Advanced Cardiac Imaging for the General Practitioner
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1 Advanced Cardiac Imaging for the General Practitioner Jennifer Dickerson, MD, FACC Assistant Professor of Medicine Clinical Director of the Echocardiography Lab Assistant Director for CMR/CT Quality Assurance Division of Cardiovascular Medicine The Ohio State University Wexner Medical Center Outline Intro to cardiac imaging/stress testing. Advanced imaging modalities MRI/CT Overview of indications and contraindications to cardiac MRI Patient selection Stress Testing with CMR Video for treadmill CMR Overview of indications and contraindications to cardiac CT Difference between Calcium score and CTA Patient selection for CTA/calcium score Clinical case for calcium score 1
2 Advanced Cardiac Imaging for the General Practitioner Sharon Roble, MD Assistant Professor of Clinical Medicine Department of Cardiovascular Medicine Division of Cardiovascular Medicine The Ohio State University Wexner Medical Center Introduction to Cardiac MRI Allows for assessment of anatomical structures in any plane yp Functional information (quantitative) Ventricular function (left and right) Intracardiac shunt assessment Stenotic lesions Infiltrative diseases/fibrosis Viability ARVD Sarcoid, Amyloid Vascular imaging (aorta) 2
3 Cardiac MRI Clinical Applications Ischemic Evaluation: Adenosine, dobutamine or treadmill stress testing Viability assessment: prior to revascularization Cardiomyopathy assessment Biventricular function assessment Ischemic/non-ischemic/infiltrative Risk for Sudden Cardiac Death Response to cardiac resynchronization therapy Additional Clinical Applications Congenital Heart Disease Aortic Evaluation Intracardiac Mass Evaluation Pericardial Disease 3
4 Advanced Cardiac Imaging for the General Practitioner Jennifer Dickerson, MD, FACC Assistant Professor of Medicine Clinical Director of the Echocardiography Lab Assistant Director for CMR/CT Quality Assurance Division of Cardiovascular Medicine The Ohio State University Wexner Medical Center Gadolinium Contrast: Two Phases of Myocardial Enhancement injection Normal Myocardium Infarcted Myocardium Ischemic Myocardium < 1 min > 5 min First-Pass Perfusion Imaging (Ischemic Assessment) Delayed Enhancement time 4
5 Patterns of Hyperenhancement Transmural Involves entire wall Consistent with myocardial infarction/ischemic event If more than 50% of wall involved, felt to be non-viable Non-transmural Endocardial, epicardial, mid-wall Non-ischemic myopathies, infiltrative diseases 5
6 DME: LAD-territory infarct scar Mid-Myocardial Hyperenhancement 6
7 Infiltrative Cardiomyopathies Myocardial biopsies subject to sampling error CMR samples the entire myocardium Sarcoidosis Amyloidosis Hemochromatosis Chagas disease Gaucher s disease, Anderson-Fabry disease, etc. Cardiac Amyloid Congo red DME TI Scout Polarized light with congo red DME TI 70msec DME TI 200msec 7
8 Myocarditis: Giant Cell DME with extensive epicardial hyperenhancement Myocarditis CMR Cine Images Markedly abnormal DME-CMR Small focus of mononuclear cells 8
9 Limitations of MRI Long acquisition times min Most imaging sequences require breath holding sec breath holds per image sequence images required to image entire heart Contraindications to MRI Pacemakers/ICDs Any ferrous material within body CKD Nephrogenic systemic fibrosis (NSF) Nephrogenic Systemic Fibrosis (NSF) Diffuse systemic fibrosis involving skin, skeletal muscle, GI tract, cardiovascular system Skin lesions symmetrical and extend distal to proximal After the administration of gadolinium in patients with renal failure (GFR<60) No cases reported in patients with GFR >30 Diagnosis: skin biopsy Lab testing non-specific Treatment supportive Restore renal function (HD not effective once patient develops NSF) Pain management For further questions, refer to OSU Radiology Departmental website on OneSource 9
10 Overview of Cardiac MRI Stress Testing Pharmacologic Adenosine/Regadenoson Dobutamine Exercise (Treadmill) Functional data NIH supported research at Ohio State 10
11 Advanced Cardiac Imaging for the General Practitioner Sharon Roble, MD Assistant Professor of Clinical Medicine Department of Cardiovascular Medicine Division of Cardiovascular Medicine The Ohio State University Wexner Medical Center Clinical Case 1 16 year-old asymptomatic basketball player ROS: no syncope, palpitations, DOE, etc. PMH: negative FH: unremarkable 11
12 Physical Examination Height 182 cm, weight 71 kg BP 118/54, HR Symmetric pulses II/VI SEM at LUSB, no positional change Rest of PE unremarkable 12
13 Diagnostic Testing Normal echocardiogram ( 1cm LV walls ) Because of abnormal ECG, patient referred for cardiac magnetic resonance CMR exam included: 3D cine Post-gad DME for scar/infiltrate Non-contrast MRA for coronary artery origins/ prox course and aorta 13
14 Clinical Case 2 36 y/o African-American male with palpitations, near-syncope PMH: sarcoidosis PE, echocardiogram unremarkable CMR to assess myocardium 14
15 Clinical Case 3 42 y/o male with atrial fibrillation refractory to drug therapy to drug therapy FH: no known cardiovascular disease PE: unremarkable Echocardiogram: low-normal EF CMR exam to delineate eate pulmonary veins pre- ablation 15
16 Dx: arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) Change in management: -RFA plus ICD placement -Screening of family members Introduction to Cardiac CT Calcium scoring No contrast Primarily for risk stratification Coronary angiography Contrast administered Calcium scoring typically done with this study Symptomatic patient with low to intermediate risk for CAD Symptomatic with indeterminate stress test Coronary artery anomalies 16
17 Calcium Scoring Calcium has high signal intensity in CT; based on x- ray attenuation relative to water Threshhold for calcium scoring typically 130 Agatston score: weighted sum of HU over slices covering the heart Calcification is one aspect of atherosclerosis Calcium score indicates: Plaque burden? Yes Luminal stenosis? No ) Hounsf field units (HU Water 0 Calcium Scoring Calcium has high signal intensity in CT; based on x- ray attenuation relative to water Threshhold for calcium scoring typically 130 Agatston score: weighted sum of HU over slices covering the heart Calcification is one aspect of atherosclerosis Calcium score indicates: Plaque burden? Yes Luminal stenosis? No ) Hounsf field units (HU Water 0 17
18 Calcium Scoring Calcium has high signal intensity in CT; based on x- ray attenuation relative to water Threshhold for calcium scoring typically 130 Agatston score: weighted sum of HU over slices covering the heart Calcification is one aspect of atherosclerosis Calcium score indicates: Plaque burden? Yes Luminal stenosis? No ) Hounsf field units (HU Water 0 Calcium Scoring Calcium has high signal intensity in CT; based on x- ray attenuation relative to water Threshhold for calcium scoring typically 130 Agatston score: weighted sum of HU over slices covering the heart Calcification is one aspect of atherosclerosis Calcium score indicates: Plaque burden? Yes Luminal stenosis? No ) Hounsf field units (HU Water 0 18
19 Calcium Scoring Calcium has high signal intensity in CT; based on x- ray attenuation relative to water Threshhold for calcium scoring typically 130 Agatston score: weighted sum of HU over slices covering the heart Calcification is one aspect of atherosclerosis Calcium score indicates: Plaque burden? Yes Luminal stenosis? No ) Hounsf field units (HU Water 0 Advanced Cardiac Imaging for the General Practitioner Jennifer Dickerson, MD, FACC Assistant Professor of Medicine Clinical Director of the Echocardiography Lab Assistant Director for CMR/CT Quality Assurance Division of Cardiovascular Medicine The Ohio State University Wexner Medical Center 19
20 Clinical Case 4 65yo Male presents for an annual physical Exercises 5 days a week without any concerning symptoms PMHx: Hyperlipidemia Medications: 20mg Simvastatin, 325mg Aspirin SoHx: 2ppd tobacco x 20 years (quit in 2009) Cigar use 1-2 2timesamonth month FmHx: Father with MI age 53, PGM, PGF and mother with MI in their 60s. Clinical Case 4 Continued PE: BP 168/83 HR 65, BMI 29 Unremarkable physical findings. Lipid Total cholesterol 221 LDL 145 HDL 41 Triglycerides
21 So Doc, how s my heart doing? I don t want to end up like my parents. 21
22 ATPIII Executive summary JACC: vol 49, 3:
23 Multi-Ethnic Study of Atherosclerosis NEJM 2008; 358;13: Patient selection for Calcium scoring CAC for intermediate risk patients (10-20% 10 year risk) without symptoms (IIa) CAC may be reasonable for low to intermediate risk patients (6-10%) (IIb) No data to support use in low risk (<6% 10- year risk). Typically young population of men less than 40 and women less than 50. Greenland et al JACC vol 56, 25,
24 Clinical Case 4 Continued Calcium score RCA 237 LAD 298 LM none Cx none Change treatment to secondary prevention guidelines Ideal patient is in the Intermediate risk (10-20% 10 yr) risk strata asymptomatic patient Result might reclassify patient to higher risk status 24
25 Advanced Cardiac Imaging for the General Practitioner Sharon Roble, MD Assistant Professor of Clinical Medicine Department of Cardiovascular Medicine Division of Cardiovascular Medicine The Ohio State University Wexner Medical Center Contraindications for calcium scoring Known CAD Symptomatic patient Cardiac hardware : pacemakers, stents, prosthetic valves 25
26 Clinical Case 5 12 year old female with no significant past medical history had syncopal event while playing in basketball game No prodrome Awoke spontaneously Physical Examination Afebrile, P-80, BP 90/50 Quiet precordium, I/IV short systolic ejection murmur, no diastolic murmur, gallop or rubs Abdomen unremarkable 26
27 Diagnostic Testing ECG showed sinus rhythm with 0.5 mm ST elevation in precordial leads. Echo showed normal biventricular function, no significant valvular disease, unable to visualize coronary arteries Referred for coronary CTA Normal Anatomy 27
28 Clinical Case 6 45 year old perimenopausal female with hypertension presents with dyspnea on exertion PMH: HTN, obesity Meds: Lisinopril/HCTZ 10/12.5mg Non-smoker Family history of coronary artery disease in her mom (60 s) and dad (60 s) 28
29 Clinical Case 6: Physical Exam PE: P-70; BP 132/75, BMI 30 HEENT: Normocephalic, +acanthosis nigrans, no carotid bruits CV: Quiet precordium, RRR, no murmurs, gallops or rubs. 2+peripheral pulses. Ext: No edema Clinical Case 6: Treadmill Nuclear Stress Testing Exercised for 9 minutes no Bruce protocol achieving 10.1 MET d 96% f di t d i l h t t METs and 96% of age-predicted maximal heart rate Baseline ECG: Sinus rhythm with 0.5 mm ST depression in anterior leads Stress ECG: Sinus tachycardia with 1.5 mm horizontal ST depression in precordial leads (indeterminate due to baseline abnormalities Imaging: Mild perfusion defect in anterior wall likely due to breast attenuation although ischemia cannot be excluded. Normal function, EF 55% 29
30 30
31 References ACC/AHA Cardiovascular CT Appropriateness Criteria, Journal of the American College Cardiology. 2012; 59 (9): ACC/AHA Guidelines for Exercise Testing: Executive Summary, Circulation. 1991; 96: OSU Department of Radiology website. 31
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