Safety of contrast agents CT / MR / Echo

Transcription

1 International Conference on Integrated Medical Imaging in Cardiovascular Diseases (IMIC 2013, IAEA) Safety of contrast agents CT / MR / Echo Philipp A Kaufmann, MD Professor and Director of Cardiac Imaging SPECT/PET/CT/MR University Hospital Zurich, Switzerland UniversitätsSpital Zürich

2 Disclosures Institutional contract with GE Healthcare UniversitätsSpital Zürich

3 Learning objectives To be aware of the most important contrast agent related safety issues. To be able to assess the individual risk. To know strategies to prevent the contrast associated risk.

4 Contrast agents in different modalities CT iodine (allergic Rx, contrast induced nephropathy CIN) MR gadolinium Echo bubbles with gas (hexafluoride)

5 Contrast Induced Nephropathy controversy CIN is a subgruop of acute kidney injury (AKIN) Almost everything about CIN is subject to debate, including its definition methods for measuring the condition causative agents the mechanism for damage the best means of prevention, and its true effect on mortality rates

6 CIN: definition Common definition: Serum creatinine increase 25% and/or 44 μmol/l = 0.5 mg/dl or more from baseline after contrast material exposure In different trials only parts of the definition were used The time point serum creatinin increase measurement was not standardized

7 CIN background Contrast-induced nephropathy (CIN) was first recognized more than 50 years ago. Bartels E, Brun GC, Gammeltof A, Gjorup LA. Acute anuria following intravenous pyelography in a patient with myelomatosis. Acta Med Scand. 1954;150: Contrast media have changed over time to become increasingly safe and well tolerated, but the indications for use of contrast media have greatly expanded. There are now more than 25,000 CT scanners worldwide.

8 CIN impact on outcome From AM et al. Mayo Clin Proc. 2008;83(10):

9 CIN impact on outcome Twofold-to-fivefold increase in mortality while patients are in the hospital, mostly related to an increase in adverse cardiac events. Hospital resource consumption is increased. Hospital lengths of stay increase by 5-10 days. Use of dialysis facilities increases 10% to 15%. Long-term mortality (at 1 year) also increases threefold. If dialysis required: In-hosp mortality up to 35%.

10 CIN facts But the minority is a CT coronary angiography! Nash K et al. Am J Kidney Dis. 2002;39:

11 CIN risk factors D. mellitus+renal failure, oral antidiabetics (metformin) Renal disease or solitary kidney disease Aged 70 years or older Sepsis or acute hypotension Cardiovascular disease Organ transplant Nephrotoxic drugs (e.g. nonsteroidal anti-inflammatory drugs, chemotherapy) Human immunodeficiency syndrome or acquired immunodeficiency syndrome

12 CIN in cath pts (n=1 196)

13 CIN: how big is the problem? Risk of CIN lower than 2% in general population. Highest for for patients who have impaired renal function in combination with diabetes. The estimated GFR, using serum creatinine measurements, is thought to be more accurate than serum creatinine level alone for measuring risk for CIN. GFR 60 to 30 ml/min: 10% to 20% risk of CIN GFR <30 ml/min: 40% to 50% risk of CIN

14 From cath to CT: differential impact Intra-arterial CM application may be more toxic. Multiple bolus injection of CM in the cath as opposed to one bolus in CT coronary angiography may have more adverse impact. Patients undergoing CT coronary angiography are younger, have much less concomitant disease.

15 CIN: Impact of different CM

16 CIN- Incidence in 5 PCI studies Aspelin et al. N Engl J Med. 2003; Jo et al. J Am Coll Cardiol. 2006; Solomon RJ et al. Circ. 2007; Nie et al. Catheter Cardiovasc Int. 2008; Wessely R et al. ACC 2008 abstract.

17 CIN in CATH

18 CIN and coronary CT angiography (CCTA) Most of the CIN risk factors are rare in CCTA, as mainly used for CAD rule out or coron. anomalies in younger patients decreased GFR unlikely nephrotoxic drugs rare iv is less nephrotoxic than ic/ia where bolus reaches kidney almost undiluted CM bolus much smaller than in cath

19 CM bolus in CT much lower than in cath Pazhenkottil et al. In J Card Imag 2010;26:

20 Procedure related CIN Cardiac cath CT overall Periph. cath ERCP Pulmon. angio Cholangiography Renal angiography For CT angio only few individual cases have been observed Nash K et al. Am J Kidney Dis. 2002;39:

21 CIN: Strategies of prevention Fischman & Reddan. Acta Radiol 2008

22 Fischman & Reddan. Acta Radiol 2008

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40 CT MRI

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42 Ultrasound contrast media Shell material plus gas

43 Ultrasound contrast media Adverse events generally rare. Contraindicated in severe heart failure (NYHA III/IV). Majority of reactions are minor (headache, nausea, sensation of heat, altered taste) and self resolving. More severe reaction rare and similar to those of Iodine.