Anatomical and Functional Imaging of CAD in CKD

Paolo Raggi, MD Professor of Medicine and

Cardiology Mazankowski Alberta Heart Institute University of Alberta,

Edmonton, AB

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Anatomical Imaging

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Invasive Angiography

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Hypertension 2003;42:263-68

MPI

Risk Stratification

Stress Echo

Invasive Angio KDIGO

Intravascular Ultrasound

Gruberg Am J Cardiol 2005;96:892-96

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Composition and plaque patterns of coronary culprit lesions and clinical characteristics of patients with chronic kidney

disease

Keiji Kono, Hideki Fujii, Kentaro Nakai, Shunsuke Goto, Junya Shite, Ken-ichi Hirata, Masafumi Fukagawa, Shinichi Nishi

Kidney International Volume 82, Issue 3, Pages 344-351 (August 2012)

DOI: 10.1038/ki.2012.118 KDIGO

Kidney International 2012 82, 344-351DOI: (10.1038/ki.2012.118)

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Optical Coherence Tomography

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Computerized Tomography

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Kramer H. JASN 2005

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Kidney Int 2013;83:1159

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Coron Art Dis 2013, 24:135-41

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Coronarycalcifica,onsandplaquecharacteris,csinpa,entswithend-stagerenaldisease:aCTstudy

JugBetal.CoronArtDis2013,24:501–508

Comparisonof:ESRDpts,age-sex-CACscorematchedandage-sexmatchednon-ESRDptsGreaterprevalenceofcalcifiedplaquesinESRD(56%vs38%vs27%,p=0.005)PlaquecomposiNon(%) ESRD Age-sex-CACAge-Sex-match-noCKD

Noncalcific 12.6 13.914.7 p=0.233Mixed 43.7 51.6 51.4 p=0.002Calcific 43.7 34.5 33.9 p=0.003

AUCofCACscoretodetect>50%luminalstenosis

0.77 0.75 0.69

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International registry 5572 patients Median f/u: 19 months

Am J Cardiol 2013;111:1563-69

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Epicardial Adipose Tissue An Overlooked Marker of Risk?!

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InflammaNoninEAT

Mazurek T. Circulation 2003;108:2460-66

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!

D’Marco L et al. NDT 2013

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Cardiac MR

Anatomy, Function, Cardiomyopathies Viability, Perfusion and Angiography

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CMR: Volume and Mass Analysis

LVendocardialcontourcontour

LVepicardialcontour

RVepicardialcontour

RVendocardialcontour

Papavassiliu,T.etal.Radiology2005;236:57-64

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KimRetal.NEJM2000;343:1443-53

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Salerno M. JACC Img 2013;6:806-22

T1 Mapping for better Tissue Characterization

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Functional Imaging

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* *

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Am J Cardiol 2008;102:1451-56

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Single independent predictor of MACE = CKD!

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Alexopoulos N. and Raggi P. Seminars in Dial 2017

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Increased arterial wall inflammation in patients with CKD. 18F-FDG uptake in the aortic arch (top) and the carotid arteries (bottom) was quantified as the TBR in controls (n=14, represented in A)

and patients with CKD (n=14, represented in B).

Sophie J. Bernelot Moens et al. JASN 2017;28:1278-1285

©2017 by American Society of Nephrology

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Ridker P et al JACC 2018;71:2405-14

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Active and indolent molecular vascular calcification. (A) Patient without structural vascular calcification. A positive Na18F PET signal, representing molecular vascular calcification, was observed in the ascending aorta (interrupted arrow). (B) Patient with active (arrow) and indolent vascular calcification in the descending aorta. Note the intense uptake of Na18F in the sternum, vertebra, and ribs

18F-Sodium Fluoride

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Radiation

Exposure Milli-Sieverts

Chest x-ray 0.1

Mammogram 0.4

FLASH coronary calcium 0.5*

Lumbar x-ray 1.5

1 year on planet Earth 3-3.5

*Meanandmediandoseoflast15casesdoneatUAH(range0.2-0.8mSv)

AmericanCollegeofRadiology+RSNA

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Yearly Natural Background Radiation

l  ~ 3.5mSv (350 mRem)/yr in the USA

–  ~2.0 mSv from radon gas from U decay –  ~0.50 mSv from cosmic and terrestrial radiation –  ~1.0 mSv other sources (including foods, water

etc)

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ALARA

l As l Low l As l Reasonably l Achievable

•  Public exposure

Dose equivalent 1 mSv

•  Occupational exposure

Dose equivalent 50 mSv

•  Embryo/fetus

Dose equivalent 0.5 mSv

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American Cancer Society 42 Expected Cancers per 100 US Adults

1 Due to Exposure to 100mSv of Radiation

Case per 10 mSv

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Summary

v  Many techniques are available

q  Most require advanced expertise for interpretation §  The radiation exposure for some of the techniques is not negligible and the best ALARA principles should be applied. Patient involvement in decision making is necessary.

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