State of the Art. Advances in Cardiovascular Imaging. ESC Congres Stockholm September 1, 2010 Frank E. Rademakers, MD, PhD, FESC

Transcription

1 State of the Art Advances in Cardiovascular Imaging ESC Congres Stockholm September 1, 2010 Frank E. Rademakers, MD, PhD, FESC

2 Coronary Artery Disease Content Patho Physiology Imaging requirements Economical considerations

3 Plaque Evolution Circulation. 2003;108:

4 Development of Human Coronary Atherosclerosis Intimal thickening Intimal xanthoma Pathologic intimal thickening Fibrous cap atheroma Thin-cap Fibroatheroma NC LP NC FC Smooth muscle cells Macrophage foam cells Extracellular lipid Cholesterol clefts Necrotic core Calcified plaque Hemorrhage Thrombus Healed thrombus Collagen FC = fibrous cap LP = lipid pool NC = necrotic core

5 Frequency of Coronary Thrombi in Culprit Lesions by Decade in Men Dying Sudden Coronary Death Percent 7o * p=0.05 # * # * # * # p=0.05 Acute Thrombus Plaque Rupture Plaque Erosion Stable Plaque Age Range in Years

6 Main Causes of Coronary Thrombosis Rupture (65%) Erosion (30%) NC Rupture Site Th Th NC Th Pathologic Intimal Thickening (50%) Fibroatheroma (50%) Th Th Th Virmani R, et al. Arterioscler Thromb Vasc Biol 2000;20:1262

7 Rupture, Stenosis, Cap Thickness and Necrotic Core Arterioscler Thromb Vasc Biol. 2010;30:

8 Causative Plaque Type Am J Cardiol 2008;101[suppl]:3F 10F

9 The Vulnerable Coronary Plaque Is Severe Before Rupture Japanese Multicenter Trial Diameter Stenosis (%) Ojio et al, Circulation, 2000

10 Risk of Occlusion and Severity of Stenosis J. Schwitter. Future Cardiol. 2006, 2(5)

11 Subject and Segment -wise Analysis N = Feature-Positive PR(+), LAP(+) 45 1 Feature-Positive PR(+) or LAP(+) Feature-Negative PR(-), LAP(-) 820 No Plaque ACS(+) 10 ACS(-) 35 ACS(+) 1 ACS(-) 26 ACS(+) 4 ACS(-) 816 ACS(+) 0 ACS(-) % 0.4% 50% stenosis in 7 and 25% stenosis in 4 Motoyama et al. JACC 2009

12 Back to the Plaque? Thromb Haemost 2009; 102:

13 Morphology versus Activity Circulation. 2003;108:

14 Imaging for targeted intervention (1) angioscopy, (2) intravascular ultrasound, (3) palpography, (4) virtual histology, (5) near-infrared/raman spectroscopy, (6) ocular coherence tomography/ocular frequency domain imaging, (7) thermography, (8) vasa vasorum imaging, (9) MRI (invasive and noninvasive), (10) PET/computed tomography (CT) and (11) molecular imaging. Current Opinion in Cardiology 2009, 24:

15 Non-invasive tools for identifying individuals at risk Current Opinion in Cardiology 2009, 24:

16 Choice of treatment J Nucl Med 2006; 47:

17 Post-test Probability of CAD (%) When to perform an imaging test? (+) test Invasive coronary angiography (-) test No imaging Pre-test (Clinical) Probability of CAD (%) Patterson et al. JACC 1989

18 SPECT Gibbons J Nucl Cardiol 2008;15:178-85

19 Diagnostic Performance of SPECT in 3-V DiseaseGated % patients 3-VD (>70%) 40% normal(12%) or low-risk 1-VD (28%) perfusion + function Lima JACC 2003;42:64

20 Stenosis classification J Am Coll Cardiol 2010;55:

21 Sensitivity MPI (SPECT) to detect LM / 3-VD perfusion + other markers Reyes Eurointerv 2010

22 FFR in Left Main Disease Circulation. 2009;120:

23 Detection of Ischemia, MR-IMPACT SPECT results of the MR-IMPACT are in close agreement with Multicenter SPECT studies using invasive coronary X-ray angiograpy as standard of reference Eur Heart J 2004; 25: Courtesy J. Schwitter University Hospital Lausanne, Switzerland

24 PET Perfusion, CFR and Prognosis Herzog B et al, J Am Coll Cardiol 2009

25 Hyperemic MBF Increases to Adenosine Stimulation (4 mg L-NAME / kg BW i.v.) 3 p < ,5 Baseline -21% L-NAME MBF (ml/min / g) 2 1,5 1 0,5 0 NS endotheliumrelated smooth muscle cell relaxation to adenosine Rest MBF Adenosine MBF Measure of Integrated Coronary Circulatory Function Buus et al, Circulation 2001

26 Subclinical CAD 13N-Ammonia PET/CT Perfusion Images MBF (ml/g/min) STRESS 1.47 REST 0.81 Myocardial Flow Reserve (MFR): 1.81

27 Event Free Survival PET determined Coronary Endothelial Vasoreactivity and Prognosis 1.0 % MBF 40% % MBF>0% and <40% Log rank 7.42 p = % MBF 0% Follow-up (months) Schindler TH, J Am Coll Cardiol 2005

28 Cardiomyopathy, MBF and Prognosis Neglia D et al. Circulation 2002

29 Hypertrophic Cardiomyopathy, MBF and Prognosis Cecchi F et al, New Engl J Med 2003

30 Future in CAD Imaging Quantification of myocardial blood flow Coronary microvascular dysfunction Risk area determination translates in superior prognostic value Subclinical disease Vascular inflammation and plaque imaging Plaque attenuation Plaque composition Vascular inflammation and plaque instability Tissue Characterisation Technical Improvements Contrast agents 3D

31 Feasibility of FDG Imaging of the Coronary Arteries Rogers et al, JACC Imaging 2010

32 15 O-water and PET MBF Images Short axis resting MBF images with (CTAC) and without (NAC) attenuation correction Stress-rest MBF quantification with 15 O-water 0.8 msv Lubberink M et al. J Nucl Med 2010

33 pre Perfusion Defect T1-FFE 5min 20min 40min 60min

34 Perfusion T2 Oxygen 90% area LCx stenosis Perfusion (Rest) Perfusion (Dipyridamole) X-ray MRI LCx T2 T2 (Rest) T2 (Dipyridamole) McCommis, Zheng. Circulation Imaging 2010; 3: 41-6

35 T1 mapping for fibrosis

36 Fibrosis treatment Circ J 2008; Suppl A: A-8 A-12

37 Health Care Costs: 16-Year Cumulative Inflation = Health Insurance Premiums Medicare Conversion Factor ($/RRU) US Consumer Price Index Sources: AMA, Kaiser Family Foundation

38 CT/MR/PET Utilization All modalities CT MR PET 163 Services per 1,000 beneficiaries OIG Analysis, Medicare Part B

39 Rate/1,000 Medicare Cardiac Procedures Stress imaging Cardiac catheterization Revascularization Acute MI Circ 113: 374, 2006

40 Economical Considerations Community Perspective Medical technology is very expensive What is the added value of a specific new technology in absolute terms and in comparison to existing or other new technologies? What is the evidence? What should the evidence be?

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42 The hierarchy of diagnostic efficacy described by Fryback and Thornbury is used as the basis of this Level 1: Technical quality of the images Level 2: Diagnostic accuracy, sensitivity and specificity of the images Level 3: Degree to which results influence physicians diagnostic thinking: prognosis Level 4: Degree to which imaging results affect patient management Level 5: Efficacy studies measure the degree of effect on patient management Level 6: Analyses of societal costs and benefits of a diagnostic imaging technology

43 Evolving View Medical technology Marginal activity Core business Specialization Hyper-specialization Money maker Target for the Regulating Authorities Target for internationalization

44 J Am Coll Cardiol 2006;48:

45 Conclusion The future of CV Imaging is bright We need quantitative perfusion, since ischemia Is the first step in the ischemic cascade Is underlying abnormality in many cardiac syndromes Drives therapeutic choices We need plaque imaging to test new strategies in early preventive measures Technical developments Trials to determine diagnostic and prognostic capabilities but also impact on patient management