MPS and Calcium Score in asymptomatic patient F. Mut, J. Vitola

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Eleanore Gordon
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1 MPS and Calcium Score in asymptomatic patient F. Mut, J. Vitola Nuclear Medicine Service, Asociacion Española Montevideo, Uruguay Quanta Diagnostico Nuclear Curitiba, Brazil

2 Clinical history Male 63 y.o., asymptomatic. Inactive but wants to start exercise. Knee osteoarthritis limiting exercise capacity. Hypertension (BP 145/90 mmhg under medication). Family history of CAD (father had sudden death at 53). Total Cholesterol = 223; HDL = 45; LDL = 128, Gluc = 0.97.

3 First step to evaluate an asymptomatic patient? a) Global risk score (i.e. Framingham). b) SPECT-MPS. c) Coronary angioct. d) Rest ECG.

4 First step to evaluate an asymptomatic patient? a) Global risk score (i.e. Framingham). b) SPECT-MPS. c) Coronary angioct. d) Rest ECG. Global risk score is a Class I indication in this setting; SPECT-MPS is Class IIB or III, Coronary angioct is Class III, and Rest ECG is Class IIA. Calculated Framingham risk score = 18% (intermediate risk for CAD events in 10 years) based on SBP, cholesterol levels, age, gender, and smoking status.

5 Which test can help stratify intermediate CAD risk patients? a) Calcium score (CAC). b) C-Reactive protein. c) Carotid intima-media thickness on ultrasound. d) All of the above.

6 Which test can help stratify intermediate CAD risk patients? a) Calcium score (CAC). b) C-Reactive protein. c) Carotid intima-media thickness on ultrasound. d) All of the above.

7 CAC 1611 Agatston (Percentile 97 for sex, age and race) High risk patient!

8 Which test can help further stratify intermediate CAD risk patients with advanced atherosclerosis? a) Treadmill test b) Myocardial perfusion study c) CT angiography d) Invasive angiography

9 Which test can help further stratify intermediate CAD risk patients with advanced atherosclerosis? a) Treadmill test b) Myocardial perfusion study c) CT angiography d) Invasive angiography In addition to the knowledge about atherosclerosis burden in our patient, short-term prognosis is dependent on the presence and degree of ischemia, the territory involved, and the LV function - all of which can be provided by MPS.

10 Myocardial perfusion study SPECT MPS, combined low workload exercise with dipyridamole, 99mTc-MIBI, one-day protocol. No symptoms or ST changes.

11 Myocardial perfusion study LVEF: stress 67%, rest 62%

12 The MPS result is consistent with: a) Anteroseptal infarction + ischemia, high risk. b) Normal perfusion. c) Inferoapical ischemia, low risk. d) Lateral wall ischemia, moderate risk.

13 The MPS result is consistent with: a) Anteroseptal infarction + ischemia, high risk. b) Normal perfusion. c) Inferoapical ischemia, low risk. d) Lateral wall ischemia, moderate risk. The images show inferoapical reversible defect, with preserved LV function both post-stress and rest = low risk for cardiac events.

14 Follow-up Patient was managed clinically for CAD, ischemic heart disease: Beta-blockers, ASA, statins. Secondary prevention (target = LDL< 70). Low level exercise: medicated and under supervision.

15 Teaching points CAC provides independent incremental information in addition to traditional risk factors in the prediction of allcause mortality. The principal difference between MPS and Ca scoring is that the former is an excellent tool for assessing shortterm risk, guiding decisions on revascularization. In contrast, atherosclerosis imaging methods like CAC provide greater long-term risk assessment, and are more useful in defining the need for aggressive medical prevention.

16 Bibliography Berman DS, Hachamovitch R, Shaw LJ, et al. Roles of nuclear cardiology, cardiac computed tomography, and cardiac magnetic resonance: Noninvasive risk stratification and a conceptual framework for the selection of noninvasive imaging tests in patients with known or suspected coronary artery disease. J Nucl Med 2006; 47: Budoff MJ, Shaw LJ, Liu ST. Long-term prognosis associated with coronary calcification: observations from a registry of 25,253 patients. J Am Coll Cardiol 2007; 49: Greenland P, Alpert JS, Beller GA, et al ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2010; 56: Xu Y, Arsanjani R, Clond M, et al. Transient ischemic dilation for coronary artery disease in quantitative analysis of same-day sestamibi myocardial perfusion SPECT. J Nucl Cardiol 2012;19:

Typical chest pain with normal ECG

Typical chest pain with normal ECG F. Mut, C. Bentancourt, M. Beretta Nuclear Medicine Service, Asociacion Española Montevideo, Uruguay Clinical history Male 41 y.o. Overweight, hypertension, high cholesterol,