Acute chest pain: game changer or waste of resources? CMR one stop shop for function, structure and perfusion

Transcription

1 Multidisciplinary Cardiovascular Research Centre Leeds Institute of Genetics, Health and Therapeutics Acute chest pain: game changer or waste of resources? CMR one stop shop for function, structure and perfusion Sven Plein, MD, PhD University of Leeds & Kings College London

2 Disclosures Educational research grant from Philips Healthcare Off label use of Gd contrast agents

3 ESC guidelines for ACS

4

5 ESC guidelines Non-STE ACS

6 ESC guidelines STEMI STEMI

7 Indications for CMR in ACS Guidelines: 1.Low risk troponin-negative ACS to decide if angiogram is necessary 2.Post STEMI to measure LV function and scar size 3.Post STEMI in multi-vessel disease Other: 1.Acute MI risk stratification 2.Differential diagnosis

8 Cine imaging LV function by CMR Reference standard for global and regional LV function Define cardiacviews axes Standardised Multiple Short axis stack

9 T2-weighted CMR Sensitive to free water in tissues Delineates myocardial oedema 16 patients with first STEMI (99m)Tc tetrofosmin before PPCI Good agreement with T2-w CMR at day 2 and 7 Carlsson et al JACC Cardiovasc Img 2009; 2:

10 Late gadolinium enhancement CMR Sensitive to distribution volume of extracellular contrast agents Delineates acute necrosis, fibrosis and chronic scar Mahrholdt H, Eur Heart J. 2005;26:

11 Late gadolinium enhancement CMR High spatial resolution Detects very small amounts of scar (~1 gram tissue) Plein S et al. JACC 2004;44:

12 Myocardial perfusion CMR Sensitive to myocardial blood flow Delineates ischaemia with high spatial resolution (2-3mm) Plein S. et al., Radiology 2008;249: Plein S et al. Radiology. 2008;249:

13 Cardiac magnetic resonance

14 Myocardial CE-MARC: aims CMR versus SPECT Results perfusion n = 752 Single-Centre (CEMARC) Greenwood JP, et al. Lancet 2012;379: n = 425 Multi-Centre (MR-IMPACT 2) Schwitter J, et al. JCMR 2012;14:61

15 Indications for CMR in ACS Guidelines: 1.Low risk troponin-negative ACS to decide if angiogram is necessary 2.Post STEMI to measure LV function and scar size 3.Post STEMI in multi-vessel disease Other: 1.Acute MI risk stratification 2.Differential diagnosis

16 Differentiating acute from chronic MI T2-weighted and LGE CMR T2W LGE Abdel-Aty et al. Circulation 2004; 109:

17 Detection of ACS Comprehensive CMR protocol in ER T2W Perfusion Cine LGE Cury P et al Circulation 2008;118:837-84

18 Detection of ACS in the ER 62 patients with chest pain, CMR from ER Compared with clinical assessment and risk factors Cury P et al Circulation 2008;118:837-84

19 Detection of ACS by CMR 68 patients with NSTE-ACS, CMR before angio Sensitivity/specificity to detect CAD on angio Plein S et al. JACC 2004;44:

20 Detection of ACS in the ER 161 patients with chest pain, CMR in ER Kwong RY et al. Circulation 2003;44:107:

21 Indications for CMR in ACS Guidelines: 1.Low risk troponin-negative ACS to decide if angiogram is necessary 2.Post STEMI to measure LV function and scar size 3.Post STEMI in multi-vessel disease Other: 1.Acute MI risk stratification 2.Differential diagnosis

22 Cine imaging LV function by CMR and Echo CMR and Echo are NOT interchangeable CMR is more reproducible than Echo Bellenger NG, Eur Heart J. 2000;21: Bellenger NGJ Cardiovasc Magn Reson. 2000;2(4):271-8

23 Infarct size by CMR vs SPECT n = 33, CMR and SPECT 7 +/-2 days after acute MI Ibrahim T, JACC 2005;45:544 55

24 Infarct size by CMR vs SPECT: dog model Wagner A, Lancet 2003;362:

25 Infarct size by CMR vs SPECT n = 78, CMR and SPECT 7 +/-2 days after acute MI CMR picked up more small and non-anterior MIs Ibrahim T, JACC 2007;49:208-16

26 Indications for CMR in ACS Guidelines: 1.Low risk troponin-negative ACS to decide if angiogram is necessary 2.Post STEMI to measure LV function and scar size 3.Post STEMI in multi-vessel disease Other: 1.Acute MI risk stratification 2.Differential diagnosis

27 ROC curves ofindifferent pulse Perfusion CMR multi-vessel CADsequences 2.5 x 2.5 mm resolution 1.3 x 1.3 mm resolution Patel A, et al. J Am Coll Cardiol. 2010;56:

28 Perfusion aims CMR vs SPECT multi-vessel CE-MARC: Results Single-Centre (CEMARC) Greenwood JP, et al. Lancet 2012;379: Multi-Centre (MR-IMPACT 2) Schwitter J, et al. JCMR 2012;14:61

29 ROC curves ofindifferent pulse Perfusion CMR multi-vessel CADsequences 30 patients with CAD, CMR prior to coronary angiogram 2.5 x 2.5 mm resolution 1.3 x 1.3 mm resolution Patel A, et al. J Am Coll Cardiol. 2010;56:

30 Indications for CMR in ACS Guidelines: 1.Low risk troponin-negative ACS to decide if angiogram is necessary 2.Post STEMI to measure LV function and scar size 3.Post STEMI in multi-vessel disease Other: 1.Acute MI risk stratification 2.Differential diagnosis

31 Infarct characteristics by CMR Infarct area (Late gadolinium enhancement) Area at risk (T2-weighted CMR) Salvage (AAR - Infarct) MVO area (Early gadolinium enhancement) Haemorrhage (T2/T2*weighted CMR)

32 Myocardial salvage by CMR Area at risk (T2w) Infarct (LGE) Salvage (T2w-LGE) Area at risk Infarct size Myocardial salvage index (MSI) = area at risk Eitel et al. JACC 2010; 55:

33 Myocardial salvage post PPCI n = 208 All-cause mortality up to 6 months Death, reinfarction, new CCF Eitel et al. JACC 2010; 55:

34 Myocardial salvage by CMR Eitel et al. JACC 2010; 55:

35 Prognosis after ACS 135 patients with chest pain, CMR in ER, clinical follow up Ingkanisorn P et al JACC 2006;44:47:1427

36 Proportion Surviving Without New CAD or Complications Prognosis after ACS 1.0 CMR (-) CMR (+) # at Risk CMR (-)105 CMR (+) Days After Enrollment Ingkanisorn P et al JACC 2006;44:47:1427

37 LGE infarct size after PPCI - outcome n = 103 Death, MI, CHF, EF<35%, malignant arrhythmias Larose et al JACC 2010;55:

38 LGE Infarct size vs other markers n = 103 Larose et al JACC 2010;55:

39 MVO and haemorrhage after PPCI n = 346 MO Hypo Core N=116 MO + Hypo Core + N=122 MO + Hypo Core N=108 Eitel et al., Circ Cardiovasc Imaging 2011;4:354-62

40 Clinical outcome after PPCI n = 346 MO = MVO Hypointense core = Haemorrhage Major adverse clinical events (HR 2.59) Eitel et al., Circ Cardiovasc Imaging 2011;4:354-62

41 Indications for CMR in ACS Guidelines: 1.Low risk troponin-negative ACS to decide if angiogram is necessary 2.Post STEMI to measure LV function and scar size 3.Post STEMI in multi-vessel disease Other: 1.Acute MI risk stratification 2.Differential diagnosis

42 Patterns of late Gadolinium enhancement MI Endocardial Myocarditis HCM Epicardial (Septal) speckles Amyloid Diffuse Sarcoid Patchy

43 Summary CMR in ACS Limited indications in current guidelines Low risk ACS LV function and infarct sizing if echo not feasible Ischaemia assessment in multi-vessel disease post STEMI Potentially high diagnostic performance Reference test for LV function and infarct size High accuracy for ACS detection But: NOT a test for acute patients! Can offer additional information Risk stratification Differential diagnosis

44 Leeds Biomedical Imaging S. Plein J. Greenwood M. Motwani A. Kidambi A. Uddin D. Ripley L. Dobson P. Swoboda A. McDiarmid B. Erhayiem P. Garg P. Bijsterveld F. Richards M. Saysell G. Bainbridge C. Richmond D. Buckley J. Ridgway J. Biglands S. Sourbron A. Zaman D. Broadbent MCRC LIGHT LEEDS

45 Upcoming meetingsjoint SCMR/EuroCMR meeting Nice, France 4-7 Febuary 2015