The best from Euro-Echo Ischemic heart disease. Fausto Rigo,FESC Department of Cardiology Mestre-Venezia Hospital,Italy

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1 The best from Euro-Echo 2011 Ischemic heart disease Fausto Rigo,FESC Department of Cardiology Mestre-Venezia Hospital,Italy

2 DECLARATION OF CONFLICT OF INTEREST No conflict of interest to be disclosed

3 Imaging in Atherosclerosis Plaque rupture, instability of plaque Acute CV event - Chronic ischemia (resting WMA) Inducibile Ischemia (WMA, SEcho, CFR) Obstructive arterial process Non Obstructive plaque ( US) Morphostruttural Alterations of Vascular Arterial Wall (IMT) Functional alteration of vascular wall (FMD, stiffness parameters) Cardiovascular Risk Factors: Traditional, Genetic, Emerging

4 Function vs Anatomy in IHD?

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8 Comparison of Exercise Stress Tests meta-analysis on 44 articles (published between 1990 and 1997) Sensitivity Specificity Ex- ECG 52% 71% Ex-Echocardiography 85% 77% Ex-Scintigraphy 87% 64% JAMA 1998;280: not adjusted for referral bias, exercise echocardiography had significantly better discriminatory power than exercise myocardial perfusion imaging

9 When to perform a stress Echo

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14 Anatomical approach to CAD: CT scan

15 Risk of radiations stratified by age and gender Picano. BMJ 2004, updated with BEIR VII, 2006

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19 EUROECHO 2011 Assessment of Doppler coronary flow reserve in clinical practice G. D. Athanassopoulos MD FESC Deputy Director Cardiology Section Onassis Cardiac Surgery Center Athens,Greek

20 Prediction of vessel patency by CFR Changes of sensitivity according to CFR LAD RCA

21 Prognostic value of CFR on LAD in diabetics with no ischemia Diabetics Nondiabetics Spontaneous events % n = 207 p < Spontaneous events % n = 923 p < Follow-up (years) Subjects at risk CFR < 2 CFR > Follow-up (years) CortigianiL Rigo F et al JACC 2007;50:1354

22 Eur Heart J, 2010 Whenever possible, it is recommended to perform dual imaging vasodilator stress echo

23 When and why should patients with coronary artery disease should have assessment of coronary artery flow reserve To improve diagnostic accuracy of stress echo/detection of underlying significant epicardial stenosis LBBB, pacing, female gender, diabetes, existing wall thickening abnormalities (previous infarction) Validation of physiological significance of existing intermediate coronary artery stenosis /definite selection for CABG definition of intermediate stenosis: 40-70% Left main disease Evaluation of patency post baloon angioplasty/stenting selection of patients with optimal physiological response to stenting Evaluation post acute myocardial infarction: microvascular function/residual ischemia Evaluation for viability Evaluation for stunning Evaluation for reperfusion injury

24 Function vs Anatomy in IHD?

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28 EAE Recommendations Myocardial Function Rosa Sicari, MD, PhD, FESC Institute of Clinical Physiology, Pisa, Italy Budapest, December 9, 2011

29 Myocardial Ischemia The direct observation of a developing systolic dysfunction combined with a post-systolic shortening indicates acute myocardial ischemia. However, the lack of clinical trials does not allow recommending specific parameters for differentiating various states of acute and chronic ischemia when baseline data are not available

30 Fibrosis and Viability Recommendation: The place of deformation analysis is the recognition and evaluation of fibrosis and myocardial viability is a matter of ongoing investigation. At present, the strongest evidence pertains to the combination of strain with low-dose dobutamine stress for the assessment of myocardial viability. Although encouraging data have been obtained with the use of deformation analysis to recognize fibrosis and distinguish nontransmural scar in the setting of resting wall motion abnormalities, clinical use of this methodology is not recommended at this time.

31 Tissue Doppler Imaging Doppler Tissue Imaging Velocity Displacement Strain rate Strain Angle dependency Color-Doppler derived strain and SR are noisy: Training needed Readily available Objective and quantitative Online measurements Excellent temporal resolution

32 Three-dimensional (3D) STE Good image quality Low temporal and spatial resolution No validation and testing No true noninvasive gold standard technique Accurate assessment of regional ventricular dynamics.

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39 Otto Kamp

40 The best from EuroEcho 2011 Which test in IHD? Which stressor? Anatomy investigation? Which technology? If new tests and treatments are used indiscriminately, their impact may be minimal for many patients, deleterious for some patients, and costly for the society Ayanian. Circulation 2006;113:333 The appropriate test

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42 Cost-effective Use of Noninvasive Tests When appropriately used, noninvasive tests are less costly than coronary angiography and have an acceptable predictive value for adverse events This is most true when the pretest probability of severe CAD is low When the pretest probability of severe CAD is high, direct referral for coronary angiography without noninvasive testing has been shown to be most cost-effective as the total number of tests is reduced Circulation 1995;91:54-65

43 If new tests and treatments are used indiscriminately, their impact may be minimal for many patients, deleterious for some patients, and costly for the society. Ayanian. Circulation 2006;113:333

44 Stress Tests - cost issues exercise ECG is least costly 1X stress echocardiography 2X stress SPECT myocardial imaging 5X coronary angiography 20X 1/00 medslides.com 44

45 Cost of cardiac imaging Echo MSCT SPECT CMR PET Heart cath Pennell. Eur Heart J 2004;25:19

46 Appropriateness in stress echo Appropriate Uncertain Inappropriate Not classifiable 32% 6% 9% 19% 19% 8% 17% 13% 9% 27% 62% 54% 62% 64% Picano. AHJ 2007 McCully. Circ imaging 2009 Mansour. JASE 2010 Cortigiani. Submitted

47 Indication Most common inappropriate indications for stress echo McCully Circ Imag 2009 Mansour JASE 2010 Cortigiani Submitted 114. Evaluation of ischemic equivalent (nonacute) in patients with low pre-test probability of CAD who have an interpretable ECG and able to exercise 124. Detection of CAD and risk assessment in asymptomatic (without ischemic equivalent) general patient population with low global CAD risk 125. Detection of CAD and risk assessment in asymptomatic (without ischemic equivalent) general patient population with intermediate global CAD risk 154. Risk assessment before non cardiac low-risk surgery 156. Risk assessment before non cardiac intermediate-risk surgery in patients with no clinical risk factors 173. Risk assessment in asymptomatic patients <2 years after PCI 12% 44% 33% 42% 17% 17% 14% 26% 28%

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49 scan Anatomical approach to CAD: CT

50 ACCURACY OF FLOW RESERVE EVALUATION FOR LAD PATENCY Cut off =1.8 Cut off =1.8 Athanassopoulos et al ESC 2005

51 2D Speckle Tracking Echo Relies on sufficient temporal resolution Significant differences among vendors (proprietary scan line) Circumferential and radial components Angle independent (not totally) Relies on good image quality

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54 Rigo F, Eur Heart J, 2008

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