B. C. Kansupada, MD, HeartCare Assoc. ACC chapter talk 4/28/06
B. C. Kansupada, MD HeartCare Assoc ACC chapter talk 4/28/06
Nuclear Imaging 2006 Bindu Kansupada, MD, MBA, FACC HeartCare Associates Member Payors Committee PACC
Disclosure Consultant/speaker bureau for: Medtronics Guident St. Judes Merck Bristol Myers Squib
Special Thanks: Dr. Polk Dr. Ronald Schwartz Dr. Braunwald
Nuclear Cardiac Imaging (Myocardial Perfusion Imaging ) Myocardial Perfusion Imaging – What is it? MPI Images – What does it look like? Clinical Value – What good is it? Comparison with other modalities – Why MPI?
What is Myocardial Perfusion Imaging? In the U.S., nuclear cardiology (MPI) procedures have overtaken non- cardiology procedures in procedural volume.
MPI is a non-invasive nuclear imaging technique that uses radioactive imaging agents to image the heart. Thallium Technetium-99 m Sestamibi Technetium-99 m Tetrofosmin What is Myocardial Perfusion Imaging?
What do MPI images look like? In a typical nuclear cardiac imaging exam, the physician reviews: – Static “Summed Perfusion Images” – Dynamic “Gated Images” Perfusion Images are viewed in three orientations: SA – Short Axis VLA – Vertical Long Axis HLA - Horizontal Long Axis
What do MPI images look like? - Summed Perfusion Images Stress Rest Stress Rest Stress Rest Stress Rest SA VLA HLA
What do MPI images look like? - Summed Perfusion Images Summed images are used to assess cardiac perfusion. Rest and Stress images are compared to determine if a region of the heart is “ischemic” – starved of oxygen In the study below, the rest image indicates normal blood flow, but the stress image indicates abnormal blood flow in the Inferior-lateral region. This may indicate “ischemia” in this region of the heart – which is supplied by the LCX (left circumflex artery). There may be stenosis in that coronary artery. Stress Rest
What do MPI images look like? Gated Images Gated images are made possible by ECG-gated SPECT Physicians can now access cardiac function: Wall motion – does the LV contract uniformly? Ejection Fraction – does the LV pump out enough blood to the body? SA HLA VLA
What Good is MPI? – Clinical Value A nuclear stress test provides excellent negative predictive value - Patients from the general population with normal MPI scans have <1% annual risk of cardiac events
What Good is MPI? – Clinical Value A gated nuclear stress test is a powerful tool to risk stratify patients for optimal management. It is in effect a “gate-keeper” to the cardiac cath lab
Coronary Distribution (Left Ventricle) Remember This The 3 coronary arteries are: LAD - left anterior descending artery RCA - right coronary artery LCX - left circumflex coronary artery
Normal Myocardial Perfusion
Myocardial Ischemia
Myocardial Infarction
Type of Nuclear Imaging
Gated Study Gating process-Functional assessment ventricular wall motion ES and ED ventricular volumes LV ejection fraction normal = 64% +/- 12%
Gated Study Radiopharmaceutical Tc-99m labeled red blood cells in-vitro and in-vivo labeling Images anterior left lateral left anterior oblique (best LV separation)
Gated Study Exercise assessment stress done with bicycle rest EF to compare stress EF Primary uses of test congestive heart failure cardiomyopathy chemo cardiotoxicity
First Pass Cardiac Study What’s ‘first pass’? temporal separation of chambers Functional assessment ventricular wall motion ES and ED ventricular volumes LV and RV ejection fractions pulmonary transit time
First Pass Cardiac Study Can be performed with exercise stress done with bicycle rest EF to compare to stress EF Primary uses of test same as gated cardiac study better than gated at right ventricle assessment and cardiac shunts
Myocardial Perfusion Study Assess coronary blood flow Demonstrate blood perfusion of the LV myocardium Software allows gating for EF 3D reconstruction of heart
Myocardial Perfusion Radiopharmaceuticals Thallium-201 chloride Tc-99m Sestamibi Tc-99m Tetrofosmin SPECT acquisition provides cross-sectional images of the myocardium in the short axis, horizontal long axis and vertical long axis planes
Myocardial Perfusion Performed at rest & stress Stress study options treadmill exercise pharmacologic stress agents adenosine persantine (dipyridamole) dobutamine
Myocardial Perfusion -Percentage of LV myocardium receiving decreased perfusion -Differentiate ischemia from MI -24 hour delayed images demonstrate myocardial viability (hibernating) -Rest-only studies can provide information on acute MI’s
Exam Results Myocardial Infarction perfusion defect on rest & stress Myocardial Ischemia perfusion defect on stress only
Diagnostic Approach
Exercise Protocol Exercise preferred modality Radiopharmaceutical injected at peak and continued exercise for another 1-2 minutes. If unable to exercise, unable to attain target heart rate, or contraindications pharmacologic testing should be performed. B-blockers should be held for 48 hours No caffeine for 24 hours.
Exercise Testing- Contra Indications Unstable Angina Decompensated CHF Uncontrolled hypertension (blood pressure > 200/115 mm of Hg) Acute myocardial infarction within last 2 to 3 days Severe pulmonary hypertension Relative contraindication AS, HCM
Exercise Testing Each of the protocols has advantages and disadvantages. Quality control from preparation, acquisition to reading assure the best data.
Myocardial PerfusionScintigraphy: Assessment of Diagnosis, Prognosis, and Treatment Response of Cardiovascular Risk. Diagnosis, Prognosis, and Response to Therapy Suspected Coronary artery disease Known stable coronary artery disease Prior to non-cardiac surgery Before and after cardiac revascularization
Myocardial PerfusionScintigraphy: Assessment of Diagnosis, Prognosis, and Treatment Response of Cardiovascular Risk Diagnosis, Prognosis, and Response to Therapy Special populations (women, diabetics) Evaluation of acute chest pain syndromes Myocardial infarction Screening: Multiple risk factors, Family history Response to medical therapy
Populations Who Benefit from SPECT MPI Diagnostic and prognostic chest pain evaluation Angina Atypical Angina Atypical Chest Pain Non-cardiac Chest Pain Peri-operative risk of non-cardiac surgery Diagnostic and prognostic evaluation of ACS Emergency Department In Hospital
Populations Who Benefit from SPECT MPI Hemodynamic/prognostic assessment of known CAD High risk asymptomatic populatios Diabetes, Metabolic syndrome, insulin resistance syndrome Family history of sibling with coronary event Mediastinal radiation Multiple coronary risk factor Monitoring effectiveness of surgical and percutaneous revascularization Monitoring effectiveness of “ medical revascularization”
Men 1394 Women + MPI + EXERCISE CLINICAL Incremental Prognostic Value of MPI Testing: Men vs. Women
Specificity of MPI with SPECT Procedures in Women P =.0004
Heart Disease in Women: Lessons From The Past Decade The importance of studying gender specific aspects of CAD have helped in the following clinical dilemmas: Presentation of CAD: women are older than men Less Specific clinical manifestations of CAD in women Greater Difficulty in Diagnosis: women>men More sever consequences of MI when it occurs in women
Detecting CAD in Women Evidence from numerous medical societies uniformly supports association of exercise ECG has lower diagnostic accuracy in women (more false positive) Critical Factors Affects Accuracy: Functional Capacity, Rest ST-T changes, Hormonal Factors SPECT was better able to identify and satisfy women at high risk for future events. Extent of total perfusion abnormality, extent of reversible perfusion abnormality, multivessel abnormality, & large perfusion abnormality are all strong predictors of future cardiac events. Await RCT data from the WOMEN study to provide further detail as to the value of SPECt in accessing risk in women.
Long –Term outcome of Patients With Intermediate-Risk Exercise Electrocardiograms who Do Not Have Myocardial Perfision Defects on Radionuclide Imaging Results Cardiovascular survival was 99.8% at 1 year, 99.0% at 5 years and 98.5% at 7 years. Near-normal scans and cardiac enlargement were independent predictors of time to cardiac death. Cardiac survival time free of myocardial infarction or revascularization was 87.1% at 7 years.
Summary: Acute Rest Imaging in 2005 Strong predictor of short-term cardiac events Very high negative predictive value for acute MI Interpretative differences between acute and stress imaging requires experience. Use in clinical decision-making and other acute situations Consider as a gateway of opportunity to assess intermediate to long term risk of patient -> value of stress imaging following acute resting evauation.
DIAD: Detection of Ischemia is Asymptomatic Diabetes Abnormalities were observed in: - 22 % of patients with > 2 risk factors (66 of 306) - 22 % of patients with < 2 risk factors (45 of 204) Greater than one in five diabetic patients without symptoms have an abnormal gated SPECT MPI Selecting only patients who meet ADA guidelines would have failed to identify 41 % of patients with ischemia
Radionuclide MPS in Pre- operative Risk Assessment Perfusion imaging works so well in predicting outcome, we tend to overuse it For patients with positive perfusion study, try to avoid revascularization unless the patient needs it regardless of upcoming surgery. Recent study demonstrates no benefit compared to beta blockade peri- operatively. High risk subsets will benefit long term. Treat patients with mild reversible defects medically Avoid noncardiac surgery within 6 weeks of bare metal stenting Among patients who have CAD, or who are at risk of CAD, consider preoperative beta blockade and statins. Several studies in clinical settings in which the ACC/AHA guidelines were followed have demonstarted their effectiveness.
Shortcut to indications for noninvasive testing- Perform if any 2 of 3 factors are present. High surgical risk operations - AAA & PVD - Long procedures with lg fluid shifts or blood loss 2. Poor functional capacity ( < 4 METs) 3. Intermediate clinical predictors presents - CAD >> Angina ( CCS I & II) >> Prior MI - CHF - Diabetes or renal insufficiency.
Coronary Blood Flow Myocardial blood flow reduction correlates with degree of stenosis Flow reserve reduces with coronary stenoses of % Able to maintain resting flow untill stenosis is %
Coronary Blood Flow Rates
Prognostic Variables of Gated SPECT
Value of Stress MPI in the general population: Stress MPI: Prognostic Significance
Prognosis Prognostic data are incremental Normal scans: <1% cardiac event rate per year Mildly abnormal scans: –<1% cardiac death rate –MI rate not affected by revascularization –Treatment may be medical (catheterization reserved for refractory symptoms)
Risk Stratification: Prognosis Risk of cardiac Death: * Low < 1 % per year * Intermediate 1 – 3 % per year * High > 3 % per year
Risk Stratification: Noninvasive Testing Markers Amount of infarcted myocardium Amount of jeopardized myocardium Degree of jeopardy Left vanticular systolic function All can be assessed by measurements of perfusion or function
TID: transit Ischemic Dilation (Stress induced LV Cavity Dilation) Severe, extensive CAD (usually with classic ischemic defect) Left Main Prox LAD MVD Microvascular disease (no stress defect; atypical defects) HTN LVH DCM
Prognostic implications of myocardial perfusion imaging.
Single-photon emission computed tomography perfusion images in two patients with stable anginal symptoms.
Incremental value Of SPECT
Evaluation of CAD: A Prognostic Approach Patients with suspected CAD referred to SPECT Normal StudyMildly Abnormal StudyMod-Severely Abnormal Study RISK OF ADVERSE EVENT LOWINTERMEDIATEHIGH Reassurance/Risk factor modification Aggressive risk factor modification Revascularization Myocardial Perfusion Imaging with Gated SPECT
Evaluation of CAD: A Diagnostic Approach Patients with possible CAD Normal DIAGNOSTIC TES Abnormal Low likelihood of CAD Intermediate to high likelihood of CAD Risk factor modification Revascularization
Cost Effective Approach
Myocardial perfusion imaging Cost effectiveness MPI as gatekeeper Incremental information
High sensitivity Exclude disease Fewer false negatives Higher downstream costs in undiagnosed pts No need for 2 nd test vs. low sensitivity low cost High specificity Reduces number of false positive tests Reduced downstream testing Principles of Cost-Effective Diagnosis and Management of CAD using MPS
END Study: Financial Analysis of Treatment Strategies 11,249 consecutive stable angina patients Two treatment groups –Direct catheterization –Stress MPI followed by selective catheterization Cohorts matched by pretest probability of CAD Strategy: cost minimization at equal mortality risk Cost evaluation –Diagnostic (early): SPECT, catheterization– Follow-up (late): includes costs of PTCA, CABG Adapted from Shaw LJ, et al.J Am CollCardiol. 1999;33: Cost- effectiveness: Assessing the Prognostic Approach
END: Angiographic findings
END Study: Outcome by Screening Strategy
Pretest Clinical Risk (n=5,423) Pretest Clinical Risk (n=5,826)* P <.01 vs catheterization.
Cost Effectiveness in Clinical Practice Patient risk assessed? Low risk, negative testing Intermediate risk, further testing If risk < 1% then no further testing needed
Why to Practice Appropriateness Criteria based Practice? One may not get reimbursed. Inappropriate test could increase financial burden to society. Possible increased radiation
Appropriateness Criteria: SPECT MPI Tables 1 through 9 sequentially list the 52 indications by purpose, clinical scenario, and their ratings, as obtained from the second-round rating sheets. In addition, Tables 10 through 12 arrange the indications into three main scoring categories—those that were rated as inappropriate (I, median score of 1 to 3), uncertain or possibly appropriate (U, median score of 4 to 6), and appropriate (A, median score of 7 to 9), respectively.
Appropriateness Criteria: SPECT MPI Table 10 lists the 13 indications that were rated as inappropriate (i.e., the imaging test is not generally accept-able and is not a reasonable approach for the indication). This does not preclude, however, the performance of the test if justifiable because of special clinical and patient circumstances. It is likely that reimbursement for the test will require a documented exception from the physician.
Table 10. Inappropriate Indications (Median Rating of 1 to 3) Indication Appropriateness Criteria (Median Score) Detection of CAD: Symptomatic—Evaluation of Chest Pain Syndrome 1. ~ Low pre-test probability of CAD ~ ECG interpretable AND able to exercise I (2.0) Detection of CAD Symptomatic—Acute Chest Pain (in Reference to Rest Perfusion Imaging) 8. ~ High pre-test probability of CAD ~ ECG: ST elevation I (1.0) Detection of CAD: Asymptomatic (Without Chest Pain Syndrome ) 10. ~ Low CHD risk (Framingham risk criteria)I (1.0) Risk Assessment: General and Specific Patient Populations— Asymptomatic 17. ~ Low CHD risk (Framingham)I (1.0) Table 10. Inappropriate Indications (Median Rating of 1 to 3)
Risk Assessment With Prior Test Results: Asymptomatic OR Stable Symptoms— Normal Prior SPECT MPI Study 21. ~ Normal initial RNI study ~ High CHD risk (Framingham) ~ Annual SPECT MPI study I (3.0) Risk Assessment With Prior Test Results: Asymptomatic OR Stable Symptoms— Abnormal Catheterization OR Prior SPECT MPI Study 23. ~ Known CAD on catheterization OR prior SPECT MPI study in patients who have not had revascularization procedure ~ Asymptomatic OR stable symptoms ~ Less than 1 year to evaluate worsening disease I (2.5) Risk Assessment With Prior Test Results: Asymptomatic— Prior Coronary Calcium Agatston Score 28.~ Agatston score less than 100I (1.5) Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery— Low-Risk Surgery 31. ~ Preoperative evaluation for non-cardiac surgery risk assessment I (1.0) Table 10. Inappropriate Indications (Median Rating of 1 to 3)
Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery— Intermediate-Risk Surgery 32. ~ Minor to intermediate perioperative risk predictor ~ Normal exercise tolerance (greater than or equal to 4 METS) I (3.0) Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery—High Risk Surgery 36. ~ Asymptomatic up to 1 year post normal catheterization, non-invasive test, or previous revascularization I (3.0) Risk Assessment: Following Acute Coronary Syndrome STEMI—Hemodynamically Signs of Cardiogenic Shock, or Mechanical Complications Unstable, 38.~ Thrombolytic therapy administeredI (1.0) Risk Assessment: Following Acute Coronary Syndrome— Asymptomatic Post-Revascularization (PCI or CABG) 40.~ Routine evaluation prior to hospital dischargeI (1.0) Risk Assessment: Post-Revascularization (PCI or CABG)—Asymptomatic 47.~ Symptomatic prior to previous revascularizationI (3.0) ~ Less than 1 year after PCI Table 10. Inappropriate Indications (Median Rating of 1 to 3)
Indication Appropriatenes s Criteria (Median Score) Detection of CAD: Symptomatic— Evaluation of Chest Pain Syndrome 3.~Intermediate pre-test probability of CAD A (7.0) ~ ECG interpretable AND able to exercise 4.~Intermediate pre-test probability of CAD A (9.0) ~ ECG uninterpretable OR unable to exercise 5.~High pre-test probability of CAD A (8.0) ~ ECG interpretable AND able to exercise 6.~High pre-test probability of CAD A (9.0) ~ ECG uninterpretable OR unable to exercise Detection of CAD: Symptomatic— Acute Chest Pain (in Reference to Rest Perfusion Imaging) 7. ~ Intermediate pre-test probability of CAD ~ ECG: no ST elevation AND initial cardiac enzymes negative A (9.0) Table 11. Appropriate Indications (Median Rating of 7 to 9)
Detection of CAD: Symptomatic— New-Onset/Diagnosed Heart Failure With Chest Pain Syndrome 9.~ Intermediate pre-test probability of CADA (8.0) Detection of CAD: Asymptomatic— New-Onset or Diagnosed Heart Failure or LV Systolic Dysfunction Without Chest Pain Syndrome 12.~ Moderate CHD risk (Framingham) A (7.5) ~ No prior CAD evaluation AND no planned cardiac catheterization Detection of CAD: Asymptomatic (Without Chest Pain Syndrome)— New-Onset Atrial Fibrillation 15.~ High CHD Risk (Framingham) A (8.0) ~ Part of the evaluation Detection of CAD: Asymptomatic (Without Chest Pain Syndrome)— Ventricular Tachycardia 16.~ Moderate to high CHD risk (Framingham)A (9.0) Table 11. Appropriate Indications (Median Rating of 7 to 9)
Risk Assessment: General and Specific Patient Populations— Asymptomatic 19.~ Moderate to high CHD risk (Framingham) A (8.0) ~ High-risk occupation (e.g., airline pilot) 20.~ High CHD risk (Framingham)A (7.5) Risk Assessment With Prior Test Results: Asymptomatic OR Stable Symptoms— Normal Prior SPECT MPI Study 22.~ Normal initial RNI study A (7.0) ~ High CHD risk (Framingham) ~ Repeat SPECT MPI study after 2 years or greater Table 11. Appropriate Indications (Median Rating of 7 to 9)
Risk Assessment With Prior Test Results: Asymptomatic OR Stable Symptoms— Abnormal Catheterization or Prior SPECT MPI Study 24. ~ Known CAD on catheterization OR prior SPECT MPI study in patients who have not had revascularization procedure A (7.5) ~ Greater than or equal to 2 years to evaluate worsening disease Risk Assessment With Prior Test Results: Worsening Symptoms— Abnormal Catheterization OR Prior SPECT MPI Study 25.~ Known CAD on catheterization OR prior SPECT MPI studyA (9.0) Table 11. Appropriate Indications (Median Rating of 7 to 9)
Indication Appropriatenes s Criteria (Median Score) Risk Assessment With Prior Test Results: Asymptomatic— Prior Coronary Calcium Agatston Score 27.~ Agatston score greater than or equal to 400A (7.5) Risk Assessment With Prior Test Results: UA/NSTEMI, STEMI, or Chest Pain Syndrome—Coronary Angiogram 29.~ Stenosis of unclear significanceA (9.0) Risk Assessment With Prior Test Results— Duke Treadmill Score 30. ~ Intermediate Duke treadmill score ~ Intermediate CHD risk (Framingham) A (9.0) Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery— Intermediate-Risk Surgery 33. ~ Intermediate perioperative risk predictor OR Poor exercise tolerance (less than 4 METS) A (8.0) Table 11. Appropriate Indications (Median Rating of 7 to 9)
Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery— High-Risk Surgery 35.~ Minor perioperative risk predictor AND A (8.0) ~ Poor exercise tolerance (less than 4 METS) Risk Assessment: Following Acute Coronary Syndrome— STEMI-Hemodynamically Stable 37. ~ Thrombolytic therapy administered ~ Not planning to undergo catheterization A (8.0) Risk Assessment: Following Acute Coronary Syndrome— UA/NSTEMI—No Recurrent Ischemia OR No Signs of HF 39.~ Not planning to undergo early catheterizationA (8.5) Risk Assessment: Post-Revascularization (PCI or CABG)— Symptomatic 41.~ Evaluation of chest pain syndromeA (8.0) Table 11. Appropriate Indications (Median Rating of 7 to 9)
Risk Assessment: Post-Revascularization (PCI or CABG)— Asymptomatic 44.~ Asymptomatic prior to previous revascularization A (7.5) ~ Greater than or equal to 5 years after CABG 45.~ Symptomatic prior to previous revascularization A (7.5) ~ Greater than or equal to 5 years after CABG Assessment of Viability/Ischemia: Ischemic Cardiomyopathy (Includes SPECT Imaging for Wall Motion and Ventricular Function) 50. ~ Known CAD on catheterization ~ Patient eligible for revascularization A (8.5) Evaluation of Left Ventricular Function 51.~ Non-diagnostic echocardiogramA (9.0) Evaluation of Ventricular Function: Use of Potentially Cardiotoxic Therapy (e.g., Doxorubicin) 52.~ Baseline and serial measurementsA (9.0) Table 11. Appropriate Indications (Median Rating of 7 to 9)
Indication Appropriateness Criteria (Median Score) Detection of CAD: Symptomatic— Evaluation of Chest Pain Syndrome 2. ~ Low pre-test probability of CAD ~ ECG uninterpretable OR unable to exercise U* (6.5) Detection of CAD: Asymptomatic (Without Chest Pain Syndrome) 11.~ Moderate CHD risk (Framingham)U (5.5) Detection of CAD: Asymptomatic— Valvular Heart Disease Without Chest Pain Syndrome 13. ~ Moderate CHD risk (Framingham) ~ To help guide decision for invasive studies U (5.5) Table 12. Uncertain Indications (Median Rating of 4 to 6)
Detection of CAD: Asymptomatic (Without Chest Pain Syndrome)— New-Onset Atrial Fibrillation 14. ~ Low CHD risk (Framingham) ~ Part of the evaluation U* (3.5) Risk Assessment: General and Specific Patient Populations— Asymptomatic 18.~ Moderate CHD risk (Framingham)U (4.0) Risk Assessment With Prior Test Results: Asymptomatic— CT Coronary Angiography 26.~ Stenosis of unclear significanceU* (6.5) Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery— High-Risk Surgery 34. ~ Minor perioperative risk predictor ~ Normal exercise tolerance (greater than or equal to 4 METS) U (4.0) Table 12. Uncertain Indications (Median Rating of 4 to 6)
Risk Assessment: Post-Revascularization (PCI or CABG)— Asymptomatic 42. ~ Asymptomatic prior to previous revascularization ~ Less than 5 years after CABG U (6.0) 43. ~ Symptomatic prior to previous revascularization ~ Less than 5 years after CABG U (4.5) Risk Assessment: Post-Revascularization (PCI or CABG)— Asymptomatic 46. ~ Asymptomatic prior to previous revascularization ~ Less than 1 year after PCI U* (6.5) 48. ~ Asymptomatic prior to previous revascularization ~ Greater than or equal to 2 years after PCI U* (6.5) 49. ~ Symptomatic prior to previous revascularization ~ Greater than or equal to 2 years after PCI U (5.5) Table 12. Uncertain Indications (Median Rating of 4 to 6)
Appropriateness Criteria: SPECT MPI Summary: Median Score 7 to Appropriate Median Score 1 to Inappropriate Median Score 4 to Uncertain
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