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Transcript of Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear...
![Page 1: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/1.jpg)
Controversies in Myocardial Perfusion Imaging
Thomas H. Hauser, MD, MMSc, FACC
Director of Nuclear CardiologyBeth Israel Deaconess Medical Center
Instructor in MedicineHarvard Medical School
Boston, MA
A major teaching hospital of Harvard Medical School
![Page 2: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/2.jpg)
Harvard Medical School
THH10/05
Outline
• Women• Diabetes• Non-Cardiac Surgery• Choice of Stress Imaging Modality
![Page 3: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/3.jpg)
Harvard Medical School
THH10/05
Outline
• Women• Diabetes• Non-Cardiac Surgery• Choice of Stress Imaging Modality
![Page 4: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/4.jpg)
Harvard Medical School
THH10/05
Case 1
68 year old woman with a history of hypertension and dyslipidemia presents with a long history of exertional dyspnea. Her physical examination is normal.
What test do you order?A. Resting echocardiogramB. ETTC. Nuclear imagingD. Cardiac catheterization
![Page 5: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/5.jpg)
Harvard Medical School
THH10/05
Women and Cardiovascular Disease
• More than 500,000 women will die this year from CAD, stroke and other cardiovascular diseases– More women die from CVD than men
• CAD is the #1 killer of women– More than the next 7 causes of death combined
AHA Statistics
![Page 6: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/6.jpg)
Harvard Medical School
THH10/05
Women and Cardiovascular Disease
AHA Statistics
![Page 7: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/7.jpg)
Harvard Medical School
THH10/05
Women and Cardiovascular Disease
• CAD risk factors are the same for men and women• Women are more likely to present with atypical
symptoms or have silent events• Physicians are less likely to consider a diagnosis
of CAD in women
Fossati et al, in Nuclear Cardiology, 2004
![Page 8: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/8.jpg)
Harvard Medical School
THH10/05
Women: Inappropriate Triage
Pope et al, N Engl J Med 2000;342:1163-70
![Page 9: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/9.jpg)
Harvard Medical School
THH10/05
Women: Less Use of Diagnostic Tests
Roger et al, JAMA. 2000;283:646-652
![Page 10: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/10.jpg)
Harvard Medical School
THH10/05
Women: ETT Alone is Inadequate
Nasir et al, Arch Intern Med. 2004;164:1610-1620
Specificity80%
Sensitivity44%
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Harvard Medical School
THH10/05
Women: Reasons for Poor Performance
• Peak HR and BP are lower • Magnitude of STD is less• Chest wall shape differs • Vascular reactivity differs• Prevalence of disease is lower
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Harvard Medical School
THH10/05
Women: MPI Diagnosis
Amanullah et al, JACC 1996;27:803
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Harvard Medical School
THH10/05
Women: MPI Risk Stratification
Berman et al, J Am Coll Cardiol 2003;41:1125–33
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Harvard Medical School
THH10/05
Case 1
68 year old woman with a history of hypertension and dyslipidemia presents with a long history of exertional dyspnea. Her physical examination is normal.
What test do you order?A. Resting echocardiogramB. ETTC. Nuclear imagingD. Cardiac catheterization
![Page 15: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/15.jpg)
Harvard Medical School
THH10/05
Case 1
68 year old woman with a history of hypertension and dyslipidemia presents with a long history of exertional dyspnea. Her physical examination is normal.
What test do you order?A. Resting echocardiogramB. ETTC. Nuclear imagingD. Cardiac catheterization
![Page 16: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/16.jpg)
Harvard Medical School
THH10/05
Case 1: Raw Data
![Page 17: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/17.jpg)
Harvard Medical School
THH10/05
Case 1: Attenuation Map
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Harvard Medical School
THH10/05
Case 1: Slices
![Page 19: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/19.jpg)
Harvard Medical School
THH10/05
Case 1: Attenuation Correction
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Harvard Medical School
THH10/05
Case 1: Gated Images
![Page 21: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/21.jpg)
Harvard Medical School
THH10/05
Case 1: Quantitative Data
![Page 22: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/22.jpg)
Harvard Medical School
THH10/05
Difficulties in Imaging Women
• Breast attenuation• Small heart size
![Page 23: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/23.jpg)
Harvard Medical School
THH10/05
Case 1
• She exercised for 4.5 minutes of a modified Bruce protocol
• Peak HR of 119 (78% predicted maximal)• Peak BP 230/92• Typical angina with stress• Ischemic ECG changes
![Page 24: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/24.jpg)
Harvard Medical School
THH10/05
Case 1
Her study is interpreted as abnormal. What do you do now?
A. Begin a trial of medical therapy without further evaluation
B. Refer for cardiac catheterization for definitive diagnosis and potential revascularization
![Page 25: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/25.jpg)
Harvard Medical School
THH10/05
Women: Referral for Evaluation and Treatment
Hachamovitch et al, JACC 1995:1457
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Harvard Medical School
THH10/05
Women and Cardiovascular Disease
• CAD is highly prevalent among women• Women can present with atypical symptoms• ETT alone is controversial for evaluation of CAD• Nuclear imaging may be preferable for the evaluation
of women for both diagnosis of CAD and determination of prognosis
• Treatment of CAD is not gender-specific
![Page 27: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/27.jpg)
Harvard Medical School
THH10/05
Outline
• Women• Diabetes• Non-Cardiac Surgery• Choice of Stress Imaging Modality
![Page 28: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/28.jpg)
Harvard Medical School
THH10/05
Case 2
A 58 year old man with type 2 diabetes visits his internist because he is worried about his CAD risk. He is taking a statin for dyslipidemia (last LDL 90). His BP is 130/80. The internist should:
A. Start aspirin and an ACE-inhibitorB. Order an ETTC. Order an ETT with nuclear imagingD. Reassure him that he is at low risk
![Page 29: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/29.jpg)
Harvard Medical School
THH10/05
Diabetes and Cardiovascular Disease
• Coronary artery disease is major complication of diabetes– Independent effect of diabetes
– In patients with type 2 diabetes, obesity, hypertension and dyslipidemia also contribute
• The prevalence of CAD is estimated at up to 55% among patients with diabetes– More than 20% may have silent ischemia
• Delayed presentation
ADA, Diabetes Care 1998;21:1551Wackers et al, Diabetes Care. 2004 Aug;27(8):1954-61
![Page 30: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/30.jpg)
Harvard Medical School
THH10/05
Evaluating CAD in Diabetics
ADA, Diabetes Care 1998;21:1551
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Harvard Medical School
THH10/05
Requirements for a Useful Screening Test
• Relatively high disease prevalence– CAD in 55% in diabetics
• Asymptomatic phase of the disease– Silent ischemia in 20%
• Available test that can detect the disease during the asymptomatic phase– Nuclear imaging
• Treatment that alters the natural history when preferentially applied during the asymptomatic phase– Lipid lowering, aspirin, ACE-inhibitor, β-blocker,
revascularization
![Page 32: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/32.jpg)
Harvard Medical School
THH10/05
Asymptomatic Diabetics
ADA, Diabetes Care 1998;21:1551
![Page 33: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/33.jpg)
Harvard Medical School
THH10/05
Diabetes and Cardiovascular Disease
Haffner et al, N Engl J Med 1998;339:229-34
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Harvard Medical School
THH10/05
Diabetes and Cardiovascular Disease
Haffner et al, N Engl J Med 1998;339:229-34
![Page 35: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/35.jpg)
Harvard Medical School
THH10/05
Diabetes = CAD
• “Some persons without established CHD will have an absolute, 10-year risk for developing major coronary events (myocardial infarction and coronary death) equal to that of persons with CHD, i.e., >20 percent per 10 years. Such persons can be said to have a CHD risk equivalent.”– Diabetes
– Non-coronary atherosclerotic disease
– Multiple risk factors
NCEP-ATP III, Circulation, Dec 2002; 106: 3143
![Page 36: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/36.jpg)
Harvard Medical School
THH10/05
Diabetes = CAD
• Patients with diabetes should be treated to the same lipid goals as those with CAD– Diabetes alone is high risk
• LDL goal of <100 (can consider a goal of <70)
– The combination of diabetes and CAD is very high risk• LDL goal of <70
NCEP-ATP III Update, Circulation, Jul 2004; 110: 227 - 239
![Page 37: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/37.jpg)
Harvard Medical School
THH10/05
Diabetes = CAD
• Aspirin therapy– Age >40
• Hypertension– Goal BP <130/80
– Treatment with two or more agents• ACE-inhibitor
• Revascularization…– Mortality benefit proven only in those with 3VD
ADA, Diabetes Care 2004;27(S1):S15
![Page 38: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/38.jpg)
Harvard Medical School
THH10/05
Case 2
A 58 year old man with type 2 diabetes visits his internist because he is worried about his CAD risk. He is taking a statin for dyslipidemia (last LDL 90). His BP is 130/80. The internist should:
A. Start aspirin and an ACE-inhibitorB. Order an ETTC. Order an ETT with nuclear imagingD. Reassure him that he is at low risk
![Page 39: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/39.jpg)
Harvard Medical School
THH10/05
Case 2
A 58 year old man with type 2 diabetes visits his internist because he is worried about his CAD risk. He is taking a statin for dyslipidemia (last LDL 90). His BP is 130/80. The internist should:
A. Start aspirin and an ACE-inhibitorB. Order an ETTC. Order an ETT with nuclear imagingD. Reassure him that he is at low risk
![Page 40: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/40.jpg)
Harvard Medical School
THH10/05
Case 2
• The patient’s internist, having recently read an editorial advocating screening MPI for patients with diabetes, refers him for ETT with nuclear imaging.
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Harvard Medical School
THH10/05
Case 2
![Page 42: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/42.jpg)
Harvard Medical School
THH10/05
Case 2
• He exercised for 7 minutes of a Bruce protocol• Peak HR of 140 (86% predicted maximal)• Peak BP 178/80• No symptoms• No ECG changes
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Harvard Medical School
THH10/05
Case 2
The study is interpreted as normal. Based on this data, the patient is now:
A. Low risk
B. Intermediate risk
C. High risk
D. Very high risk
![Page 44: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/44.jpg)
Harvard Medical School
THH10/05
Risk Stratification in Diabetics
Giri et al, Circulation. 2002;105:32-40
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Harvard Medical School
THH10/05
Risk Stratification in Diabetics
Berman et al, J Am Coll Cardiol 2003;41:1125–33
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Harvard Medical School
THH10/05
Risk Stratification in Diabetics
Berman et al, J Am Coll Cardiol 2003;41:1125–33
![Page 47: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/47.jpg)
Harvard Medical School
THH10/05
Case 2
The study is interpreted as normal. Based on this data, the patient is now:
A. Low risk
B. Intermediate risk
C. High risk
D. Very high risk
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Harvard Medical School
THH10/05
Case 2
The study is interpreted as normal. Based on this data, the patient is now:
A. Low risk
B. Intermediate risk
C. High risk
D. Very high risk
![Page 49: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/49.jpg)
Harvard Medical School
THH10/05
Diabetes and Cardiovascular Disease
• Coronary artery disease is common in diabetes and results in significant mortality and morbidity
• Diabetics without CAD have the same risk for adverse events as non-diabetics with CAD
• Screening diabetics for CAD is controversial• The prognosis for diabetics with an abnormal MPI
result is worse than for patients without diabetes• A normal MPI result in diabetes does not imply
low risk
![Page 50: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/50.jpg)
Harvard Medical School
THH10/05
Outline
• Women• Diabetes• Non-Cardiac Surgery• Choice of Stress Imaging Modality
![Page 51: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/51.jpg)
Harvard Medical School
THH10/05
Case 3
A 64 year-old man with history of diabetes is referred to you for evaluation prior to elective repair of an abdominal aortic aneurysm. He feels well and plays golf every weekend without symptoms. He has had no prior cardiac evaluation. What do you recommend?
A. No further testing needed
B. Resting echocardiogram
C. Nuclear imaging with dipyridamole stress
D. Cardiac catheterization
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Harvard Medical School
THH10/05
Peri-Operative Cardiac Complications
• 30 million patients undergo procedures that require general anesthesia each year.
• 10 million either have CAD or have a significant risk of CAD
• 1 million have cardiac complications– $20 billion
Mangano et al, NEJM 1995;333:1750
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Harvard Medical School
THH10/05
Operative Risk of Death or MI
Ashton, C. M. et. al. Ann Intern Med 1993;118:504-510
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Harvard Medical School
THH10/05
Determining Operative Risk
• Rapid determination of those that do not need
testing• Patient
– Clinical risk predictors– Exercise tolerance
• Procedure– Procedural risk
• +/- Testing
Eagle et al, 2002 AHA/ACC Guidelines
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No Testing Needed
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Harvard Medical School
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Patient: Clinical Risk Predictors
Eagle et al, 2002 AHA/ACC Guidelines
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Major Clinical Predictors
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Patient: Clinical Risk Predictors
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Intermediate Clinical Predictors
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Patient: Exercise Tolerance
Eagle et al, 2002 AHA/ACC Guidelines
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Harvard Medical School
THH10/05
Intermediate Risk Predictors
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The Procedure
Eagle et al, 2002 AHA/ACC Guidelines
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Minor Risk Predictors
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Harvard Medical School
THH10/05
Intermediate Risk Predictors
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Risk Stratification with Nuclear Imaging
D ip yrida m o le-T h a lliu m -2 01
C a nce led6 .4 %
E ve n t R a te1 8 % (N = 5 2 3)
N o R e va sc
E ve n t R a te5 .9 % (N = 5 7)
R e va sc
R e vers ib leD e fe c t
E ve n t R a te1 1 % (N = 3 4 7)
F ixe d D e fe ct
E ve n t R a te3 .2 % (N = 4 3 0)
N o rm al
N o R e ve rs ib leD e fe c t
N = 1 ,9 94
Shaw et al. JACC 1996;27:787
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Case 3
A 64 year-old man with history of diabetes is referred to you for evaluation prior to elective repair of an abdominal aortic aneurysm. He feels well and plays golf every weekend without symptoms. He has had no prior cardiac evaluation. What do you recommend?
A. No further testing needed
B. Resting echocardiogram
C. Nuclear imaging with dipyridamole stress
D. Cardiac catheterization
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Harvard Medical School
THH10/05
Case 3
A 64 year-old man with history of diabetes is referred to you for evaluation prior to elective repair of an abdominal aortic aneurysm. He feels well and plays golf every weekend without symptoms. He has had no prior cardiac evaluation. What do you recommend?
A. No further testing needed
B. Resting echocardiogram
C. Nuclear imaging with dipyridamole stress
D. Cardiac catheterization
![Page 68: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/68.jpg)
Harvard Medical School
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Case 3
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Harvard Medical School
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Case 3
He is referred for cardiac catheterization and found to have an 80% middle LAD stenosis. The interventionalist should:
A. Do nothing
B. Refer him for CABG
C. Stent the lesion
D. Perform PTCA
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Reducing Peri-Operative Risk
• Revascularization– CABG
– PTCA
– Stents
• Medical therapy– β-Blockers
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CABG Reduces Mortality
Eagle et al, Circulation. 1997;96:1882-1887
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…Or Does It?
McFalls et al. NEJM 351 (27): 2795
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Harvard Medical School
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… Or Does It?
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Harvard Medical School
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PTCA Reduces Adverse Events…
Posner et al, Anesth Analg 1999;89:553–60
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Harvard Medical School
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PTCA Increases Events Within 30 Days
Posner et al, Anesth Analg 1999;89:553–60
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Stents Increase Mortality
• 40 consecutive patients who underwent surgery within 6 weeks of PCI
• 8 deaths (20%)– Antiplatelet agents held in 7
• 11 episodes of major bleeding (28%)
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Harvard Medical School
THH10/05
β-Blockers Reduce Mortality
Mangano et al, NEJM 1996; 335:1713-1721, N = 192 with CAD or RF
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Harvard Medical School
THH10/05
β-Blockers Reduce Mortality
Poldermans et al. NEJM 341 (24): 1789
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Harvard Medical School
THH10/05
β-Blockers Reduce Mortality
Poldermans et al. NEJM 341 (24): 1789
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Harvard Medical School
THH10/05
Unproven Benefit
• Statins• ACE-inhibitors
• Nitrates• Calcium channel blockers
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Harvard Medical School
THH10/05
Case 3
He is referred for cardiac catheterization and found to have an 80% middle LAD stenosis. The interventionalist should:
A. Do nothing
B. Refer him for CABG
C. Stent the lesion
D. Perform PTCA
![Page 82: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/82.jpg)
Harvard Medical School
THH10/05
Case 3
He is referred for cardiac catheterization and found to have an 80% middle LAD stenosis. The interventionalist should:
A. Do nothing
B. Refer him for CABG
C. Stent the lesion
D. Perform PTCA
![Page 83: Controversies in Myocardial Perfusion Imaging Thomas H. Hauser, MD, MMSc, FACC Director of Nuclear Cardiology Beth Israel Deaconess Medical Center Instructor.](https://reader035.fdocuments.us/reader035/viewer/2022062318/551b5300550346dd1a8b602e/html5/thumbnails/83.jpg)
Harvard Medical School
THH10/05
Non-Cardiac Surgery
• Patients with CAD or CAD risk factors frequently undergo non-cardiac surgery
• Most patients do not need further evaluation prior to their procedure
• Selected patients with risk factors and/or poor exercise tolerance may require risk stratification with nuclear imaging
• CABG and β-blockers reduce peri-operative mortality and morbidity
• PTCA and stents increase peri-operative mortality and morbidity
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Harvard Medical School
THH10/05
Outline
• Women• Diabetes• Non-Cardiac Surgery• Choice of Stress Imaging Modality
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Harvard Medical School
THH10/05
Nuclear Imaging vs. Echocardiography
• The relative test performance between nuclear imaging and echocardiography is unknown– Nuclear imaging probably more sensitive
– Echocardiography probably more specific
• Nuclear imaging is more expensive– Nuclear perfusion at rest and with stress, with gating
• $739
– Echo at rest and with stress, with doppler and color• $358
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Echo is Better
Kuntz, K. M. et. al. Ann Intern Med 1999;130:709-718
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Harvard Medical School
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Is Echo Better
Kuntz, K. M. et. al. Ann Intern Med 1999;130:709-718
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THH10/05
Cost Effectiveness of Nuclear Imaging
Hachamovitch et al. Circulation 2002;105:823
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Prevalence of CAD
Kuntz, K. M. et. al. Ann Intern Med 1999;130:709-718
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Harvard Medical School
THH10/05
Cost Effectiveness of Nuclear Imaging
Hachamovitch et al. Circulation 2002;105:823
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Choice of Stress Imaging Modality
• Nuclear imaging is more expensive than echocardiography
• The increased expense of nuclear imaging is probably justified
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Summary
• Women– CAD is prevalent in women– Nuclear imaging may be preferable for the evaluation of women
for both diagnosis of CAD and determination of prognosis
• Diabetes– Diabetes = high CAD risk– Screening for CAD with nuclear imaging is controversial
• Non-Cardiac Surgery– Nuclear imaging is a valuable tool for risk stratification– β-blockers reduce peri-operative mortality
• Choice of Stress Imaging Modality– No clear answer