RM Solutions - cardioegypt2011

10/25/2011
Highlights
CT/CMR/Nuclear Imaging
CardioEgypt 2011
Islam Shawky A‐Aziz, Aziz, MD
Al‐Azhar University
Evaluation of Coronary Artery
Plaque Vulnerability using PET/CT
RM Solutions
Hossam Sherif, MD
Assistant Professor of Critical Care Medicine
Cairo University
ESC 2011, Sharm Al Shiekh
1

10/25/2011
Cardiac CT Scan
Is the most effective method for detecting calcifications in
the plaque.
The atheroma has to be advanced enough to have large
areas of calcification (> 2 mm 2 ) that the scanner software
can recognize.
Such regions start occurring within the heart arteries
about 2–3 decades after atheroma starts developing.
The absence of calcifications does not necessarily imply
the absence of vulnerable plaque.
Cardiac PET/CT
Wykrzykowska J. JNM, 2009
With spatial resolution > 5 mm in the new PET scanners,
further evaluation of cardiovascular imaging:
g
RM Solutions
- Characterization of Coronary Artery Plaque (CAP)
Vulnerability using co-registration with CT,
- Discrimination between subendocardial and
subepicardial blood flow,
- Imaging of different cardiac reporter gene expression.
Bravo PE. J Cardiovasc Transl Res, 2011
2

10/25/2011
Conclusions
18 F-FDG PET/CT imaging g is poised to play a potentially
important role by providing information on the biology of
atherosclerotic lesions, thereby complementing the only
structural information that can be derived from other
imaging technologies.
Such biological assessment of atherosclerotic plaques may
evolve into a clinical application as a risk assessment tool
for cardiovascular disease, and may facilitate the
evaluation of anti-atherosclerotic drugs.
RM Solutions
3

10/25/2011
Dr. Adel Allam, MD,FASNC
Professor of Cardiology, Al Azhar University
Atherosclerosis
Flow limiting stenosis
Yes or No
Yes or No
Calcium scoring
Doppler flow wire
CT Angiography
g Stress imaging
g
RM Solutions
0% 30% 50% > 70% > 90%
4

10/25/2011
Normal MPI scan in 58 y old male
patient.
C.T coronaries of the same
patient showing no calcification
RM Solutions
Normal MPI scan in 60 y
old patient.
LAD of the same patient
showing heavy CAC.
5

10/25/2011
DISTRIBUTION OF CORONARY CALCIUM SCORES
50.00%
45.00%
40.00%
35.00%
30.00%
49.4%
RM Solutions
25.00%
20.00%
15.00%
10.00%
5.00%
20.8%
16.1%
8.9%
13.7%
4.8%
0.00%
0 1-10 11-100 > 101-400 > 400
6

10/25/2011
We concluded that the majority of Egyptians patients with negativee
myocardial perfusion imaging have low CAC score.
Although still 13.7% of the patients has CAC score > 100.
And the predictors of significant CAC score would include age, gender, risk
factors particularly (diabetes mellitus, hypertension and smoking) .
RM Solutions
7

10/25/2011
RM Solutions
‣ Cardiac resynchronization therapy (CRT) is
approved for the treatment of patients with
advanced heart failure (HF) symptoms.
‣ LVEF < 35 and wide QRS (> 120 ms)
8

10/25/2011
‣ Patient in HF NYHA Class III or IV
‣ LVEF < 35%
‣ LV dyssynchronous
QRS > 130 ms (electrically).
Mechanically (accurately and reproducibly).
‣ Is lateral wall infarcted
Usual placement for 3rd lead.
Bleeker et al, Circulation 2006; 113:969-976.
RM Solutions
Class III Heart Failure
LVEF (Echo) = 32%
Class III Heart Failure
LVEF (Echo) = 27%
9

10/25/2011
Gated SPECT imaging has the ability to quantify LV
dyssynchrony, myocardial perfusion and LV function.
Dyssynchrony data as measured by the quantitative
phase analysis indices (PSD + PHB) and myocardial
perfusion and function data may improve the
discriminative ability of GSPECT imaging for selection of
patients for CRT.
RM Solutions
10

10/25/2011
Radionuclide Imaging in Heart
Failure
Dr. Mohamed Farid, MD.
Prof. of Cardiology, Faculty
of Medicine,
Al Azhar University.
•
RM Solutions
•
•
•
•
11

10/25/2011
Myocardial perfusion imaging in the
acute care setting
Does it still have a role
RM Solutions
Prof Dr/Sahar Azab ,MD
Prof Of Cardiology , Alexandria
12

10/25/2011
Conclusions
‣Acute MPI remains an important technology
that t can identify the few high‐risk h ikpatients
t
among those with a low‐risk presentation.
‣Appropriate utilization can reduce costs while
improving outcomes.
‣ In spite of newer, evolving tecnologies,
acute MPI continue to have a significant role
in the acute evaluation of ED chest pain
RM Solutions
13

10/25/2011
Borderline (intermediate)
coronary plaques
Magdy Rashwan, MD
Professor of cardiology
University of Alexandria
Egypt
An intermediate borderline coronary
lesion is defined on angiography as a
luminal narrowing with a diameter
stenosis more than 40% but less than
70%.
RM Solutions
Assessment of a coronary lesion with
intermediate severity continues to be a
challenge for cardiologists.
14

10/25/2011
SOME ANGIOGRAPHICALLY SEVERE
LESIONS ARE NOT ISCHEMIC
SOME ANGIOGRAPHICALLY MILD LESIONS
ARE HEMODYNAMICALLY SIGNIFICANT
RM Solutions
Adenosine
FFR = 50 / 92 = 0.53
“Pseudo‐Mild Stenosis”
15

10/25/2011
SOME ANGIOGRAPHICALLY MILD
LESIONS HEAVILY BURDENED BY PLAQUE
The debate between morphological and
functional approaches is going ever more in
favor of function assessment.
RM Solutions
FFR currently enjoys class IA recommendation
ahead of revascularization
Functional angioplasty
16

10/25/2011
Cardiac Imaging for the
Investigation of Chest Pain:
Which Test is Best
RM Solutions
Dr. R. S. Khattar DM FRCP FACC FESC
Consultant Cardiologist and Honorary Clinical Senior Lecturer
Manchester Royal Infirmary and University of Manchester
17

10/25/2011
NICE Guidelines for Recent Onset
Suspected Cardiac Chest Pain 2010
• Low likelihood of CAD (10-29%)
– CT coronary calcification scores ± CT coronary
angiography
• Intermediate likelihood of CAD (30-60%)
– Stress echo, nuclear imaging, MR, CT
• High Likelihood of CAD (61-90%)
– Invasive coronary angiography or stress echo/nuclear
imaging
Summary
• Use a tailored approach to the investigation of chest pain
based on the patient’s pre-test probability of CAD
RM Solutions
• Exercise ECG may still have a role in patients with low
pre-test probability of CAD
• Stress echo, nuclear imaging, MR or CT for intermediate
pre-test probability group - depends on local expertise
• Ischaemia testing or invasive coronary angiography in
patients with high pre-test probability of CAD
18

10/25/2011
RM Solutions
GAMELA NASR , MD
Professor of Cardiology, Consultant in national
Insurance & Sporting hospitals Cairo
Master of Medical Education Holland-SCU
Diploma of E Teaching NORWAY
19

10/25/2011
RM Solutions
39
40
20

10/25/2011
Echocardiography
• Increase in systolic
contraction at low dose
dobutamine
presence of viable
myocardium
RM Solutions
41
• New regional wall
motion defects, decline
in EF, increase in endsystolic
volume with
stress myocardial
ischemia
21

10/25/2011
MRI Gadolinium‐DTPA
RM Solutions
Conclusions: Visualization of coronary collaterals to the infarct-related
artery by coronary angiography may predict with a high sensitivity but a
low specificity the presence of viability in the territory supplied by that
artery.
22

10/25/2011
RM Solutions
Dr. Ashraf Badawi
MD Cardiology
Ain Shams Faculty of Medicine
23

10/25/2011
• Found in ~0.1%‐1.3% of patients undergoing
cardiac catheterization
• Can be associated with congenital heart disease or
be isolated anomaly
• Invasive angio evaluation can be challenging;
misdiagnosis happens in up to 50% of cases
g pp p 5
• So, although it is rare but it is an important cause of
CP, arrhythmia, MI & sudden cardiac death.
• And also it is TREATABLE
• CT angiography g allows evaluation of not
RM Solutions
just arterial caliber and lumen but also
their origin, course and relationship to
adjacent structures.
24

10/25/2011
• Anomalies of origin and course.
• Absent LM trunk.
RM Solutions
25

10/25/2011
RM Solutions
• Anomalous coronary arteries are rare but
potentially life‐threatening & treatable causes
for CP, MI & sudden cardiac death
• CTA plays vital role in making diagnosis.
• Not difficult to diagnose once familiar with basic
variations on anomalous anatomy and which
are the dangerous variants
26

10/25/2011
RM Solutions
27

10/25/2011
MSCT-CA
Latest
Appropriateness
Criteria
Islam Shawky A-Aziz
Assist. Prof. of Cardiology
Al-Azhar University
RM Solutions
28

10/25/2011
Appropriateness Criteria
2006 2010
• 39 indications
• 13 Appropriate
• 13 Uncertain
• 13 Inappropriate
• 93 indications
• 35 Appropriate
• 29 Uncertain
• 29 Inappropriate
RM Solutions
29

10/25/2011
Finally,
Appropriateness criteria
are not substitutes t for
sound clinical judgment
and practice experience
with each patient and
clinical presentation
RM Solutions
30

10/25/2011
Case presentations
• Dr. Amr Adel
• Dr. Hany Mouris
• Dr. Muhammad Mandour
RM Solutions
رباه النرجو خلودا فديارنا ليست ھنا
وجنات خلدك حلمنا وترابھا وطن لنا
رباه فاجمعنا بھا واجعل اعاليھا لنا
31