Current Applications Of Cardiac Imaging NUCLEAR MEDICINE

Current Applications of CardiacImagingNUCLEAR MEDICINEInternational Conference on Integrated Medical Imagingin Cardiovascular Diseases – 2013Paola Smanio MD, PhDProfessor of Cardiology and Nuclear MedicineDirector of the Nuclear Medicine and PET/CT CenterDante Pazzanese Heart Institute - São Paulo BrazilFleury Medical Center - São Paulo Brazil

CARDIOVASCULAR IMAGING

NON-INVASIVEDIAGNOSTIC METHODS ECG NUCLEAR MEDICINE EXERCISE STRESS TEST- SPECT ECHOCARDIOGRAM-PET CALCIUM SCORING- MIBG- 123I CORONARY TOMOGRAPHY- MAGNETIC RESSONANCE IMAGING- MUGA67GALLIUM

DIAGNOSTIC ESTRATEGY AVAILABILITY GUIDELINES/APPROPRIATNESS CRITERIA CLINICAL EXPERTISE OBJECTIVE OF THE STUDY AND PRETEST LIKELIHOOD CHARACTERISTICS OF THE METHOD X PATIENT (asthma, acoustic window,limitation to exercise) SINGLE METHODX ASSOCIATION OF METHODS

ERA OF MULTIMODALITY OFDIAGNOSTIC TESTSANATOMYEVIDENCE ACT IN OUTCOMEHELPINGCLINICAL DECISION

398.978 p Coronary Angiography in 663 centers only 149.739 (37,6%) with significant CAD

NUCLEAR MEDICINE

J Nucl Cardiol 2013

NUCLEAR MEDICINE

CURRENT APPLICATIONS EVALUATION OF PATIENTS WITH SUSPECT CAD EVALUATION OF SUBCLINICAL ATHEROSCLEROSIS EVALUATION OF ISCHEMIA THERAPIES IN PATIENTS WITH ASSESSMENT OF THE HIGH RISK PATIENT:CAD: MEDICAL, REVASCULARIZATIONMULTIVESSEL, DIABETIC, RENAL FAILURE ACUTE REST MPI IN THE EMERGENCY DEPARTMENT ASSESSMENT OF WOMEM RADIONUCLIDE IMAGING IN HEART FAILURE ASSESSMENT OF ATHLETES AND FOR EXERCISEPRESCRIPTION- ASSESSMENT OF MYOCARDIAL VIABILITY- ETIOLOGY OF LV DISFUNCTION ASSESSMENT OF ELDERLY- PROGNOSIS : MIBG -123I RISK STRATIFICATION- EVALUATION OF SYNCHRONY OF LV CONTRACTION PREOPERATIVE RISK ASSESSMENT FOR NON-CARDIAC SPECT X PET IMAGINGSURGERYBraunwald Heart Disease 2008.Nuclear Cardiology. Practical Applications. Gary Heller and Robert Hendel 2 ed.C

EVALUATION OF PATIENTSWITH SUSPECT CAD

PRE TEST PROBABILITY - ASSESSMENT OF RISKBraunwald Heart Disease 2008.

APPROPRIATED INDICATIONSHendel R et al. JACC 2009

EVIDENCE 997MIBIAjustado MIBIGated-SPECT9493Ficaro2001MIBIGated 2NH3/FDGPET98100AuthorOklocke AHA/ACC Guidelines.2003

STRESS TEST X ACURACYstress agent and . J Nucl Cardiol 1996Dobuta10090807060% 5040302010085%70%CPMECGANGINAHeller G et al. Am J Cardiol 1991;68-569.

RISK STRATIFICATIONMPI –ASSESSMENT OF RISK IN THE POPULATIONYEAR1994-2003Nº PATIENTSFOLLOW UP2,3(1,8-3,9 Y)69.655HIGH RISKLOW RISK5,9(4,6-8,5)0,85(0,6-1,2)MPI – PATIENTS WITH KNOWN CADYEARSNº STUDIESNº PATIENTSFOLLOW UPNL MPIABNL MPI1994-20011316.00028 months0-1,3 %2,0-14,3 %Shaw L and Iskandrian JNCardiol 2004 -PROGNOSTIC VALUE OF GATED MYOCARDIAL PERFUSION SPECT

15-Year outcome after normal exercise 99mTcsestamibi myocardial perfusion imaging:What isthe duration of low risk after a normal scan?Schinkel AFL et al.J Nucl Cardiol 2012;19:901-6Conclusion. Patients withsuspected or known CADandnormalexercise99mTc-sestamibiMPIhave a favorable 15-yearprognosis.Follow-up should be closerin patients with indicatinghigher risk status.

Patients with known CAD and a normal SPECT MPI study have afavorable long-term prognosis. The annualized cardiac mortality and/or non-fatal M I was 1,2%. The inability to perform exercise test was associated with animpaired outcome. Independent predictors to cardiac death and non-fatal MI wereDiabetes and rate-pressure product at peak stress.

ASSESSMENT OF HIGH RISK PATIENTS

Value of myocardial perfusion imaging in theassessment of ischemia in asymptomatic renaldisease patients before dialysis123 pSmanio P. et al. ICNC 2013 and submitted Arq.Brasil.Cardiol.

DIAGNOSTIC VALUE OF MPIBEFORE RENAL TRANSPLANT128 (75%)170 P22ISCHEMIANORMALVankataraman R and Iskandrian A. Am J Cardiol2008.102(11):1451.

2000.PtsHakeem et al. JNucl Cardiol junho 2011.

Global Prevalence of DiabetesEstimates for the year 2000 and projections for 20302000Country2030DM 002000203080604020020-4445-64 65Wild S. Diabetes care 27:1047-1053,2004

PREVALENCE OF SIGNIFICANT CAD INASYMPTOMATIC DIABETIC WOMEN34 P104 PETTSENSIT32,7%67,3%44,1%MPI94,1%(43% 85% MPHR)SPECIF61,4%92,4%( 37,5% – ECG BASAL: abnormal ST)Sem DACCom DACSmanio P. Arq Bras Cardiol 2007 Nov;89(5):263-9, 290-7.

25% DM already have CAD at the moment of DiabetesdiagnosticHIGH RISKXINCLUIDING ASYMPTOMATICDIAD – 14 CENTERS, VOLUNTEERS22%- abnormal SPECT 6% severe!!!Wackers et al, 2004 Diabetes Care 27: 1954Wackers F. Diabetes care 2007.

WOMEN MORTALITYDEATHS PER 1.000.000 INHABITANTS FOR CAD CAUSE - BRAZIL 2004MENWOMENTOTAL50.102 (58%)36.679 (42%)86.679Brazilian Health Secretary of State. SEADE 2004AHA/ACC/ASNC. (USA, 2003) Mortality in Women

WOMEN AND CAD physiopathology,manifestation, diagnosisstart older, atypical symptoms worst prognosisWomen are lesser investigated1st manifestation MI or cardiac deathEarly investigation is veryimportantMosca L. Circulation 2004.

STRESS TEST X ficityKwok et al. Am J Cardiol. 1995; 83: 660-6

EXERCISE STRESS TEST X PEC Mieres J.Am J Cardiol 2007;99:1096-1099

CARDIAC MORTALITY IN DIABETIC MEN AND WOMENBASED IN THE RESULTS OF SPECTCardiac Mortality98MenWomen76543210NormalBerman et al, 2003JACC 41: 1125Mildly AbnMildly AbnNO DIFFERENCE TO NON-DIABETICSSevere Abn

MPI IN ELDERLYATTENTION CAROTID STENOSIS ATRIO-VENTRICULAR BLOCK FEW SYMPTOMS ARE MENTIONED INTERATION WITH OTHER DRUGS ABNORMAL EKG 3412p – 616 70ª MPI was considered a safe test Hashimoto A. J Nucl Cardiol 1999:8;512

DIAGNOSTIC ACURACY IN ELDERLY NORMALCYRATE Wang J Nucl Cardiol. Sept. 1995

CHALLENGES OF THECauses of Sudden Death in AthletesATHLETE ‘S HEART1: 100 000 athletes normal/year 35 years 35 yearsCADOcasional80%HCM26%Anomalous coronary14%RV arrythmogenicdysplasia3% (USA),22% (Italy)Myocarditis6%Aneurism Rupture(Marfan)3%Aortic Stenosis3%Dilated Cardiomyopathy2%Electrics SyndromesRareComotio cordisRare (USA)Miocardial bridge4%N H Prakken, B K Velthuis. Br J Sports Med 2009;43:677–684

MYOCARDIAL PERFUSION IMAGINGASSOCIATED TO CARDIOPULMONARYSTRESS TEST

PREOPERATIVE RISK ASSESSMENTFOR NON-CARDIAC SURGERY

PERISURGICAL RISK ASSESSMENTCLINICAL RISK x DP- MIBI RISKKenneth Brown J Nucl Cardiol. 2004

RECOMENDATIONHoeks S et al. J Nucl Cardiol 2007Caramelli B. Arq Bras Cardiol 207;88(5):e139-e178

ASSESSMENT OF MULTIVESSEL DISEASE

Myocardial perfusion imaging in the evaluation ofmultivessel disease patients68 p with documented CADMPI within 7 days after angiographySiqueira M, Vieira Neto E, Kelendjian J, Smanio P. Arq. Bras. Cardiol. 2011;97(3):194-8

MULTIVESSEL AND LM SIGNIFICANT DISEASE101 p, NO PREVIOUS MIBerman D et al. J Nucl Cardiol 2007;14:521-8

J N Cardiol. Dezembro 2010J Nucl Cardiol 2005;12:145-7.JACC 2010

181614121086420CAC 1000VOLUNTJ Nucl Cardiol Dez 2010ASSINTRozanski A e cols. JACC 200749:1352-1361

SUBCLINICAL ATHEROSCLEROSIS FAMILY HISTORY OF PREMATURECAD HIGH RISK WORK: pilots, firemen,policemen DIABETIC VASCULAR DISEASE ERECTILE DISFUNCTION AUTOIMMUNE DISEASE, AIDS PRESURGICAL RISK ASSESSMENT CHRONIC RENAL FAILURE LOW FUNCTIONAL CAPACITY CAC 400J Nucl Cardiol 2008;15:e6-19.

EVALUATION OF ISCHEMIA THERAPIESIN PATIENTS WITH CAD:MEDICAL, REVASCULARIZATION

REDUCTION OF ISCHEMIA WITHCLINICAL TREATMENT

New Cardiac Scanners in Clinical UseDynamic SPECT(D-SPECT)New systems surround thepatient’s heart with detectorand acquire all angles at once.Discovery NM 530James A. Patton, PhD, Vanderbilt U., SNM 2006Garcia EV, Faber TL, Esteves FP.J Nucl Med. 2011 Feb;52(2):210-7.

STRESS ONLY16,854 consecutive patients who had a normal gated stress SPECTstudy and were followed for a median of 4.5 years-AMI/mortalityMahmariam J. J Nucl Cardiol 2010;17:529–35.

A2 AgentsZoghbi and Iskandrian. JNCardiol. Fev 2012

RADIONUCLIDE IMAGING OF CARDIACAUTONOMIC INNERVATION Cardiac autonomic function plays a crucial role inthe health and disease ation and poor prognosis. Increased global cardiac uptake appears to have ahigh negative predictive value in terms of cardiacevents (deaths and arrhythmias) and may have arole in guiding therapy Helping to better select pts unresponsive toconventional medical therapies that would benefitfrom devices therapies such as: ICD, CRT, LAVDor cardiac transplantationJi S Y and Travin MI . J Nucl cardiol 2010

At baseline, CRT responders showed a significantly larger histogrambandwidth (94 23 vs. 68 21 , P 0.01) and a larger phase SD(26 6 vs. 18 5 , P 0.01) than did nonrespondersJ Nucl Cardiol 2008;15:127-36.J Nucl Med 2009; 50:718–725J Nucl Cardiol 2011;18:685–94.

ADVANTAGES OFRb-82 PET/CT vs SPECT Better efficiency Faster exam Lesser exposure dose Less attenuation artifacts Better spatial resolution and contrast Real time ejection fraction Measurement of coronary flow reserveQuantification of regional myocardial blood flow (ml/min/g)

Patient EMS ‐ MibiCourtesy Dr Meneghetti

Patient EMS ‐ Rubidium ‐82Courtesy Dr Meneghetti

Patient EMS ‐ Rubidium – 82 –Cedars‐Sinai

PET -18FDG ASSESSMENT OFMYOCARDIAL VIABILITY

EIXOCURTOTÁLIOREPOUSOTÁLIOREINJEÇÃOPET - 18FDGEIXOHORIZONTALEIXOVERTICAL

PET Flurpiridaz F-18

FUTURE DIRECTIONS

INTEGRATION

INTEGRATIONTECHNIQUES E SPECIALITIES

What is this ?2

nuclear medicine - spect -pet - mibg-123i-67gallium - muga. diagnostic estrategy availability guidelines/appropriatness criteria clinical expertise objective of the study and pretest likelihood characteristics of the method x patient (asthma, acoustic window, limitation to exercise) single method x association of methods. fisiology anatomy era of multimodality of diagnostic tests impact in .