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