ct or pet/ct for coronary artery disease from knuuti - november
TRANSCRIPT
Juhani Knuuti, MD, PhD, FESC
Turku PET Centre
CT or PET/CT for coronary artery disease
Rotterdam 2012
University of Turku • Åbo Akademi University • Turku University HospitalTurku PET Centre
Turku PET Centre
University of Turku
Turku, Finland
Disclosure: Juhani Knuuti, M.D.
Juhani Knuuti, M.D. has financial interests to disclose. Potential conflicts of interest have been resolved.
Research Support / Grants None
University of Turku • Åbo Akademi University • Turku University HospitalTurku PET Centre 2
Research Support / Grants NoneStock/Equity (any amount) NoneConsulting LantheusEmployment NoneSpeakers Bureau / Honoraria Philips
Research contracts (institutional): Orion Pharma, Turku Imanet Ltd, GE Healthcare, GSK, Merck, Bayer-Schering, Novartis, Lundbeck, Roche; Lantheus
Imaging and CADCurrent main trends
� From ischemic cascade to CAD cascade� From diagnosis of CAD to guidance of
University of Turku • Åbo Akademi University • Turku University HospitalTurku PET Centre
� From diagnosis of CAD to guidance of therapy
� Novel imaging applications• Quantification• Imaging of vulnerable plaque
hypoperfusion
diastolic dysfunction
Myo
card
ial p
erfu
sion
Myo
card
ial p
erfu
sion metabolic alterations
Paradigm shift 1: From ischemic to CAD cascade
Preclinical atherosclerosis
Non-obstructive CAD
University of Turku • Åbo Akademi University • Turku University HospitalTurku PET Centre
diastolic dysfunction
systolic dysfunction
ECG-Changes
angina
Signs of ischaemiaSigns of ischaemia
Myo
card
ial p
erfu
sion
Myo
card
ial p
erfu
sion
Multislice CT vs. Myocardial Perfusion Multislice CT vs. Myocardial Perfusion Regional comparison in 140 patients
Data from Schuijf et al. 2006, Di Carli et al. 2006, Hacker et al. 2005, and Rispler et al. 2006
MDCT findings in patients with normal SPECT perfusion imaging result
University of Turku • Åbo Akademi University • Turku University HospitalTurku PET Centre
Werkhoven JM, et al Am J Cardiol. 2008 Jan 1;101(1):40-5.
CT angiography
LAD LCXRCA
Curved MPR reconstructions of the major coronary vessels
Case LP
>50%
>50%
30-40%
CT Acquisition:
• Premedication: Metoprolol 10 mg i.v. HR 46/min
• Acquisition: Prospective step-and-shoot protocol, mA 650, 120 kV
• Contrast: Iomeron 400mg/ml 68 ml
• Radiation dose 7.4 mSV
Case:LP
PET perfusion imaging during stress Displayed as fused volume rendered images scaled to absolute scale 0-3.5 ml/g/minNormal perfusion: above 2.5 ml/g/min: yellow or red
3.5 ml/g/min
Case:LP
PET Acquisition:
• Injected Dose: 1100 MBq O-15-water
• Stress: Adenosine 140 µg/min/kg for 6.5 min
• Acquisition time: dynamic 4.5 min
• Radiation dose 0.9 mSV
0.0 ml/g/min
Invasive angiography + FFR
FFR: 0.86 (normal)
FFR: 0.92 (normal)
Right Left
Case LP
48%
46%
60%
FFR: ?
FFR = Fractional flow reserve – invasive measurement of the stenosis functional gradient
during adenosine infusion
Case:LP
Prognostic Value of Myocardial Perfusion SPECT
7,4
6
8
10
P < 0.001
n = 12 000 pts
0,6
0
2
4
6
Iskander S et al. JACC 1998;32:57
normal abnormal
Additional prognostic value of CT and perfusion imaging
Van Verkhoven et al J Am Coll Cardiol 2009;53: 623–32
N=541
Imaging and CADCurrent main trends
� From ischemic cascade to CAD cascade� From diagnosis of CAD to guidance of
University of Turku • Åbo Akademi University • Turku University HospitalTurku PET Centre
� From diagnosis of CAD to guidance of therapy
� Novel imaging applications• Quantification• Imaging of vulnerable plaque
Paradigm shift 2: From diagnosis to guidance of therapy
Anatomy
(Obstructive CAD)
Flow-Limiting
(Perfusion, FFR)
Optimal Medical Treatment
University of Turku • Åbo Akademi University • Turku University HospitalTurku PET Centre
Optimal Medical Treatment
Complete Functional Revascularization and optimal medical treatment
DEFER JACC 2007;49:2105FAME NEJM 2009;360:213FAME JACC 2010;56:177
Hachamovitch Circulation 2003;107:2900 COURAGE NEJM 2007;356:1503COURAGE Circulation 2008;117:1283
Noninvasive function: Perfusion, WMA Invasive function: FFR
Functional consequences of stenoses
LAD
D1
Turku PET Centre, Finland
D1
LAD
D1
Invasive Anatomy vs. Functional Consequences
deri
ved
FF
R
0.6
0.8
1.0
Angiographic Diameter Stenosis (%)
Pre
ssu
re-d
eri
ved
FF
R
0 20 40 60 80 100
0.0
0.2
0.4
N = 2334
Wijns, de Bruyne, Vanhoenacker, JNC 2007;93:856-61
Tonino et al. FAME
CT angiography
LAD LCXRCA
Curved MPR reconstructions of the major coronary vessels
Case LP
>50%
>50%
30-40%
CT Acquisition:
• Premedication: Metoprolol 10 mg i.v. HR 46/min
• Acquisition: Prospective step-and-shoot protocol, mA 650, 120 kV
• Contrast: Iomeron 400mg/ml 68 ml
• Radiation dose 7.4 mSV
Case:LP
PET perfusion imaging during stress Displayed as fused volume rendered images scaled to absolute scale 0-3.5 ml/g/minNormal perfusion: above 2.5 ml/g/min: yellow or red
3.5 ml/g/min
Case:LP
PET Acquisition:
• Injected Dose: 1100 MBq O-15-water
• Stress: Adenosine 140 µg/min/kg for 6.5 min
• Acquisition time: dynamic 4.5 min
• Radiation dose 0.9 mSV
0.0 ml/g/min
LAD RCA C E
Multivessel disease: What is the culprit lesion?
FFR=0.54
FFR=0.94
University of Turku • Åbo Akademi University • Turku University HospitalTurku PET Centre
D1
3.5
ml/g/min0
D F
FFR=0.63
Multivessel disease: What is the culprit lesion?
RCA LCX LAD
Case: stenoses in all major vessels; RCA is culprit
University of Turku • Åbo Akademi University • Turku University HospitalTurku PET Centre
Microvascular diseaseAbsolute perfusion decreased but no epicardial disease
Relative perfusion Absolute perfusion
University of Turku • Åbo Akademi University • Turku University HospitalTurku PET Centre
Hybrid noninvasive (PET/CT) vs. Hybrid invasive (ICA + FFR)
Sensitivity (%)Specificity (%)PPV (%) NPV (%) Accuracy (%)MDCT 75 95 76 94 91PET 94 93 77 98 93MDCT-PET hybrid 95 99 96 99 98
Figure 3: Vessel Analysis against ICA +FFR
50
60
70
80
90
100
pe
rce
nta
ge
MDCT
PET
Vessel analysis in patients with intermediate likelihood of CAD, N=107
University of Turku • Åbo Akademi University • Turku University HospitalTurku PET Centre
Kajander et al Circulation 2010
0
10
20
30
40
50
pe
rce
nta
ge
PET
MDCT-PET hybrid
MDCT 76 94 91
PET 77 98 93
MDCT-PET hybrid 96 99 98
PPV (%) NPV (%) Accuracy (%)
Challenges and solutions of perfusion imaging
Challenge Solution� LM disease ?� Balanced 3 vessel disease ?
University of Turku • Åbo Akademi University • Turku University HospitalTurku PET Centre
� Multivessel disease ?� Anatomical location ?� Non-ischemic CAD ?� Microvascular disease ?
Challenges and solutions of ischemia imaging
Challenge Solution� LM disease Hybrid
� Balanced 3 vessel disease
University of Turku • Åbo Akademi University • Turku University HospitalTurku PET Centre
� Multivessel disease� Anatomical location Hybrid
� Non-ischemic CAD Hybrid
� Microvascular disease /Hybrid
Impact of hybrid imaging on downstream resource utilizationImpact of hybrid imaging on downstream resource utilization
Revascu
lari
sati
on
s
86%100%
80%
60%
p<0.001
45%
96%
University of Turku • Åbo Akademi University • Turku University HospitalTurku PET Centre
Revascu
lari
sati
on
s
CAD yieldPer CATH
CATHrate
40%
20%
0%
REVASCPer CATH
45%
NEJM 2010
USA
N=400‘000
39%
GER
N=840‘000
36%
Eur Heart J 2011 Jul 30.
Imaging and CADCurrent main trends
� From ischemic cascade to CAD cascade� From diagnosis of CAD to guidance of
University of Turku • Åbo Akademi University • Turku University HospitalTurku PET Centre
� From diagnosis of CAD to guidance of therapy
� Novel imaging applications• Quantification• Imaging of vulnerable plaque
Challenges and solutions of CAD/ishchemia imaging
Challenge Solution� LM disease Hybrid� Balanced 3 vessel disease Quantification
University of Turku • Åbo Akademi University • Turku University HospitalTurku PET Centre
� Multivessel disease Quantification
� Anatomical location Hybrid� Non-ischemic CAD Hybrid� Microvascular disease Quantification/
Hybrid
Quantification of myocardial perfusion
Which patients will benefit?� Balanced 3 vessel or multivessel
disease
University of Turku • Åbo Akademi University • Turku University HospitalTurku PET Centre
disease� Culprit lesion vs. non-culprit lesion in
multi vessel disease� Early changes in coronary dysfunction
Absolute flow vs Relative flow
University of Turku • Åbo Akademi University • Turku University HospitalTurku PET Centre
Kajander et al Circ Cardiovasc Imaging. 2011
Absolute flow is as good as flow reserve!
University of Turku • Åbo Akademi University • Turku University Hospital
Joutsiniemi et al (Circ Imaging)
Imaging and CADCurrent main trends
� From ischemic cascade to CAD cascade� From diagnosis of CAD to guidance of
University of Turku • Åbo Akademi University • Turku University HospitalTurku PET Centre
� From diagnosis of CAD to guidance of therapy
� Novel imaging applications• Quantification• Imaging of vulnerable plaque
�
Motoyama J Am Coll Cardiol 2009
MDCT Characterization of Coronary Plaques
Motoyama J Am Coll Cardiol 2009
LAD
Left main
LAD
LCX
Plaque characterization using CT vs. Myocardial Perfusion SPECT
Van Verkhoven et al J Am Coll Cardiol 2009;53: 623–32 N=541
MDCT Characterization of Coronary Plaques -
Prognosis
Large low attenuation plaque areaPositive remodelingSpotty calcification
Motoyama J Am Coll Cardiol 200915 ACS in 1059 patients
Dual gated 18F-FDG PET/CT of coronary arteries in
ACS patients
CTA CTA-PET Fusion
Acute LAD plaque rupture
Myocardial FDG uptake supressed by low carbohydrate, high fat diet
Turku PET Centre, FinlandLankinen at al ICNC 2011
Dual gated Dual gated 1818FF--FDG PET/CT of coronary arteries in ACS patientsFDG PET/CT of coronary arteries in ACS patients
• 39 year old man
• Risk factors of CAD:
• Smoking
• Family history +
• 5 days of UAP
• ECG: lateral T-inversion• ECG: lateral T-inversion
• TNT +
• LCX subtotal occlusion stented
TBR ratio 4.2
Turku PET Centre, FinlandLankinen EHJ 2011 (abstract)
Turku PET Centre, Finland
Dual gated Dual gated 1818FF--FDG PET/CT of coronary arteries in ACS patientsFDG PET/CT of coronary arteries in ACS patients
• 20 ACS (non-STEMI or UAP) patients
• Dual-gated 18F FDG PET/CT (3d after onset of symptoms)
• High-fat diet intervention to suppress myocardial uptake (Williams AJR 2008)
• Visual coronary FDG uptake in 80% of patients (3 prior to intervention)
• TBR 3.2±1.3 (range 1.8-5.4)
Turku PET Centre, Finland
Lankinen EHJ 2011 (abstract)
Turku PET Centre, Finland
• Complicated for patients (sequential)• Logistic challenges (hybrid)• Higher work load
Concerns on sequential / hybrid Concerns on sequential / hybrid imaging for CAD imaging for CAD
• Higher work load• Non-standardized image analysis• Radiation burden• Lacking evidence and indications• Costs and cost-effectivenes
Comparison of risks for fatal event
1000
140119200
400
600
800
1000T
he r
isk p
er
10 0
00
140119
16 9 2 0,5 15 1 1 12 5 6 1 230
200
Risk o
f fata
l car
diac e
vent
(10-
year
s)
Aspirin
, life
time
risk o
f fat
al ble
eding
Mot
or ve
hicle
accid
ent
Pedes
trian
acc
ident
Drownin
gBicy
cling
Calcium
scor
e
CT an
giogr
aphy
Dobut
amine
stre
ss e
choc
ardio
grap
hy (C
E)
Dobut
amine
stre
ss C
MR
Adeno
sine
cont
rast
enha
nced
CM
R
Exerc
ise S
PECT perfu
sion
imag
ing
Dipyrid
amole
SPECT pe
rfusio
n im
aging
Adeno
sine
PET per
fusio
n im
aging
Inva
sive
angio
grap
hySince upper limit of lifetime risk of any imaging test was 23 per 10 000only 2.3% of the events need to be prevented to completely cancel the risk of imaging.