MPS and Calcium Score
in asymptomatic patient
F. Mut, J. Vitola
Nuclear Medicine Service, Asociacion Española
Montevideo, Uruguay
Quanta Diagnostico Nuclear
Curitiba, Brazil
• Male 63 y.o., asymptomatic.
• Inactive but wants to start exercise.
• Knee osteoarthritis limiting exercise capacity.
• Hypertension (BP 145/90 mmHg under medication).
• Family history of CAD (father had sudden death at 53).
• Total Cholesterol = 223; HDL = 45; LDL = 128, Gluc = 0.97.
Clinical history
First step to evaluate an asymptomatic patient?
a) Global risk score (i.e. Framingham).
b) SPECT-MPS.
c) Coronary angioCT.
d) Rest ECG.
First step to evaluate an asymptomatic patient?
a) Global risk score (i.e. Framingham).
b) SPECT-MPS.
c) Coronary angioCT.
d) Rest ECG.
• Global risk score is a Class I indication in this setting; SPECT-MPS is
Class IIB or III, Coronary angioCT is Class III, and Rest ECG is Class IIA.
• Calculated Framingham risk score = 18% (intermediate risk for CAD
events in 10 years) based on SBP, cholesterol levels, age, gender, and
smoking status.
Which test can help stratify intermediate CAD risk patients ?
a) Calcium score (CAC).
b) C-Reactive protein.
c) Carotid intima-media thickness on ultrasound.
d) All of the above.
Which test can help stratify intermediate CAD risk patients ?
a) Calcium score (CAC).
b) C-Reactive protein.
c) Carotid intima-media thickness on ultrasound.
d) All of the above.
CAC
1611 Agatston (Percentile 97 for sex, age and race)
High risk patient !
Which test can help further stratify intermediate CAD risk patients with advanced atherosclerosis ?
a) Treadmill test
b) Myocardial perfusion study
c) CT angiography
d) Invasive angiography
Which test can help further stratify intermediate CAD risk patients with advanced atherosclerosis ?
a) Treadmill test
b) Myocardial perfusion study
c) CT angiography
d) Invasive angiography
• In addition to the knowledge about atherosclerosis burden in our
patient, short-term prognosis is dependent on the presence and
degree of ischemia, the territory involved, and the LV function - all of
which can be provided by MPS.
• SPECT MPS, combined low workload exercise with
dipyridamole, 99mTc-MIBI, one-day protocol.
• No symptoms or ST changes.
Myocardial perfusion study
Myocardial perfusion study
LVEF: stress 67%, rest 62%
a) Anteroseptal infarction + ischemia, high risk.
b) Normal perfusion.
c) Inferoapical ischemia, low risk.
d) Lateral wall ischemia, moderate risk.
The MPS result is consistent with:
a) Anteroseptal infarction + ischemia, high risk.
b) Normal perfusion.
c) Inferoapical ischemia, low risk.
d) Lateral wall ischemia, moderate risk.
The MPS result is consistent with:
• The images show inferoapical reversible defect, with preserved LV
function both post-stress and rest = low risk for cardiac events.
Follow-up
• Patient was managed clinically for CAD, ischemic heart
disease: Beta-blockers, ASA, statins.
• Secondary prevention (target = LDL< 70).
• Low level exercise: medicated and under supervision.
• CAC provides independent incremental information in addition to traditional risk factors in the prediction of all-cause mortality.
• The principal difference between MPS and Ca scoring is that the former is an excellent tool for assessing short-term risk, guiding decisions on revascularization.
• In contrast, atherosclerosis imaging methods like CAC provide greater long-term risk assessment, and are more useful in defining the need for aggressive medical prevention.
Teaching points
• Berman DS, Hachamovitch R, Shaw LJ, et al. Roles of nuclear cardiology,
cardiac computed tomography, and cardiac magnetic resonance: Noninvasive
risk stratification and a conceptual framework for the selection of noninvasive
imaging tests in patients with known or suspected coronary artery disease. J
Nucl Med 2006; 47:1107–18.
• Budoff MJ, Shaw LJ, Liu ST. Long-term prognosis associated with coronary
calcification: observations from a registry of 25,253 patients. J Am Coll Cardiol
2007; 49:1860-70.
• Greenland P, Alpert JS, Beller GA, et al. 2010 ACCF/AHA guideline for
assessment of cardiovascular risk in asymptomatic adults: executive summary:
a report of the American College of Cardiology Foundation/American Heart
Association Task Force on Practice Guidelines. J Am Coll Cardiol 2010;
56:2182-99.
• Xu Y, Arsanjani R, Clond M, et al. Transient ischemic dilation for coronary
artery disease in quantitative analysis of same-day sestamibi myocardial
perfusion SPECT. J Nucl Cardiol 2012;19:465-73.
Bibliography
