Imaging of Coronary Atherosclerosis. Dr Marc Dweck BHFSenior Lecturer Edinburgh Heart Centre& University of Edinburgh

Transcription

1 Imaging of Coronary Atherosclerosis Dr Marc Dweck BHFSenior Lecturer Edinburgh Heart Centre& University of Edinburgh

2 Echo CT Angiography& Plaque MRI - Assess Anginal Symptoms SPECT PERFUSION - Risk Stratification & Prediction of MI PET DISEASEACTIVITY 2

3 Plaque Burden

4 Carotid Ultrasound

5 Carotid Ultrasound and Coronary Plaque Burden Baber JACC2015

6 CTCalcium Scoring Detrano R,. N Engl JMed. 2008

7 Advancesin CTimaging slice 1 slice Overlapping algorithm 4 slice 16 slice 64 slice Int J Cardiovasc Imaging 2009, 25: 31-42

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9 Obstructive Coronary Atherosclerosis ~90%Specificity and Sensitive for Obstructive Coronary Heart Disease Buddoff JACC 2008 Miller NEJM 2008

10 Non-Obstructive Plaque Advantage compared to perfusion imaging

11 Non-Obstructive Coronary Artery Disease & Prognosis Maddox JAMA 2014

12 Importance of Non-Obstructive Plaques Falk Circulation 1995

13 CT Useful in the Assessment of CAD Do they have coronary artery disease? Statins & Aspirin Do they have angina? Anti-anginal medication ± PCI Do they have severe 3VD or LMSdisease? Revascularisation (CABG)

14 Randomization 1:1 n=4,146 Newby. The Lancet Standard of Care n=2,073 Computed Tomography Coronary Angiogram n=3 Standard of Care + CT Coronary Angiogram n=2, % Data for the Primary End-point Intention-to-Treat Analysis Data for Primary Endpoint n=2,073 CT Coronary Angiogram n=1,778 Non-completion Ill-health/death Patient default Technical Other Data for Primary Endpoint n=2,

15 CT Incre a s e s Dia gnos tic Ce rta inty Overall Changes in Diagnosis: 25% versus 1%, P<0.001 Dia g n o s is o f Co ro n a ry He a rt Dis e a s e Ce rta in ty 2.56 [ ] Fre q u e n c y 1.09 [ ] Dia g n o s is o f An g in a Ce rta in ty Fre q u e n c y 1.79 [ ] 0.93 [ ] Re la tive Ris k [95% Co n fid e n c e In te rva ls ]

16 CTCA Incre a s e s P re s cription of Anti-platelet and Statin Therapy Therapy AnAntiplatelet ti-p la te le t Th e ra p y CTCA P<0.001 P<0.001 Standard Care SStatin ta tintherapy Th e ra p y CTCA Frequency (%) Frequency (%) Nu m b e r o f P a rtic ip a n ts (%) Overall Changes in Treatments: 23%versus 5%, P<0.001 P<0.001 P<0.001 Standard Care Follow-Up ears) Fo llo w Up (Y (ye a rs ) Follow-Up (Years) Fo llo w Up (ye a rs ) Me d ia n 46 [30-64] d a ys fro m c lin ic to p re s c rip tio n Me d ia n 50 [30-70] d a ys fro m c lin ic to p re s c rip tio n Williams et al. JACC2016;67:

17 CTCA Incre a s e s Corona ry Re va s cula ris a tion Coronary Angiography Coronary Revascularisation HR 1.20 [ ], P=0.061 HR 1.06 [ ], P= CTCA 20 S ta n d a rd Ca re CTCA 10 S ta n d a rd Ca re CTCA S ta n d a rd Ca re P ro p o rtio n o f p a tie n ts with a n e ve n t (%) P ro p o rtio n o f p a tie n ts with a n e ve n t (%) Fo llo w Up (ye a rs ) CTCA S tan d a rd Ca re Fo llo w Up (ye a rs )

18 CHD De a th a n d No n -fa ta l MI Post-hoc 50-Day Landmark Analysis Implementation Delay Impact of Alterations in Therapy P ro p o rtio n o f p a tie n ts with a n e ve n t (%) S ta n d a rd Ca re - CTCA Performed - Result Reviewed - Management Changed - Invasive Angiography Arranged - Prescription issued CTCA 1.0 HR0.50 [ ] P= CTCA S ta n d a rd Ca re Da ys Williams et al. JACC2016;67: Fo llo w Up (ye a rs )

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20 The Future

21 FFRCT FFR 0.71

22 CTFFR Normal SPECT-MPI

23 High risk plaque characteristics on CT Positive remodelling and low attenuation plaque (necrotic core) Motoyama JACC2015

24 High risk plaque characteristics on CT (D) Motoyama JACC2015

25 Autoplaque: Automated plaque characterization Dr Damini Dey, Cedars Sinai

26 High Intensity Plaque on CMR High signal due to methaemoglobin in acute luminal thrombus or intraplaque haemorrhage Single Centre study of 568 patients 55 patients had high intensity plaque Patients with these plaques had an increased risk of future coronary events (hazard ratio: 8.93; 95% CI: 3.23 to 24.7; p < 0.001) Noguchi JACC2014

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28 18F-Fluoride post STEMI Coronary Angiogram (LCA) Fused 18F-Fluoride PET CT Joshi, Dweck, Newby. The Lancet. 2014

29 18F-Fluoride post STEMI Coronary Angiogram (LCA) CT Joshi, Dweck, Newby. The Lancet. 2014

30 Patients with Myocardial Infarction 18F-Fluoride Identifies the Ruptured Plaque B" Joshi, Dweck, Newby. The Lancet. 2014

31 18F-Fluoride vs. VH-IVUS & Histology HISTOLOGY VH-IVUS FJ Irkle Nature Communications 2015, Vesey Circ CVS Imaging 2016 Joshi, Dweck, Newby. The Lancet. 2014

32 PET/ CT IMAGING

33 Prediction of Recurrent Events with 18F-Fluoride to Identify Ruptured and High-risk Coronary Artery Plaques in Patients with Myocardial Infarction

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35 Acknowledgements Universit y of Edinburgh Prof David Newby Prof Nicholas Mills Prof Keith Fox Dr Nicholas Boon Dr Tania Pawade Dr Russell Everett Dr Tim Cartilidge Dr AlexVesey Dr William Jenkins Dr Phil Adamson Dr Alastair Moss Dr Mhairi Doris The British Heart Foundation This work was supported by the following BHF grants Dr JamesRudd Dr Andrew Davenport - Clinical Research Training Fellowship (FS/ 10/ 026) - Extension to Clinical Research Training Fellowship (FS10/ 026) - Clinical Research Training Fellowship (FS/ 12/ 84/ 29814) - British Heart Foundation Project Grant (PG/ 12/ 8/ 29371) - British Heart Foundation Centre of Research Excellence Award. - British Heart Foundation Clinical Lectureship - British Heart Foundation Intermediate Fellowship Cedars Sinai, LA M ount Sinai, New York Dr Daniel Berman Dr Piotr Slomka Dr Damini Dey Dr Zahi Fayad Dr Valentin Fuster Dr Jagat Narula Universit y of Cambridge

36 MI arising from a nonobstructive plaque Dweck JACC2016

37 Pan Coronary Vulnerability

38 Will 18F-Fluoride Predict Events? Disease Progression Clinical Events (Cardiac Death or MI)

39 All cause death Myocardial infarction Me ta -a na lys is Significant reduction in the annual rate of myocardial infarction No difference in all cause mortality Bitte ncourt e t a l. Circula tion CVI 2016

40 The PROMISETrial Primary Endpoint Douglas et al. N Engl JMed 2015;372:

41 SCOT-HEART vs. PROMISE SCOT-HEART Trial PROMISE Trial 90-Da y In va s ive Co ro n a ry An g io g ra m 12% 10% Ob s tru c tive Co ro n a ry He a rt Dis e a s e 25% 11% Co ro n a ry Re va s c u la ris a tio n 12% 5% Myo c a rd ia l Infa rc tio n (/10 ye a r) 8.4% 3.3% Ca rd io va s c u la r De a th (/10 ye a r) 2.0% - All-c a u s e De a th (/10 ye a r) 5.0% 7.0% Inva s ive Corona ry Angiogra phy Clinica l Eve nts

42 IVUS Puri et al. Eur Heart J 2013;34: