digital reactive hyperemia (endo-pat 2000), a novel diagnostic … · 2015. 7. 7. · digital...
TRANSCRIPT
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Digital reactive hyperemia
(Endo-PAT 2000), a novel
diagnostic test for the
assessment of endothelial
function
Sungha Park
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Endothelium as a CVD risk
factors transducerTraditional Risk Factors
Endothelial Dysfunction:
“The Risk of the Risk Factors”
Non-Traditional
Risk Factors
Local Factors
(Shear)
Genetic
Predisposition
Unknown
Factors
Vascular
RemodellingInflammation
Vascular
ContractionThrombosis
Plaque
Rupture
Bonetti et al.
ATVB 2003; 23:168
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Four questions about
endothelial function
• Can we measure it specifically and accurately
• Is it associated with CVD risk factors
• Is it associated with CVD
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Quantitative coronary angiography
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Venous Occlusion Plethysmography
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Brachial Flow Mediated Dilation
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Endo PAT system overview
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Peripheral arterial tone
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Endo PAT probe
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Pressure-Volume Compliance Curve
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Example of finger PWA recording
Kuvin JT et al. Am Heart J 2003;146:168-174
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Examination Protocol
• Study performed in a thermoneutral environment
• Overnight fasting
• Refrain from smoking, alcohol and caffeine on the
day of the examination
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PAT reactive hyperemia protocol
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Endo PAT demonstration
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PAT ratio
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Correcting for baseline diameterPAT Response Vs. Baseline Amplitude
N=310
10 point
average
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Systemic correction
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PAT measurement
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Results
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Endo-PAT 2000 Advantages
• Non-invasive
• Easy to use, non user-dependent
• Automatic analysis
• Supports both clinical and research applications
• Reliable and reproducible
• FDA cleared and CE marked & CSA certified
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Advantages of Endo-PAT2000 Vs. FMD
• Controls for systemic effects
• Normalizes for baseline amplitude
• Non user-dependent – technician operated &
automated analysis
• Data archiving supports research applications
• Occlusion quality assessment
• Better reproducibility
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CASE 1
M/ 53
HTN (+), DM (-), Smoking (-)
Endo-PAT index 2.364
FMD % Diameter-RH 7.3
% Diameter-NTG 12.2
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CASE 1 FMD
Baseline
Reactive hyperemia NTG
0.410 cm
0.440 cm : 7.3 % ↑ 0.460 cm : 12.2 % ↑
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CASE 1 Endo-PAT
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CASE 2
M/ 44
HTN (+), DM (-), Smoking (+)
Endo-PAT index 2.00
FMD % Diameter-RH 4.1
% Diameter-NTG 4.1
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CASE 2 FMD
Baseline
Reactive hyperemia NTG
0.393 cm
0.409 cm : 4.1 % ↑ 0.409 cm : 4.1 % ↑
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CASE 2 Endo-PAT
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Role of NO in Reactive Hyperemia
• Performed by Prof. Gerhard-Herman et al.,
Harvard Med School
• A prospective study of Reactive Hyperemia
mechanism
• 21 normal patients before and after L-NAME
(eNOS inhibitor)
• 20 control patients before and after saline
• PAT was used to measure endothelial response
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Harvard Study - Results
•Average reduction in response to L-NAME =61%
The Effect of Nitric Oxide Inhibition on PWA Following Release of Occlusion
0
20
40
60
80
100
120
140
160
180
1 2 3 4 5
Contro l
L -NAM EIncrease in Pulse-Wave Amplitude (%)
Case examples
Gerhard-Herman M et al. Circulation 2002;102:Suppl II:851
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PAT Vs. FMD
Courtesy of Dr. Kuvin,
New-England Medical
Center
N=89
Kuvin JT et al. Am Heart J 2003;146:168-174
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PAT Vs. FMD
p
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Four questions about
endothelial function
• Can we measure it specifically and accurately
• Is it associated with CVD risk factors
• Is it associated with CVD
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PAT hyperemia and CV risk factors
Kuvin JT et al. Am Heart J 2003;146:168-174
Number of cardiac risk factors
0 3 6
R=0.3, P=0.02
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CHD risk vs. Endo-PAT index
0.0
1.0
2.0
3.0
4.0
5.0
1.01.52.02.53.03.5
0.0
1.0
2.0
3.0
4.0
5.0
0.20.40.60.81.01.2
Endo-PAT index Log Endo-PAT index
Relative risk
R = 0.375 , P = 0.003 R = 0.361 , P = 0.004
YUMC data 2005
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Four questions about endothelial function
• Can we measure it specifically and accurately
• Is it associated with CVD risk factors
• Is it associated with CVD
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PAT Hyperemic Response – Mayo StudyCompared to Coronary Response to Acetylcholine
Abnormal
Endothelial
Function
Baseline Acetylcholine
Normal
Endothelial
Function
Bonetti PO et al. J Am Coll Cardiol 2004;44:2137-2141
PAT
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PAT Hyperemic Response Compared to Coronary Response to Acetylcholine
(Abnormal if CBF
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PAT hyperemia and CAD
P=0.004
n=35 n=33
(Exercise Myocardial
Perfusion Imaging)
Kuvin JT et al. Am Heart J 2003;146:168-174
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Conclusion
• Reactive hyperemia PWA is a novel method to
measure endothelial function
• It is easy to use and relatively objective
• The gold standard is still FMD: More clinical
experience is needed with regards to clinical
studies