Imaging Prof Geneviève DERUMEAUX Hôpital Henri Mondor Créteil, FRANCE Conflicts of Interest Speaker/advisor/research grant for Actelion, Sanofi, Servier, Toshiba # esccongress www.escardio.org/esc2014
IMAGING TOPIC 1 New 2014 ESC guidelines TOPIC 2 Imaging Atherosclerosis Evaluation Risk marker TOPIC 3 LV function assessment
IMAGING Imaging in new 2014 guidelines # esccongress www.escardio.org/esc2014
2014 ESC/EACTS Guidelines on myocardial revascularization: Indications for imaging Symptomatic patients (Intermediate risk) Stress imaging IA CT Angiography IIa A Hybrid Imaging IIa B Knuuti, (FI) / Zamorano, (ES) / S. Windecker, (CH)
2014 ESC guidelines on the diagnosis and treatment of aortic diseases: Imaging of aorta Advantages/Limitations TTE TOE CT MRI Angio Ease of use +++ ++ +++ ++ + Diag. Reliability + +++ +++ +++ ++ Serial examinations ++ + ++(+) +++ - +++ only for follow-up after aortic stenting (metallic struts), otherwise limit radiation Repetitive imaging of the aorta diameter over time to assess change in diameter Use the same imaging modality IC Use similar method of measurement IC Lowest iatrogenic risk imaging IC R.Erbel (DE) / 1119
2014 ESC Guidelines on diagnosis/management of Hypertrophic Cardiomyopathy: CMR indications Diagnosis: detection of increased LV wall thickness Disease phenotype: myocardial fibrosis, abnormal MV apparatus coronary microcirculatory function ECG Echocardiography is central to the diagnosis and monitoring of HCM (IA in all pts.) P.M. Elliott (GB)
EURObservational research programme cardiomyopathy registry: Use of CMR/LGE 1115 consecutive patients who fulfilled conventional criteria for cardiomyopathy (26 centres) CMR LGE HCM HCM P.M. Elliott (GB)
2014 ESC Guidelines on diagnosis/management of acute pulmonary embolism: Central role of CT/Added value of Echo in unstable patients Suspected Acute PE with shock/hypotension CT available Class IC - No Echo Class IC RV Overload/Dysfunction + YES + Reperfusion therapy S.V. Konstantinides (GR)
IMAGING Imaging Atherosclerosis # esccongress www.escardio.org/esc2014
Systemic atherosclerotic inflammation following Acute Myocardial Infarction: Increased 18F-FDG PET uptake in remote atheroma In murine models, acute MI exacerbates atherosclerotic inflammation and progression : is it the same in humans? Regions of interests around aorta 18F-FDG PET study 40 pts. with recent MI - 40 pts. with stable angina 18F-FDG 18F-FDG tissue to background tissue to background ratios ratios 18F-FDG in stable angina and myocardial infarction 3.0 3.0 2.5 2.5 2.0 2.0 1.5 P<0.0001 P=0.03 Stable Angina (n=40) NSTEMI (n=14) STEMI (n=26) 1.5 In MI patients, 18F-FDG PET activity correlated with the size of the P<0.0001 infarct (troponin level) (r=0.43) p=0.01) P=0.03 Stable Angina (n=40) NSTEMI (n=14) STEMI (n=26) N.V. Joshi, (UK) /ESC Hot line session 2014
Myocardial Infarction (MI) Begets MI: The extent of MI predicts early recurrent MI 1003 patients from the GRACE registry Size of the initial infarct was an independent predictor of recurrent early MI at 30 days MI exacerbates systemic atherosclerotic inflammation, destabilises remote atheromatous plaque, causes an increase in early recurrent atherothrombotic events Survival free from recurrent Survival myocardial free from infarction recurrent (%) myocardial infarction (%) 100 100 98 96 94 92 90 88 98 96 94 92 90 88 Tertile-3 versus tertile-1: RR 4.30 [95%CI, 1.85-9.96], p=0.001 86 86 0 0 5 5 10 10 15 15 20 20 25 25 30 30 Troponin I Days Days from from index index event event D ays D ays 0 0 10 10 20 20 30 30 Tertile Tertile 1 1 332 332 326 326 324 324 323 323 Tertile Tertile 2 2 336 336 325 325 317 317 313 313 Tertile Tertile 3 3 335 335 312 312 304 304 298 298 Tertile Tertile 1 1 Tertile Tertile 2 2 Tertile Tertile 3 3 N.V. Joshi, (UK) /ESC Hot line session 2014
Epicardial Adipose Tissue: Relationship with plaque characteristics/vulnerability EAT was assessed in 406 patients referred for 64-slice CT Vulnerable coronary plaque components: presence of non-calcified plaque (NCP) High risk plaques and EAT thickness Factors EAT (>5.6mm) Gender (male) Diabetes Multiple logistic analysis after adjustment of age, hypertension, dyslipidemia Y. Morimitsu (JP) / P2549
Epicardial Adipose Tissue: Predicts progression of coronary artery calcification (CAC) EAT quantification To determine the association of EAT volume with progression of CAC-score in the general population (Heinz Nixdorf Recall Study) without known CAD MV-adjusted** CAC score at enrollment and after 5 years of follow-up in 3367 subjects Fat Volume Age Groupe All participants <55 (n=1136) 55-<65 (n=1372) % progression in CAC+1 (95% Cl) 6.1 (1.2-11.2) 19.8 (8.9-31.7) 2.5 (-4.8-10.4) p-value 0.01 0.0002 0.5 65 (n=859) 3.9 (-7.2-7.9) 0.98 A.A. Mahabadi (DE) / 3839
IMAGING LV Function assessment # esccongress www.escardio.org/esc2014
2D speckle-tracking after chest radiation: Detection of subclinical LV dysfunction Acute adverse effects of RT on cardiac function are not well characterised 40 women with left sided breast cancer, treated by lumpectomy without chemotherapy, undergoing only adjuvant RT (mean cumulative dose 58.9±9.5 Gy) Standard and 2D STE was obtained at baseline, during RT and 6 weeks post RT Parameter Baseline During RT 6 wks post RT P value LVEF (%) 63 ± 5 62 ± 4 62 ± 4 NS Global Long S -20.44 ± 2.66-18.60 ± 2.70 * -18.34 ± 2.86 * <0.05 Global Cir S -18.52 ± 3.45-19.20 ± 3.30-19.30 ± 2.86 NS Global Rad S 56.66 ± 18.57 46.93 ± 14.56 * 49.22 ± 15.81 * <0.05 Global Long Strain is modestly correlated with radiation dosage These findings may have implications in breast cancer patients receiving additional cardiotoxic chemotherapy Q. Lo (AU) / P644
3D speckle-tracking Echo (STE): Area strain but not LVEF predicts outcome in primary mitral regurgitation Management of asymptomatic pts. with primary MR remains controversial 41 asymptomatic pts. with severe primary MR and LVEF > 60% Clinical F-Up at 18 months Composite end-point (n=8): new onset of dyspnea, admission for heart failure Log rank test p=0.033 3D STE is a promising tool for predicting the development of symptoms E. Casas Rojo, (SP) / 226
HIGHLIGHT ON IMAGING 2014 TAKE HOME MESSAGE Imaging plays a major role in diagnosis and decisionmaking in cardiology Acute MI exacerbates systemic atherosclerotic inflammation and disease progression (18F FDG PET) Epicardial fat is a confirmed marker of advanced atherosclerosis LVEF underestimates the extent of LV dysfunction whereas 2D/3D strain imaging accurately detects LV impairment at an earlier stage (e.g., in breast cancer and in primary mitral regurgitation)
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