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The use of Cardiac CT and MRI in Clinical Practice Matthew W. Martinez, MD Assistant Professor of Medicine LVPG - Lehigh Valley Heart Specialists Lehigh.

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Presentation on theme: "The use of Cardiac CT and MRI in Clinical Practice Matthew W. Martinez, MD Assistant Professor of Medicine LVPG - Lehigh Valley Heart Specialists Lehigh."— Presentation transcript:

1 The use of Cardiac CT and MRI in Clinical Practice Matthew W. Martinez, MD Assistant Professor of Medicine LVPG - Lehigh Valley Heart Specialists Lehigh Valley Health Network Oct. 3, 2009

2 DISCLOSURE Relevant Financial Relationship(s) None Off Label Usage None

3 Learning Objectives Review basics of cardiac MRI and CTA Review basics of cardiac MRI and CTA Review utility of cardiac CT and MRI in clinical practice Review utility of cardiac CT and MRI in clinical practice Clinical cases Clinical cases

4 Echo SPECT PET MRI Noninvasive Tests for the Diagnosis of Coronary Artery Disease TMET CT

5 Cardiac MRI Black-Blood (Spin-Echo) White-Blood SSFP Still Images Morphology Edema Cine Imaging Morphology and function Delayed Enhancement Still Images Delayed Enhancement

6 = 2D echo SSFP = 2D echo

7 Delayed Enhancement-MRI Images obtained minutes post-contrast (Gd) Images obtained minutes post-contrast (Gd) Normal myocardium – Black * Normal myocardium – Black * Necrosis/scarring/inflammation – Hyperenhanced Necrosis/scarring/inflammation – Hyperenhanced Image in Press – Nature of Clinical Practice

8 Infarct size by MRI Delayed Enhancement Abundance of validation data in animal models Abundance of validation data in animal models Dog with near- transmural infarct Dog with near- transmural infarct Visible on SPECT and DE-MRI Visible on SPECT and DE-MRI 3 dogs with subendocardial infarcts 3 dogs with subendocardial infarcts Visible on DE-MRI only Visible on DE-MRI only CP

9 Hyperenhancement Patterns Subendocardial infarct Transmural infarct Ischemic Mid-wall HE Epicardial HE Nonischemic Idiopathic dilated cardiomyopathy Myocarditis Idiopathic dilated cardiomyopathy Myocarditis Hypertrophic cardiomyopathy Right ventricular pressure overload Hypertrophic cardiomyopathy Right ventricular pressure overload Sarcoidosis Myocarditis Anderson–Fabry disease Sarcoidosis Myocarditis Anderson–Fabry disease Shah DJ et al: Magnetic resonance of myocardial viability

10 Mass RV Function Cardiomyopathies

11 Cardiac MRI LVEF LVEF LV mass LV mass Wall Motion Wall Motion LV ESV LV ESV LV EDV LV EDV LV stroke volume LV stroke volume RV ESV RV EDV RV Stroke volume RVEF Functional Analysis Analysis Infarct identification Infarct identification Infarct size Infarct size Viability Viability Tissue characterization

12 CP Imaging Evaluation of Chest Pain Unstable Hemodynamics and Complications Unstable Hemodynamics and Complications Prognosis Viability Prognosis Viability Function Infarct size Function Infarct size ACS

13 Cardiac MRI LVEF LVEF LV mass LV mass Wall Motion Wall Motion LV ESV LV ESV LV EDV LV EDV LV stroke volume LV stroke volume RV ESV RV EDV RV Stroke volume RVEF Functional Analysis Analysis Infarct identification Infarct identification Infarct size Infarct size Viability Viability Prognosis Prognosis Tissue characterization

14 Case 1 57-year-old woman Sudden onset of achy, continuous, substernal, 8/10 chest pain Sudden onset of achy, continuous, substernal, 8/10 chest pain Radiating to back Radiating to back Pain came on at rest Pain came on at rest Cardiac Risk Factors Never Smoker Hyperlipidemia (untreated) Sedentery Lifestyle Troponin – 0.56, 0.5 (3h), 0.36 (6h)

15 Echocardiogram

16 Cardiac Catheterization

17

18

19 Cardiac MRI

20 Acute MI

21 Importance of unrecognized Myocardial scar Aim: Assess the prognostic significance of unrecognized myocardial scar by MRI in patients without a history of MI Aim: Assess the prognostic significance of unrecognized myocardial scar by MRI in patients without a history of MI 195 patients without known prior MI 195 patients without known prior MI 1) Pts with unknown status of CAD referred for assessment of LV fxn, scar 1) Pts with unknown status of CAD referred for assessment of LV fxn, scar 2) Pts with angiographic CAD referred for prediction of segmental wall motion after revascularization (22) 2) Pts with angiographic CAD referred for prediction of segmental wall motion after revascularization (22) 16 month follow-up 16 month follow-up Circulation, 2006

22 Case Presentation 2 History of Present Illness History of Present Illness 46 year old man presents to ED, 6:30 AM with 10/10 chest pain 46 year old man presents to ED, 6:30 AM with 10/10 chest pain Began 4:30 AM - Radiated to left arm Began 4:30 AM - Radiated to left arm No SOB, no n/v No SOB, no n/v Feeling ill with episodic CP over past 2 weeks Feeling ill with episodic CP over past 2 weeks Past Medical History Hyperlipidemia at health fair Medications none Social History Social History 30 pack year history, currently smokes 1 pack/week 30 pack year history, currently smokes 1 pack/week

23 Initial ECG

24 Angiography Results Troponin Elevation: Baseline hr hr 0.49

25 Cardiac MRI

26 Delayed Enhancement Myocarditis

27 Etiologies of Elevations of Cardiac Troponins Plaque rupture mediated necrosis STEMI STEMI nSTEMI nSTEMI Alterations in coronary vasomotor tone Coronary spasm Coronary spasm Subarachnoid hemorrhage Subarachnoid hemorrhage Intracranial hemorrhage Intracranial hemorrhage Apical Ballooning Syndrome Apical Ballooning Syndrome Transplant vasculopathy Transplant vasculopathy Sub-endocardial myocyte necrosis CHF Hypertensive crisis Acute pulmonary embolism Tachycardia-mediated – CHF, Pressure overload Volume-Pressure overload (renal failure, CHF, fluid resuscitation) Anemia Hypotension Aortic Stenosis and / or Regurgitation Hypertrophic Cardiomyopathy Amyloid heart disease

28 Problem Solving Tool Troponin is extremely sensitive for detecting myocardial cell necrosis Troponin is extremely sensitive for detecting myocardial cell necrosis 9-14% of patients who present with ACS will have normal or non-significant disease on coronary angiography 9-14% of patients who present with ACS will have normal or non-significant disease on coronary angiography This cohort of patients have been shown to have a poorer prognosis; potentially from clinical uncertainty (TACTICS-TIMI-18) This cohort of patients have been shown to have a poorer prognosis; potentially from clinical uncertainty (TACTICS-TIMI-18)

29

30 Development of CT DSCT 128-slice 2009 MDCT 320-slice 2008 MDCT 4-slice 1998 MDCT 16-slice 2002 MDCT 40-slice 2005 DSCT 64-slice 2006 MDCT 8-slice 2001 MDCT 64-slice 2004

31

32 CT Scanning Minimally Invasive Angiography

33 Nuclear Cardiac Imaging Diagnostic Accuracy Imaging Modality # of Studies Patients Sen. (%) Spec. (%) Accuracy SPECT 99m Tc* > 45 ~7, % CTA*>20~2, “GOLD” Standard - Angiography

34 MDCT in Clinical Practice A Clinician’s Viewpoint Gold Standard Gold Standard  Anomalous coronary vessels  Coronary fistula, aneurysms Coronary Disease Coronary Disease  Great for ruling out CAD  OK (but not great) for disease severity

35 What are you looking for? Atherosclerosis Fixed obstruction Ischemic burden

36 High Probability Intermediate Probability Low Probability Typical chest pain Typical chest pain ECG changes & cardiac enzyme elevation ECG changes & cardiac enzyme elevation Personal history of CAD Personal history of CAD “Definite” signs of CAD: Patient Population

37 High Probability Intermediate Probability Low Probability Atypical chest pain Atypical chest pain Discordant symptoms & stress test results Discordant symptoms & stress test results  High risk factors & negative stress test  Low risk factors & positive stress test Patient reluctant to have a cath “Indeterminate” signs of CAD: Patient Population

38 High Probability Intermediate Probability Low Probability Patient Population CTA

39 High Probability Intermediate Probability Low Probability “Worried well” “Worried well” “Doubtful” signs of CAD: Patient Population

40 High Probability Intermediate Probability Low Probability Patient Population ? CTA ?

41 High Probability Intermediate Probability Low Probability Patient Population ? CTA ? CTA

42 History 49yr female previously healthy 49yr female previously healthy 6+ months of dyspnea on exertion 6+ months of dyspnea on exertion No personal history of hyperlipidemia, HTN, CAD, smoking, and family history No personal history of hyperlipidemia, HTN, CAD, smoking, and family history Currently on no cardiac medications Currently on no cardiac medications BMI = 36. BMI = 36.

43 History Exercise Time: 7.3 minutes Exercise Time: 7.3 minutes Test was stopped due to dyspnea and leg fatigue Test was stopped due to dyspnea and leg fatigue 32,736 (SBP x HR) 32,736 (SBP x HR) Stress Echo with an area of anterior ischemia was noted from mid to the base Stress Echo with an area of anterior ischemia was noted from mid to the base ECG was negative ECG was negative

44 Appropriateness for CT

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46

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49 References supporting the use of coronary CTA following equivocal exercise sestamibi Schuijf, J., et. al, “Relationship between Noninvasive Coronary Angiography with Multi-slice Computed Tomography and Myocardial Perfusion Imaging” Journal of the American College of Cardiology; December 19, Schuijf, J., et. al, “Relationship between Noninvasive Coronary Angiography with Multi-slice Computed Tomography and Myocardial Perfusion Imaging” Journal of the American College of Cardiology; December 19, Rubinstein, R., et. al, “Usefulness of 64-slice multidetector computed tomography in diagnostic triage of patients with chest pain and negative or nondiagnostic exercise stress test result” American Journal of Cardiology 2007; 99: Rubinstein, R., et. al, “Usefulness of 64-slice multidetector computed tomography in diagnostic triage of patients with chest pain and negative or nondiagnostic exercise stress test result” American Journal of Cardiology 2007; 99: Danciu, S., et. al, “Usefulness of multislice computed tomography coronary angiography to identify patients with abnormal myocardial perfusion stress in whom diagnostic catheterization could be avoided” American Journal of Cardiology 2007; 100: Danciu, S., et. al, “Usefulness of multislice computed tomography coronary angiography to identify patients with abnormal myocardial perfusion stress in whom diagnostic catheterization could be avoided” American Journal of Cardiology 2007; 100: Dewey, M., et. al, “Head-to-head comparison of multislice computed tomography and exercise electrocardiography for diagnosis of coronary artery disease” European Heart Journal 2007; 28: Dewey, M., et. al, “Head-to-head comparison of multislice computed tomography and exercise electrocardiography for diagnosis of coronary artery disease” European Heart Journal 2007; 28:

50 55 y/o woman Substernal chest discomfort 2 mos Emotion and sometimes exertion Today 10 min chest and back pain at rest  ED Postmenopausal Prior smoker >15 yrs ago No FH No meds Mild HTN Case 2 –chest pain

51 Exam: no murmur BP 142/88 Troponin: <.01 Creat: 0.8

52 Acute chest pain What do you want to know? Probability CAD Risk of acute event Low/inter High  Angio Low Intermediate

53 What to Do? Sestamibi Stress Echo Coronary CTA

54 CTA vs Standard of Care in Chest Pain Goldstein JACC : Chest pain Low risk 197 pts Standard care NormalNondiagSevere MSCT Stress Nucs HOME Angio

55 Goldstein JACC : CTA – 67% normal and discharged 9% severe CAD  cath 24% needed further eval Length of stay: lowered by 43% 12.5 hrs vs 22.1 hrs Cost of care: lowered by 15% $1586 vs $1872

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57 Conclusions Cardiac MRI Cardiac MRI EF, ESV, EDV, RV function, infarct size EF, ESV, EDV, RV function, infarct size ICM vs DCM ICM vs DCM ACS ACS Cardiac CT Cardiac CT Excellent for exclusion of CAD in low to intermediate risk Excellent for exclusion of CAD in low to intermediate risk ED patients, “equivocal stress test” ED patients, “equivocal stress test”

58 THANK YOU!


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