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Controversies in Myocardial Perfusion Imaging

A major teaching hospital of Harvard Medical School. Controversies in Myocardial Perfusion Imaging. Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor in Medicine Harvard Medical School Boston, MA. Outline. Women Diabetes

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Controversies in Myocardial Perfusion Imaging

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  1. A major teaching hospital of Harvard Medical School Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor in Medicine Harvard Medical School Boston, MA

  2. Outline • Women • Diabetes • Non-Cardiac Surgery • Choice of Stress Imaging Modality

  3. Outline • Women • Diabetes • Non-Cardiac Surgery • Choice of Stress Imaging Modality

  4. Case 1 68 year old woman with a history of hypertension and dyslipidemia presents with a long history of exertional dyspnea. Her physical examination is normal. What test do you order? • Resting echocardiogram • ETT • Nuclear imaging • Cardiac catheterization

  5. Women and Cardiovascular Disease • More than 500,000 women will die this year from CAD, stroke and other cardiovascular diseases • More women die from CVD than men • CAD is the #1 killer of women • More than the next 7 causes of death combined AHA Statistics

  6. Women and Cardiovascular Disease AHA Statistics

  7. Women and Cardiovascular Disease • CAD risk factors are the same for men and women • Women are more likely to present with atypical symptoms or have silent events • Physicians are less likely to consider a diagnosis of CAD in women Fossati et al, in Nuclear Cardiology, 2004

  8. Women: Inappropriate Triage Pope et al, N Engl J Med 2000;342:1163-70

  9. Women: Less Use of Diagnostic Tests Roger et al, JAMA. 2000;283:646-652

  10. Women: ETT Alone is Inadequate Specificity 80% Sensitivity 44% Nasir et al, Arch Intern Med. 2004;164:1610-1620

  11. Women: Reasons for Poor Performance • Peak HR and BP are lower • Magnitude of STD is less • Chest wall shape differs • Vascular reactivity differs • Prevalence of disease is lower

  12. Women: MPI Diagnosis Amanullah et al, JACC 1996;27:803

  13. Women: MPI Risk Stratification Berman et al, J Am Coll Cardiol 2003;41:1125–33

  14. Case 1 68 year old woman with a history of hypertension and dyslipidemia presents with a long history of exertional dyspnea. Her physical examination is normal. What test do you order? • Resting echocardiogram • ETT • Nuclear imaging • Cardiac catheterization

  15. Case 1 68 year old woman with a history of hypertension and dyslipidemia presents with a long history of exertional dyspnea. Her physical examination is normal. What test do you order? • Resting echocardiogram • ETT • Nuclear imaging • Cardiac catheterization

  16. Case 1: Raw Data

  17. Case 1: Attenuation Map

  18. Case 1: Slices

  19. Case 1: Attenuation Correction

  20. Case 1: Gated Images

  21. Case 1: Quantitative Data

  22. Difficulties in Imaging Women • Breast attenuation • Small heart size

  23. Case 1 • She exercised for 4.5 minutes of a modified Bruce protocol • Peak HR of 119 (78% predicted maximal) • Peak BP 230/92 • Typical angina with stress • Ischemic ECG changes

  24. Case 1 Her study is interpreted as abnormal. What do you do now? • Begin a trial of medical therapy without further evaluation • Refer for cardiac catheterization for definitive diagnosis and potential revascularization

  25. Women: Referral for Evaluation and Treatment Hachamovitch et al, JACC 1995:1457

  26. Women and Cardiovascular Disease • CAD is highly prevalent among women • Women can present with atypical symptoms • ETT alone is controversial for evaluation of CAD • Nuclear imaging may be preferable for the evaluation of women for both diagnosis of CAD and determination of prognosis • Treatment of CAD is not gender-specific

  27. Outline • Women • Diabetes • Non-Cardiac Surgery • Choice of Stress Imaging Modality

  28. Case 2 A 58 year old man with type 2 diabetes visits his internist because he is worried about his CAD risk. He is taking a statin for dyslipidemia (last LDL 90). His BP is 130/80. The internist should: • Start aspirin and an ACE-inhibitor • Order an ETT • Order an ETT with nuclear imaging • Reassure him that he is at low risk

  29. Diabetes and Cardiovascular Disease • Coronary artery disease is major complication of diabetes • Independent effect of diabetes • In patients with type 2 diabetes, obesity, hypertension and dyslipidemia also contribute • The prevalence of CAD is estimated at up to 55% among patients with diabetes • More than 20% may have silent ischemia • Delayed presentation ADA, Diabetes Care 1998;21:1551 Wackers et al, Diabetes Care. 2004 Aug;27(8):1954-61

  30. Evaluating CAD in Diabetics ADA, Diabetes Care 1998;21:1551

  31. Requirements for a Useful Screening Test • Relatively high disease prevalence • CAD in 55% in diabetics • Asymptomatic phase of the disease • Silent ischemia in 20% • Available test that can detect the disease during the asymptomatic phase • Nuclear imaging • Treatment that alters the natural history when preferentially applied during the asymptomatic phase • Lipid lowering, aspirin, ACE-inhibitor, β-blocker, revascularization

  32. Asymptomatic Diabetics ADA, Diabetes Care 1998;21:1551

  33. Diabetes and Cardiovascular Disease Haffner et al, N Engl J Med 1998;339:229-34

  34. Diabetes and Cardiovascular Disease Haffner et al, N Engl J Med 1998;339:229-34

  35. Diabetes = CAD • “Some persons without established CHD will have an absolute, 10-year risk for developing major coronary events (myocardial infarction and coronary death) equal to that of persons with CHD, i.e., >20 percent per 10 years. Such persons can be said to have a CHD risk equivalent.” • Diabetes • Non-coronary atherosclerotic disease • Multiple risk factors NCEP-ATP III, Circulation, Dec 2002; 106: 3143

  36. Diabetes = CAD • Patients with diabetes should be treated to the same lipid goals as those with CAD • Diabetes alone is high risk • LDL goal of <100 (can consider a goal of <70) • The combination of diabetes and CAD is very high risk • LDL goal of <70 NCEP-ATP III Update, Circulation, Jul 2004; 110: 227 - 239

  37. Diabetes = CAD • Aspirin therapy • Age >40 • Hypertension • Goal BP <130/80 • Treatment with two or more agents • ACE-inhibitor • Revascularization… • Mortality benefit proven only in those with 3VD ADA, Diabetes Care 2004;27(S1):S15

  38. Case 2 A 58 year old man with type 2 diabetes visits his internist because he is worried about his CAD risk. He is taking a statin for dyslipidemia (last LDL 90). His BP is 130/80. The internist should: • Start aspirin and an ACE-inhibitor • Order an ETT • Order an ETT with nuclear imaging • Reassure him that he is at low risk

  39. Case 2 A 58 year old man with type 2 diabetes visits his internist because he is worried about his CAD risk. He is taking a statin for dyslipidemia (last LDL 90). His BP is 130/80. The internist should: • Start aspirin and an ACE-inhibitor • Order an ETT • Order an ETT with nuclear imaging • Reassure him that he is at low risk

  40. Case 2 • The patient’s internist, having recently read an editorial advocating screening MPI for patients with diabetes, refers him for ETT with nuclear imaging.

  41. Case 2

  42. Case 2 • He exercised for 7 minutes of a Bruce protocol • Peak HR of 140 (86% predicted maximal) • Peak BP 178/80 • No symptoms • No ECG changes

  43. Case 2 The study is interpreted as normal. Based on this data, the patient is now: • Low risk • Intermediate risk • High risk • Very high risk

  44. Risk Stratification in Diabetics Giri et al, Circulation. 2002;105:32-40

  45. Risk Stratification in Diabetics Berman et al, J Am Coll Cardiol 2003;41:1125–33

  46. Risk Stratification in Diabetics Berman et al, J Am Coll Cardiol 2003;41:1125–33

  47. Case 2 The study is interpreted as normal. Based on this data, the patient is now: • Low risk • Intermediate risk • High risk • Very high risk

  48. Case 2 The study is interpreted as normal. Based on this data, the patient is now: • Low risk • Intermediate risk • High risk • Very high risk

  49. Diabetes and Cardiovascular Disease • Coronary artery disease is common in diabetes and results in significant mortality and morbidity • Diabetics without CAD have the same risk for adverse events as non-diabetics with CAD • Screening diabetics for CAD is controversial • The prognosis for diabetics with an abnormal MPI result is worse than for patients without diabetes • A normal MPI result in diabetes does not imply low risk

  50. Outline • Women • Diabetes • Non-Cardiac Surgery • Choice of Stress Imaging Modality

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