ESC CONGRESS 2010 Stockholm, august 28 september 1, 2010 CORONARY ARTERY DISEASE AND NUCLEAR IMAGING: AN UPDATE PERFUSION SCINTIGRAPHY IN HIGH-RISK ASYMPTOMATIC PATIENTS Pasquale Perrone Filardi Federico II University of Naples, Italy
WHY SCREENING ASYMPTOMATIC HIGH RISK PATIENTS? TO IDENTIFY OCCULT SEVERE CORONARY ARTERY DISEASE THAT MAY BENEFIT FROM REVASCULARIZATION Type II diabetic patients First-degree relatives of patients with premature CAD IN ASYMPTOMATIC HIGH RISK PATIENTS FOLLOWING REVASCULARIZATION Type II diabetic patients Incomplete revascularization Suboptimal revascularization TO MONITOR THE EFFICACY OF THERAPY ON ISCHEMIA REDUCTION IN HIGH RISK PATIENTS WITH EXTENSIVE INDUCIBLE-ISCHEMIA Chronic CAD patients following revascularization or medical therapy
REVASCULARIZATION VS MEDICAL THERAPY IN TYPE II DIABETES. THE BARI 2D TRIAL NEJM 2009
Prevalence of abnormal SPECT in asymptomatic diabetic patients without clinical evidence of coronary artery disease Wackers et al. Diabetes Care 2004
IMPACT OF SCREENING FOR ASYMPTOMATIC ISCHEMIA IN DIABETIC PATIENTS WITHOUT KNOWN CAD The DIAD Trial. JAMA. 2009;301:1547
CHANGES AFTER 3-YEARS FOLLOW-UP OF MYOCARDIAL ISCHEMIA IN ASYMPTOMATIC DIABETICS SCREENED BY MPI Wackers et al. for the DIAD Investigators. Diabetes Care 2007;30:2892
Relationship Between the Extent of Coronary Calcification and The Prevalence/Severity of Myocardial Perfusion Abnormality in Asymptomatic Diabetics Anand et al., Eur Heart J 2006
EVENT FREE SURVIVAL IN RELATION TO STRESS ECG AND MPS IN SIBLINGS OF PATIENTS WITH PREMATURE CAD Blumenthal, R. S. et al. Circulation 1996;93:915-923
Comparison of Coronary Calcium and Stress Myocardial Perfusion Imaging in Siblings of Individuals With Premature CAD Blumenthal et al. Am J Cardiol 2006
MPS AND CARDIAC CT IN ASYMPTOMATIC SUBJECTS A POSITION PAPER FROM ESC WG ON NUCLEAR CARDIOLOGY AND CARDIAC CT Perrone-Filardi et al. on behalf of ESC WG. Eur Heart J 2010
Cumulative event-free survival EVENT-FREE SURVIVAL IN RELATION TO PRESENCE OF INDUCIBLE ISCHEMIA IN POST-PCI PATIENTS Zellweger et al., JACC 2003 1.0.9 No ischemia.8.7.6.5.4.3.2.1 0.0 0 200 400 600 800 1200 1400 Time MPS to event (days) Silent ischemia Symptomatic ishemia p = 0.006 p = 0.12 p < 0.0001
Cumulative event-free survival EVENT-FREE SURVIVAL IN RELATION TO EXTENT OF INDUCIBLE ISCHEMIA IN POST-PCI PATIENTS Zellweger et al., JACC 2003 1.0.9 SDS = 0.8.7.6.5.4.3.2.1 0.0 SDS = 1-4 SDS > 4 0 200 400 600 800 1200 1400 Time MPS to event (days) p = 0.03 p = 0.005
ACC/AHA Guidelines for Clinical Use of Radionuclide Imaging after Revascularization Class I (usually appropriate, considered useful) Assessment of ischemia in symptomatic patients Assessment of selected asymptomatic patients - abnormal exercise test early after revascularization - abnormal rest ECG precluding exercise test - post-revascularization exercise test initially negative positive Assessment of high risk patients (3-6 months after PCI; 6-12 after CABG) decreased LV function, multivessel CAD, incomplete revascularization, proximal LAD stenosis, diabetes mellitus, hazardous occupations, suboptimal PCI results, previous cardiac arrest, complicated postoperative course Class III (generally not appropriate) Routine testing of asymptomatic post-revascularization patients
COURAGE TRIAL Boden W et al. N Engl J Med 2007;10.1056/NEJMoa070829
Optimal Medical Therapy With or Without PCI to Reduce Ischemic Burden. Results From the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) Trial Nuclear Substudy. Shaw LJ et al. Circulation 2008 Main findings: Adding PCI to optimal medical therapy resulted in greater reduction in inducible ischemia compared with optimal medical therapy alone.
Optimal Medical Therapy With or Without PCI to Reduce Ischemic Burden. Results From the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) Trial Nuclear Substudy Shaw LJ et al. Circulation 2008 Entire population Pts with moderato-to-severe pre-treatment ischemia Main findings: Patients with ischemia reduction had lower unadjusted risk for death or MI, particularly if baseline ischemia was moderate to severe.
MPS AND CARDIAC CT IN ASYMPTOMATIC SUBJECTS A POSITION PAPER FROM ESC WG ON NUCLEAR CARDIOLOGY AND CARDIAC CT Perrone-Filardi et al. on behalf of ESC WG. Eur Heart J 2010
PREDICTION OF DEATH OR MI IN RELATION TO DUKE SCORE IN PTS WITH KNOWN OR SUSPECTED CAD Hachamovitch et al., Circulation 1996 Event Rate (%) 10 8 6 Normal Scan Mildly Abnormal Scan Severely Abnormal Scan 51 185 168 22 40 n=2113 f.u. 566 d 4 28 2 113 0 762 Low (0.9%) 834 Intermediate (2.5%) Duke Treadmill Score High (7.7%)
Event Risk Stress Stress Rest Rest A Extent of ischemia (# of reversible segments) B Adapted from Ladenheim et al et al, JACC 1986
PREDICTION OF DEATH/MI BY SPECT IN PATIENTS WITH NORMAL REST ECG Hachamovitch et al., Circulation 2002 Hard Event Rate/Year (%) 10.0 Normal p<0.05 Mild Abnormalities 8.0 Moderate-Severe Abnormalities p<0.05 6.0 4.0 p<0.05 2.0 0.0 Low Intermediate High Duke Tradmill Score
Predicted Cardiac Mortality (%) Prognostic Value of Adenosine SPECT in Diabetic and Non-Diabetic Women and Men Berman et al., JACC 2003 (modified) Predicted Cardiac Mortality (%) Men Women 10 Non Diabetics 10 Diabetics 8 8 8.5 6 6.1 6.1 6 6.0 4 2 0.8 0.8 1.6 1.6 2.7 2.8 4 2 0.8 1.5 1.6 3.3 3.4 4.1 0 Normal Mild Abnormal Moderate Abnormal Severe Abnormal 0 Normal Mild Abnormal Moderate Abnormal Severe Abnormal
BENEFITS OF REVASCULARIZATION VS MEDICAL THERAPY IN RELATION TO EXTENT OF ISCHEMIA IN CAD Hachamovich et al., Circulation 2003
Effect of Disease Prevalence on Predictive Accuracy of a Diagnostic Test Gheorghiade M, Bonow RO In: Kelley W, ed. Textbook of Medicine, 1996: 371-385 5% Disease Prevalence (Pre-test likelihood of CAD) 200 Patients 5% 95% Patients 10 CAD 190 No CAD 80% Sens 90% Spec Positive Test Results 8 + 19 + TP FP Predictive Accuracy 8 27 = 30%