death in

More information

Welcome! To submit questions during the presentation: or Text:

Welcome! To submit questions during the presentation:   or Text: Welcome! To participate in the interactive Q & A please do the following: 1. Download the Socrative Student App 2. Enter Teacher s Room Code: ZD0F3X5Q 3. Select Quiz: Intermountain Cardiac Stress Testing

More information

Multiple Gated Acquisition (MUGA) Scanning

Multiple Gated Acquisition (MUGA) Scanning Multiple Gated Acquisition (MUGA) Scanning Dmitry Beyder MPA, CNMT Nuclear Medicine, Radiology Barnes-Jewish Hospital / Washington University St. Louis, MO Disclaimers/Relationships Standard of care research

More information

The 2016 NASCI Keynote: Trends in Utilization of Cardiac Imaging: The Coronary CTA Conundrum. David C. Levin, M.D.

The 2016 NASCI Keynote: Trends in Utilization of Cardiac Imaging: The Coronary CTA Conundrum. David C. Levin, M.D. The 2016 NASCI Keynote: Trends in Utilization of Cardiac Imaging: The Coronary CTA Conundrum David C. Levin, M.D. October 16, 2016 MPI Utilization Rates/1000[includes PET] total radiologists 2014 total

More information

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE Centre for Clinical Practice

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE Centre for Clinical Practice NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE Centre for Clinical Practice Review consultation document Review of Clinical Guideline (CG95) Chest pain of recent onset: Assessment and diagnosis

More information

Current Guidelines for Diagnosis of AMI Chest pain ST change on EKG Cardiac Enzymes

Current Guidelines for Diagnosis of AMI Chest pain ST change on EKG Cardiac Enzymes Noninvasive Cardiac Imaging in Myocardial Infarction Sangchol Lee Sungkyunkwan University Samsung Medical Center Current Guidelines for Diagnosis of AMI Chest pain ST change on EKG Cardiac Enzymes Do We

More information

J. Schwitter, MD, FESC Section of Cardiology

J. Schwitter, MD, FESC Section of Cardiology J. Schwitter, MD, FESC Section of Cardiology CMR Center of the CHUV University Hospital Lausanne - CHUV Switzerland Centre de RM Cardiaque J. Schwitter, MD, FESC Section of Cardiology CMR Center of the

More information

ADVANCED CARDIOVASCULAR IMAGING. Medical Knowledge. Goals and Objectives PF EF MF LF Aspirational

ADVANCED CARDIOVASCULAR IMAGING. Medical Knowledge. Goals and Objectives PF EF MF LF Aspirational Medical Knowledge Goals and Objectives PF EF MF LF Aspirational Know the basic principles of magnetic resonance imaging (MRI) including the role of the magnetic fields and gradient coil systems, generation

More information

CHRONIC CAD DIAGNOSIS

CHRONIC CAD DIAGNOSIS CHRONIC CAD DIAGNOSIS Chest Pain Evaluation 1. Approach to diagnosis of CAD 2. Classification of chest pain 3. Pre-test likelihood CAD 4. Algorithm for chest pain evaluation in women 5. Indications for

More information

Getting the Most Out of Stress Echo

Getting the Most Out of Stress Echo Getting the Most Out of Stress Echo Vera H. Rigolin, MD, FASE, FACC, FAHA Professor of Medicine Northwestern University Feinberg School of Medicine Medical Director, Echocardiography Laboratory Northwestern

More information

Radiologic Assessment of Myocardial Viability

Radiologic Assessment of Myocardial Viability November 2001 Radiologic Assessment of Myocardial Viability Joshua Moss, Harvard Medical School Year III Patient EF 66yo female with a 3-year history of intermittent chest pain previously relieved by sublingual

More information

A Light in the Dark: Cardiac MRI and Risk Mitigation. J. Ronald Mikolich MD Professor of Internal Medicine Northeast Ohio Medical University (NEOMED)

A Light in the Dark: Cardiac MRI and Risk Mitigation. J. Ronald Mikolich MD Professor of Internal Medicine Northeast Ohio Medical University (NEOMED) A Light in the Dark: Cardiac MRI and Risk Mitigation J. Ronald Mikolich MD Professor of Internal Medicine Northeast Ohio Medical University (NEOMED) Dr. Mikolich has NO financial disclosures relative to

More information

MR Assessment of Myocardial Viability

MR Assessment of Myocardial Viability MR Assessment of Myocardial Viability Definition of Viability Clinical Metabolism: Presence of glucose uptake Perfusion / Perfusion reserve Morphology: Wall thickness, wall thickening Contractility: Recovery

More information

Troponin = 35. Objectives. Low Risk Chest Pain. Does this patient have ACS? Does this patient have ACS? Objectives

Troponin = 35. Objectives. Low Risk Chest Pain. Does this patient have ACS? Does this patient have ACS? Objectives Objectives Low Risk Chest Pain Jeffrey Tabas, MD Professor of Emergency Medicine Office of CME UCSF School of Medicine Improve speed and accuracy in assessing patients with possible ACS! Avoid pitfalls

More information

Cardiac magnetic resonance imaging in rheumatoid arthritis: promising or misleading? Sophie Mavrogeni MD FESC

Cardiac magnetic resonance imaging in rheumatoid arthritis: promising or misleading? Sophie Mavrogeni MD FESC Cardiac magnetic resonance imaging in rheumatoid arthritis: promising or misleading? Sophie Mavrogeni MD FESC Onassis Cardiac Surgery Center Athens Greece Nothing to disclose Financial disclosure Cardiac

More information

Multimodality Imaging in Spontaneous Coronary Artery Dissection in the Peripartum Period

Multimodality Imaging in Spontaneous Coronary Artery Dissection in the Peripartum Period Multimodality Imaging in Spontaneous Coronary Artery Dissection in the Peripartum Period Marysia Tweet, MD NASCI Annual Meeting October 18 th, 2016 2016 MFMER slide-1 DISCLOSURE No relevant financial relationship(s)

More information

Cardiac CT Angiography

Cardiac CT Angiography Cardiac CT Angiography Dr James Chafey, Radiologist Why do we need a better test for C.A.D? 1. CAD is the leading cause of death in the US CAD 31% Cancer 23% Stroke 7% 2. The prevalence of atherosclerosis

More information

Ve V rmont rmon Card Car iac d Netw Ne ork tw Scott E. Friedman April 28, 2016

Ve V rmont rmon Card Car iac d Netw Ne ork tw Scott E. Friedman April 28, 2016 Vermont Cardiac Network Scott E. Friedman April 28, 2016 Conflict Disclosures Th S k h d i ifi fi i l l i hi ih The Speaker has reported no significant financial relationship with any companies whose product

More information

Chest pain management. Ruvin Gabriel and Niels van Pelt August 2011

Chest pain management. Ruvin Gabriel and Niels van Pelt August 2011 Chest pain management Ruvin Gabriel and Niels van Pelt August 2011 Introduction Initial assessment Case 1 Case 2 and 3 Comparison of various diagnostic techniques Summary 1-2 % of GP consultations are

More information

Women and Vascular Disease

Women and Vascular Disease Women and Vascular Disease KEVIN F. REBECK PA-C VASCULAR TRANSPLANT SURGERY 1 The Scope of the Problem One woman dies every minute from cardiovascular disease in the U.S.! The Scope of the Problem CVD

More information

A Light in the Dark: Cardiac MRI and Risk Mitigation. J. Ronald Mikolich MD Professor of Internal Medicine Northeast Ohio Medical University (NEOMED)

A Light in the Dark: Cardiac MRI and Risk Mitigation. J. Ronald Mikolich MD Professor of Internal Medicine Northeast Ohio Medical University (NEOMED) A Light in the Dark: Cardiac MRI and Risk Mitigation J. Ronald Mikolich MD Professor of Internal Medicine Northeast Ohio Medical University (NEOMED) Dr. Mikolich has NO financial disclosures relative to

More information

QCVC Committees Scientific Activities Central Hall General Information FAC. SPECT tomography has the advantage of quantifying biventricular volumes.

QCVC Committees Scientific Activities Central Hall General Information FAC. SPECT tomography has the advantage of quantifying biventricular volumes. QCVC Committees Scientific Activities Central Hall General Information FAC Thematic Units Arrhythmias and Electrophysiology Basic Research Bioengineering and Medical Informatics Cardiac Surgical Intensive

More information

63 yo woman with chest pain

63 yo woman with chest pain 63 yo woman with chest pain Coronary Microvascular Disease: Does It Exist? EA Amsterdam, MD Distinguished Professor Cardiology and Internal Medicine UC Davis School of Medicine and Medical Center Sacramento,

More information

Which Test When? Avoid the Stress of Stress Testing. Marc Newell, MD, FACC, FSCCT Minneapolis Heart Institute

Which Test When? Avoid the Stress of Stress Testing. Marc Newell, MD, FACC, FSCCT Minneapolis Heart Institute Which Test When? Avoid the Stress of Stress Testing Marc Newell, MD, FACC, FSCCT Minneapolis Heart Institute Outline Understand the importance of coronary artery disease assessment Understand the basics

More information

Detailed Order Request Checklists for Cardiology

Detailed Order Request Checklists for Cardiology Next Generation Solutions Detailed Order Request Checklists for Cardiology 8600 West Bryn Mawr Avenue South Tower Suite 800 Chicago, IL 60631 www.aimspecialtyhealth.com Appropriate.Safe.Affordable 2018

More information

General Cardiovascular Magnetic Resonance Imaging

General Cardiovascular Magnetic Resonance Imaging 2 General Cardiovascular Magnetic Resonance Imaging 19 Peter G. Danias, Cardiovascular MRI: 150 Multiple-Choice Questions and Answers Humana Press 2008 20 Cardiovascular MRI: 150 Multiple-Choice Questions

More information

ECG Workshop. Nezar Amir

ECG Workshop. Nezar Amir ECG Workshop Nezar Amir Myocardial Ischemia ECG Infarct ECG in STEMI is dynamic & evolving Common causes of ST shift Infarct Localisation Left main artery occlusion: o diffuse ST-depression with ST elevation

More information

The role of Magnetic Resonance Imaging in the diagnosis of viability & Coronary Artery Disease

The role of Magnetic Resonance Imaging in the diagnosis of viability & Coronary Artery Disease The role of Magnetic Resonance Imaging in the diagnosis of viability & Coronary Artery Disease G.P. Spanos, MSc, Phd Head of CardioVascular Imaging Tomographia Diagnostic Center Cardiovascular magnetic

More information

A case of post myocardial infarction ventricular septal rupture CHRISTOFOROS KOBOROZOS, MD

A case of post myocardial infarction ventricular septal rupture CHRISTOFOROS KOBOROZOS, MD A case of post myocardial infarction ventricular septal rupture CHRISTOFOROS KOBOROZOS, MD NAVAL HOSPITAL OF ATHENS case presentation Female, 81yo Hx: diabetes mellitus, hypertension, chronic anaemia presented

More information

Imaging in Heart Failure: A Multimodality Approach. Thomas Ryan, MD

Imaging in Heart Failure: A Multimodality Approach. Thomas Ryan, MD Imaging in Heart Failure: A Multimodality Approach Thomas Ryan, MD Heart Failure HFrEF HFpEF EF50% Lifetime risk 20% Prevalence 6M Americans Societal costs - $30B 50% 5-year survival 1 Systolic

More information

Disclosure Information

Disclosure Information Coronary CTA Pearls and Pitfalls Ricardo C. Cury, MD, FSCCT, FAHA, FACC Chairman of Radiology Radiology Associates of South Florida Director of Cardiac Imaging Miami Cardiac and Vascular Institute Past-President

More information

Takotsubo Cardiomyopathy: Pathophysiology and Assessment

Takotsubo Cardiomyopathy: Pathophysiology and Assessment Takotsubo Cardiomyopathy: Pathophysiology and Assessment Roberto M Lang, MD Tako-Tsubo Cardiomyopathy Broken Heart Syndrome Apical Balooning 1. Sato H, Tateishi H, Uchida T, et al. Takotsubo type cardiomyopathy

More information

Acute Myocardial Infarction

Acute Myocardial Infarction Acute Myocardial Infarction Hafeza Shaikh, DO, FACC, RPVI Lourdes Cardiology Services Asst.Program Director, Cardiology Fellowship Associate Professor, ROWAN-SOM Acute Myocardial Infarction Definition:

More information

Acute heart failure in a patient with lower urinary tract infection Case report of an infection-induced Reverse Takotsubo syndrome

Acute heart failure in a patient with lower urinary tract infection Case report of an infection-induced Reverse Takotsubo syndrome Acute heart failure in a patient with lower urinary tract infection Case report of an infection-induced Reverse Takotsubo syndrome N.Μoschos, A.Dimitra, E.Tsakiri, D.Stavrianakis, A.Nouli CARDIOLOGY DEPARTMENT

More information

Spontaneous Coronary Artery Dissection

Spontaneous Coronary Artery Dissection Spontaneous Coronary Artery Dissection Malissa J. Wood, MD FACC FAHA Co-Director MGH Heart Center Corrigan Women s Heart Health Program Massachusetts General Hospital 40 y/o female transferred from OSH

More information

MRI ACS-ben. Tamás Simor MD, PhD, Med Hab. University of Pécs, Heart Institute

MRI ACS-ben. Tamás Simor MD, PhD, Med Hab. University of Pécs, Heart Institute MRI ACS-ben Tamás Simor MD, PhD, Med Hab Time Course of Changes in Infarct Size, Viable Myocardium, and LV Mass After Reperfused and Nonreperfused MI Blue lines denote reperfused myocardial infarction

More information

4/11/2017. Cardiomyopathy. John Steuter, MD Bryan Heart. Disclosures. No Conflicts. Cardiomyopathy. WHO Classification

4/11/2017. Cardiomyopathy. John Steuter, MD Bryan Heart. Disclosures. No Conflicts. Cardiomyopathy. WHO Classification Cardiomyopathy John Steuter, MD Bryan Heart Disclosures No Conflicts Cardiomyopathy WHO Classification Anatomy & physiology of the LV 1. Dilated Enlarged Systolic dysfunction 2. Hypertrophic Thickened

More information

DIFFERENTIATING THE PATIENT WITH UNDIFFERENTIATED CHEST PAIN

DIFFERENTIATING THE PATIENT WITH UNDIFFERENTIATED CHEST PAIN DIFFERENTIATING THE PATIENT WITH UNDIFFERENTIATED CHEST PAIN Objectives Gain competence in evaluating chest pain Recognize features of moderate risk unstable angina Review initial management of UA and

More information

Sung A Chang Department of Internal Medicine, Division of Cardiology, Sungkyunkwan University School of Medicine, Samsung Medical Center

Sung A Chang Department of Internal Medicine, Division of Cardiology, Sungkyunkwan University School of Medicine, Samsung Medical Center CMR Perfusion and Viability A STICH Out of Time? Sung A Chang Department of Internal Medicine, Division of Cardiology, Sungkyunkwan University School of Medicine, Samsung Medical Center Can Imaging Improve

More information

Cardiac Imaging Tests

Cardiac Imaging Tests Cardiac Imaging Tests http://www.medpagetoday.com/upload/2010/11/15/23347.jpg Standard imaging tests include echocardiography, chest x-ray, CT, MRI, and various radionuclide techniques. Standard CT and

More information

Acute Coronary Syndrome. Sonny Achtchi, DO

Acute Coronary Syndrome. Sonny Achtchi, DO Acute Coronary Syndrome Sonny Achtchi, DO Objectives Understand evidence based and practice based treatments for stabilization and initial management of ACS Become familiar with ACS risk stratification

More information

CCS/CAIC/CSCS Position Statement on Revascularization Multi-vessel CAD. Teo et al, Canadian Journal of Cardiology 2014;30:

CCS/CAIC/CSCS Position Statement on Revascularization Multi-vessel CAD. Teo et al, Canadian Journal of Cardiology 2014;30: CCS/CAIC/CSCS Position Statement on Revascularization Multi-vessel CAD Teo et al, Canadian Journal of Cardiology 2014;30: 1482-1491 Parallel Paper: Canadian Cardiovascular Society Guidelines for the Diagnosis

More information

DELAYED ENHANCEMENT IMAGING IN CHILDREN

DELAYED ENHANCEMENT IMAGING IN CHILDREN NASCI 38 TH ANNUAL MEENG, SEATLE October 3-5, 21 1. DELAYED ENHANCEMENT IN CHILDREN Shi-Joon Yoo, MD Lars Grosse-Wortmann, MD University of Toronto Canada -1. 1. 1. Magnitude image Magnitude images -1.

More information

12 Lead EKG Chapter 4 Worksheet

12 Lead EKG Chapter 4 Worksheet Match the following using the word bank. 1. A form of arteriosclerosis in which the thickening and hardening of the vessels walls are caused by an accumulation of fatty deposits in the innermost lining

More information

Imaging ischemic heart disease: role of SPECT and PET. Focus on Patients with Known CAD

Imaging ischemic heart disease: role of SPECT and PET. Focus on Patients with Known CAD Imaging ischemic heart disease: role of SPECT and PET. Focus on Patients with Known CAD Hein J. Verberne Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands International Conference

More information

CT for Myocardial Characterization of Cardiomyopathy. Byoung Wook Choi, Yonsei University Severance Hospital, Seoul, Korea

CT for Myocardial Characterization of Cardiomyopathy. Byoung Wook Choi, Yonsei University Severance Hospital, Seoul, Korea CT for Myocardial Characterization of Cardiomyopathy Byoung Wook Choi, Yonsei University Severance Hospital, Seoul, Korea Cardiomyopathy Elliott P et al. Eur Heart J 2008;29:270-276 The European Society

More information

HIGHLIGHT SESSION. Imaging. J. L. Zamorano Gomez (Madrid, ES) Disclosures: Speaker Philips

HIGHLIGHT SESSION. Imaging. J. L. Zamorano Gomez (Madrid, ES) Disclosures: Speaker Philips Imaging. J. L. Zamorano Gomez (Madrid, ES) Disclosures: Speaker Philips Agenda ECHO Diagnosis & Prognosis : Functional MR Severity Aortic Stenosis CT How to select pts for TAVI Adding prognostic info to

More information

I have no financial disclosures

I have no financial disclosures Manpreet Singh MD I have no financial disclosures Exercise Treadmill Bicycle Functional capacity assessment Well validated prognostic value Ischemic assessment ECG changes ST segments Arrhythmias Hemodynamic

More information

Abnormal, Autoquant Adenosine Myocardial Perfusion Heart Imaging. ID: GOLD Date: Age: 46 Sex: M John Doe Phone (310)

Abnormal, Autoquant Adenosine Myocardial Perfusion Heart Imaging. ID: GOLD Date: Age: 46 Sex: M John Doe Phone (310) Background: Reason: preoperative assessment of CAD, Shortness of Breath Symptom: atypical chest pain Risk factors: hypertension Under influence: a beta blocker Medications: digoxin Height: 66 in. Weight:

More information

Stable Angina: Indication for revascularization and best medical therapy

Stable Angina: Indication for revascularization and best medical therapy Stable Angina: Indication for revascularization and best medical therapy Cardiology Basics and Updated Guideline 2018 Chang-Hwan Yoon, MD/PhD Cardiovascular Center, Department of Internal Medicine Bundang

More information

Cardiac MRI: Appropriateness. Scott Mattson, DO, FACC Lutheran Medical Group Fort Wayne, IN

Cardiac MRI: Appropriateness. Scott Mattson, DO, FACC Lutheran Medical Group Fort Wayne, IN Cardiac MRI: Appropriateness Scott Mattson, DO, FACC Lutheran Medical Group Fort Wayne, IN Approaches to Appropriateness The indication The patient The scanner and technologists The interpreting physician

More information

Evaluation of Myocardial Viability: What Have We Learned from STICH? Professor of Medicine David Geffen School of Medicine at UCLA. Heart Failure (HF)

Evaluation of Myocardial Viability: What Have We Learned from STICH? Professor of Medicine David Geffen School of Medicine at UCLA. Heart Failure (HF) Evaluation of Myocardial Viability: What Have We Learned from STICH? Daniel S. Berman, MD Director, Cardiac Imaging Cedars-Sinai Heart Institute CSMC 2013 Professor of Medicine David Geffen School of Medicine

More information

Role of CMR in heart failure and cardiomyopathy

Role of CMR in heart failure and cardiomyopathy Role of CMR in heart failure and cardiomyopathy Hajime Sakuma Department of Radiology, Mie University Late gadolinium enhancement (LGE) LGE MRI can demonstrate site of necrosis, fibrosis or deposition

More information

Myocardial Infarction

Myocardial Infarction Myocardial Infarction MI = heart attack Defined as necrosis of heart muscle resulting from ischemia. A very significant cause of death worldwide. of these deaths, 33% -50% die before they can reach the

More information

Supplementary material 1. Definitions of study endpoints (extracted from the Endpoint Validation Committee Charter) 1.

Supplementary material 1. Definitions of study endpoints (extracted from the Endpoint Validation Committee Charter) 1. Rationale, design, and baseline characteristics of the SIGNIFY trial: a randomized, double-blind, placebo-controlled trial of ivabradine in patients with stable coronary artery disease without clinical

More information

Cardiac Imaging. Kimberly Delcour, DO, FACC. Mahi Ashwath, MD, FACC, FASE. Director, Cardiac CT. Director, Cardiac MRI

Cardiac Imaging. Kimberly Delcour, DO, FACC. Mahi Ashwath, MD, FACC, FASE. Director, Cardiac CT. Director, Cardiac MRI Cardiac Imaging Kimberly Delcour, DO, FACC Director, Cardiac CT Mahi Ashwath, MD, FACC, FASE Director, Cardiac MRI Cardiac Imaging Discuss the clinical applications of and indications for: Cardiac CT Nuclear

More information

Coronary interventions

Coronary interventions Controversial issues in the management of ischemic heart failure Coronary interventions Maciej Lesiak Department of Cardiology, University Hospital in Poznan none DECLARATION OF CONFLICT OF INTEREST CHF

More information

Cardiology Updates: Syncope and Stress Testing. Kathleen Morris, DO Cardiology Fellow St. Vincent Hospital

Cardiology Updates: Syncope and Stress Testing. Kathleen Morris, DO Cardiology Fellow St. Vincent Hospital Cardiology Updates: Syncope and Stress Testing Kathleen Morris, DO Cardiology Fellow St. Vincent Hospital Disclosures NONE PART ONE: Let s start with SYNCOPE Objectives: Definition of Syncope Brief review

More information

9/23/2011. Cardiac MRI Evaluation of Cardiomyopathy and Myocarditis. Primary Hypertrophic Cardiomyopathy. Cardiomyopathy.

9/23/2011. Cardiac MRI Evaluation of Cardiomyopathy and Myocarditis. Primary Hypertrophic Cardiomyopathy. Cardiomyopathy. Cardiomyopathy Cardiac MRI Evaluation of Cardiomyopathy and Myocarditis Laureen Sena Children s Hospital Boston, MA NASCI 2011 Baltimore, Maryland Primary Hypertrophic ARVD Dilated Restrictive Unclassified

More information

The Final 10-Year Follow-up Results from the Bari Randomized Trial J Am Coll Cardiol (2007) 49;1600-6

The Final 10-Year Follow-up Results from the Bari Randomized Trial J Am Coll Cardiol (2007) 49;1600-6 The Final 10-Year Follow-up Results from the Bari Randomized Trial J Am Coll Cardiol (2007) 49;1600-6 n&list_uids=17433949 64-Multislice Detector Computed Tomography Coronary Angiography as Potential Alternative

More information

What the Cardiologist needs to know from Medical Images

What the Cardiologist needs to know from Medical Images What the Cardiologist needs to know from Medical Images Gerald Maurer Department of Cardiology Medical University of Vienna What kinds of Cardiologists Plumbers Electricians Photographers And then there

More information

1) Severe, crushing substernal chest pain 2) radiate to the neck, jaw, epigastrium, or left arm. 3- rapid and weak pulse 4- nausea (posterior MI).

1) Severe, crushing substernal chest pain 2) radiate to the neck, jaw, epigastrium, or left arm. 3- rapid and weak pulse 4- nausea (posterior MI). 1) Severe, crushing substernal chest pain 2) radiate to the neck, jaw, epigastrium, or left arm. 3- rapid and weak pulse 4- nausea (posterior MI). 5- cardiogenic shock (massive MIs >40% of the left ventricle)

More information

My Patient Needs a Stress Test

My Patient Needs a Stress Test My Patient Needs a Stress Test Amy S. Burhanna,, MD, FACC Coastal Cardiology Cape May Court House, New Jersey Absolute and relative contraindications to exercise testing Absolute Acute myocardial infarction

More information

Late Gadolinium Enhancement by Cardiac Magnetic Resonance Imaging and Major Adverse Coronary Events

Late Gadolinium Enhancement by Cardiac Magnetic Resonance Imaging and Major Adverse Coronary Events Pacific University CommonKnowledge School of Physician Assistant Studies College of Health Professions Summer 8-12-2017 Late Gadolinium Enhancement by Cardiac Magnetic Resonance Imaging and Major Adverse

More information

10/22/16. Lay of the land. Definition of ACS. Why do we worry about ST elevations?

10/22/16. Lay of the land. Definition of ACS. Why do we worry about ST elevations? Lay of the land Update on Acute Coronary Syndrome: Five Things Hospitalists Must Know Dhruv S. Kazi, MD, MSc, MS Assistant Professor Department of Medicine (Cardiology), Department of Epidemiology and

More information

When Should I Order a Stress Test or an Echocardiogram

When Should I Order a Stress Test or an Echocardiogram When Should I Order a Stress Test or an Echocardiogram Updates in Cardiology 2015 March 7, 2015 Donald L. Lappé, MD, FAHA, FACC Chairman, Cardiovascular Department Medical Director, Intermountain Cardiovascular

More information

Review of Cardiac Imaging Modalities in the Renal Patient. George Youssef

Review of Cardiac Imaging Modalities in the Renal Patient. George Youssef Review of Cardiac Imaging Modalities in the Renal Patient George Youssef ECHO Left ventricular hypertrophy (LVH) assessment Diastolic dysfunction Stress ECHO Cardiac CT angiography Echocardiography - positives

More information

Cardiogenic Shock. Carlos Cafri,, MD

Cardiogenic Shock. Carlos Cafri,, MD Cardiogenic Shock Carlos Cafri,, MD SHOCK= Inadequate Tissue Mechanisms: Perfusion Inadequate oxygen delivery Release of inflammatory mediators Further microvascular changes, compromised blood flow and

More information

Cardiac MRI: Clinical Application to Disease

Cardiac MRI: Clinical Application to Disease Cardiac MRI: Clinical Application to Disease Jessi Smith, MD Cardiothoracic imaging, Indiana University Slides courtesy of Stacy Rissing, MD Outline Imaging planes Disease findings Pulse sequences used

More information

CASES IN ADVANCED IMAGING

CASES IN ADVANCED IMAGING CASES IN ADVANCED IMAGING DAVID A. ORSINELLI, MD PROFESSOR, CLINICAL INTERNAL MEDICINE THE OHIO STATE UNIVERSITY DIVISION OF CARDIOVASCULAR MEDICINE OHIO ACC ANNUAL CONFERENCE OCTOBER 2010 WHICH IMAGING

More information

The Universal Definition of Myocardial Infarction 3 rd revision, 2012

The Universal Definition of Myocardial Infarction 3 rd revision, 2012 The Universal Definition of Myocardial Infarction 3 rd revision, 2012 Joseph S. Alpert, MD Professor of Medicine, University of Arizona College of Medicine, Tucson, AZ; Editor-in-Chief, American Journal

More information

Testing the Asymptomatic CAD Patient: When and Why?

Testing the Asymptomatic CAD Patient: When and Why? Testing the Asymptomatic CAD Patient: When and Why? Timothy M. Bateman M.D. Co-Director, Cardiovascular Radiologic Imaging Mid America Heart Institute Professor of Medicine University of Missouri-Kansas

More information

Imaging of Coronary Artery Disease: II

Imaging of Coronary Artery Disease: II Acta Radiológica Portuguesa, Vol.XIX, nº 74, pág. 45-51, Abr.-Jun., 2007 Imaging of Coronary Artery Disease: II Jean Jeudy University of Maryland School of Medicine Department of Diagnostic Radiology Armed

More information

Stress Echocardiography: Illustrative Cases Sunil Mankad, MD, FACC, FCCP, FASE Associate Professor of Medicine Mayo Clinic College of Medicine Director, Transesophageal Echocardiography Associate Director,

More information

Imaging in Ischemic Heart Disease: Role of Cardiac MRI

Imaging in Ischemic Heart Disease: Role of Cardiac MRI Imaging in Ischemic Heart Disease: Role of Cardiac MRI Chiara Bucciarelli Ducci MD, PhD, FESC, FRCP Consultant Senior Lecturer Cardiologist Bristol Heart Institute, University of Bristol, UK Chair elect,

More information

Heart Failure. Cardiac Anatomy. Functions of the Heart. Cardiac Cycle/Hemodynamics. Determinants of Cardiac Output. Cardiac Output

Heart Failure. Cardiac Anatomy. Functions of the Heart. Cardiac Cycle/Hemodynamics. Determinants of Cardiac Output. Cardiac Output Cardiac Anatomy Heart Failure Professor Qing ZHANG Department of Cardiology, West China Hospital www.blaufuss.org Cardiac Cycle/Hemodynamics Functions of the Heart Essential functions of the heart to cover

More information

Imaging Saves Lives: An Evidence-Based Choice of Modality Magnetic Resonance Imaging

Imaging Saves Lives: An Evidence-Based Choice of Modality Magnetic Resonance Imaging Imaging Saves Lives: An Evidence-Based Choice of Modality Magnetic Resonance Imaging Oliver Bruder Department of Cardiology Elisabeth Hospital Essen Germany Growth of CV Imaging Shaw; JACCi 2010 Novel

More information

CNR, G. Monasterio Foundation, Clinical Physiology Institute Pisa

CNR, G. Monasterio Foundation, Clinical Physiology Institute Pisa CNR, G. Monasterio Foundation, Clinical Physiology Institute Pisa Stockholm Aug 29, 2010 Role of MRI in the acute Myocardial Infarction? massimo lombardi Two days after infarct (top row), the T2 hyperintense

More information

Chapter 5 Section 1.1. Diagnostic Radiology (Diagnostic Imaging)

Chapter 5 Section 1.1. Diagnostic Radiology (Diagnostic Imaging) Radiology Chapter 5 Section 1.1 Issue Date: March 7, 1986 Authority: 32 CFR 199.4(a), (b)(2)(x), (c)(2)(viii), (e)(14) and 32 CFR 199.6(d)(2) 1.0 CPT 1 PROCEDURE CODES 70010-72292, 73000-76499, 77071-77084,

More information