DISCLOSURES

Honorarium – Research and Conferences in Nuclear Cardiology

BMS, CVT, Astellas, Pgx Health/Forest laboratories, Lantheus Medical Imaging International Atomic Energy Agency

Royalties – Publications in Nuclear Cardiology Springer-Verlag-Nuclear Cardiology and Correlative Imaging: a teaching file, NY, 2004 Lippincott Williams & Wilkins, - Nuclear Medicine teaching File, 2009

João V. Vitola, MD, PhD

Cardiologist and Nuclear Medicine Physician

Quanta Diagnostico Nuclear

Curitiba - Brazil

Hybrid Imaging Improving Nuclear Cardiology Practice

The Achilles Heel

Recognizing and Correcting for NC Artifacts Reducing false positive rate as much as possible

Improving Nuclear Cardiology Practice

HW Strauss, BL Zaret, ND Martin,

HP Wells, Jr, and MD Flamm, Jr

Noninvasive evaluation of

regional myocardial perfusion

with potassium 43. Technique in

patients with exercise-induced

transient myocardial ischemia

Radiology 1973 108: 85-90

Nuclear Cardiology in 1973 and in 2012

Look at the global picture – who is my patient ? Estimate the pre test probability of disease

The Achilles Heel

Patient Centered Imaging and Quality

1- Medical history – talk to the patient

Estimation of pre test probability – symptoms, risk factors Interview needed to better define ideal stress protocols Needed to define which question clinician wants to answer Diagnosis ? Prognosis ? Culprit artery ? Viability? Function ?

2- Stress data

Estimate functional capacity Some Diagnostic and Prognostic info Duke Score (time – 5 x ST mm – 4 x angina) New pre test probability before imaging Define ideal for post stress imaging 15’ vs 30’ vs 60’

3- Imaging analysis

4 –Final report (1+2+ 3)

Consider info from history and stress test for image interpretation (more sensitive or specific reading – consider artifacts)

Improving Nuclear Cardiology Practice Patient Centered Imaging and Quality

Medical team should participate actively Decide best type of stress – keep good quality control, systematically review image before releasing patient, verify acquisition / processing (preferably process yourself), decide when to do additional images (delayed), reacquire in prone if needed, repeat study if necessary (inadequate IV injection/SQ) - Look for motion, evaluate statistics, body habitus (attenuation), history / rest ECG (prior MI ? LBBB/PCM ?)

The Achilles Heel

How to Recognize and to Correct for NC Artifacts

case

70 yo Man HTN, Disl BMI 34 Atypical Pain Duke score -1

Prone Imaging

case

SPECT 99mTc-MIBI -stress-rest

No history of CAD Atypical Chest Pain Question 1 What is your interpretation ? A - Silent Inferior MI B – Inferior MI, LAD ischemia C – Diaphragmatic attenuation D – Inferior MI, Dilated LV E – Not sure, need more data

SPECT 99mTc-MIBI -stress-rest

No history of CAD Atypical Chest Pain Question 1 What is your interpretation ? A - Silent Inferior MI B – Inferior MI, LAD ischemia C – Diafragmatic attenuation D – Dilated LV, Inferior MI E – Not sure, need more data

Question 2

What could be helpful to differentiate a true defect and diaphragmatic attenuation in this patient ?

A- Prone Imaging

B- Attenuation correction

C – Rest ECG and TMT results

D- Gated SPECT

E – All of the above

Question 2

What could be helpful to differentiate a true defect and diaphragmatic attenuation in this patient ?

A- Prone Imaging

B- Attenuation correction

C – Rest ECG and TMT results

D- Gated SPECT

E – All of the above

PET 82Rb

Courtesy of J. Machac-Mt Sinai, NY

Attenuation Correction using PET- CT

SPECT 99mTc-MIBI

• Use LV Function data - Gated SPECT

– Wall motion and thickening at rest and after stress

What can we do to overcome the problem ?

Gated Tc-99m SPECT improving specificity in women

67.2

84.492.2

0

20

40

60

80

100

70 % Stenosis

Tl-201

Tc-99m

Gated

Taillefer et al JACC 1997;29:69-77

Sp

ecif

icit

y (

%)

0

5

10

15

20

25

30

35

40

45

50

Male Female

% E

qu

ivo

cal

Inte

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tati

on

s

Supine NC

Supine NC/Prone

Supine NC/AC

All

Malkerneker D et al. J Nucl Cardiol 2007

Prone + AC on SPECT-CT – reduce number of equivocal studies

Camera Time Consuming !!!

Before and After Attenuation Correction

Before

Before

Before

After

After

After

Before

Before

Before

After

After

After

Before and After Attenuation Correction

SPECT-CT Imaging (No Attenuation Correction)

SPECT-CT Imaging (After Attenuation Correction)

Relevant questions in 2012

What information do we need to manage our patient ?

Is new imaging technology reducing CV mortality ?

Is technology translating in cost effective care ?

Have we already maximize extracting the information from

basic techology ?

Vitola JV

Vitola JV, Shaw L, Allam A, Peix A et al JNC, 2009

Worldwide Utilization of MPI– Underutilized in Many Nations

High Moderate – High Moderate Moderate – Low Low Inexistent Limited info

Having both information from Nuclear (physiology) and CT (Anatomy) : competition and / or cooperation ?

• Cooperation increasing – both are non-invasive – Roles being defined for calcium score and anatomy by CT

• Potential for competition: – For pratical purposes CT excludes CAD (high NPV, low PPV)

– A negative CT implies no nuclear on follow up (including nuclear after + TMT)

– Acute chest pain in ER

Calcium Score – long term prognosis

Diagnosis of CAD

Secondary Prevention

Plaques/Obstruction – continue

investigation

Ischemic burden

Prognosis – 1 - 2 years

Need to revascularize

Eixo Curto

Eixo Longo Vertical

Eixo Longo Horizontal

Cortes Tomográficos-Referência

QUANTA Diagnostico Nuclear

75 yo women, no history of CAD – mild antero-septal ischemia ?

Good Chance for Contribution and Feedback to NC

Negative CT: Mibi showed microvascular ischemia ? Breast attenuation ?

Negative MPI but very “advanced” atherosclerosis No revascularization but aggressive secondary prevention

Man, 57 yo, HTN, Dyslipidemia, Obese and sedentary Denies DM , Family hx, Smoking Asymptomatic on check up

Calcium score 2037 LAD 962 LCX 194 RCA 881

Calcium score 2037 LAD 962 LCX 194 RCA 881

Calcium score 2037 LAD 962 LCX 194 RCA 881

Berman DS et al. J Nucl Med 2006:47:1107-1118.

Calcium Score Superior Compared to Framingham Score

Framingham Risk Score

Man, 57 yo, HTN, Dyslipidemia, Obese and sedentary Denies DM , Family hx, Smoking Asymptomatic

CCS 2037

In asymptomatic patients with CCS > 400, what is the probability of a positive SPECT ?

A : < 10% B : 10 – 20% C : 20-30% D : 30-40% E : 40-50%

A : < 10% B : 10 – 20% C : 20-30% D : 30-40% E : 40-50%

In asymptomatic patients with CCS > 400, what is the probability of a positive SPECT ?

Eixo Curto

Eixo Longo Vertical

Eixo Longo Horizontal

Cortes Tomográficos-Referência

Deliver the highest possible quality NC imaging AC using SPECT CT can help Identify your value and recognize your limitations Nuclear and CT – there is more room for cooperation than competition

Conclusions

Thank you

joaovitola@quantamn.com.br