Imaging Ischemic Heart Disease

Role of Echocardiography

Danilo NegliaFTGM, Pisa, Italy

Chair NC&CCT SectionVice-President EACVI

Thanks to:Eugenio Picano, Rosa Sicari and Emilio PasanisiIFC CNR and FTGM, Pisa, Italy

Fausto Rigo Mestre-Venezia Hospital, Italy

The Full Spectrum of IHDIHD Mortality Rate in 21 World Regions (2010)

males

females

Moran AE, Circulation 2014

Aging of the Population Projected Costs of IHD by Age

65-79

> 80

The Full Spectrum of IHDNeed to Improve Outcome and Reduce Costs

Laslett LJ, JACC 2012

Danilo Neglia

Cardiovascular ImagingNeed for “WISE and PERSONALIZED” use in clinical practice

Increase in use: 70%  (in 2000‐2007)Patients:  10 million /yearCosts: $ 80 billion /year

Shaw LJ…and Douglas PS, JACC Cardiovascular Imaging 2010

ACS

Stable IHD

Speaker

SuspectedACS

STEMI

ST/T wavechanges

Normalundiagnostic

ICAPCI

2D-ECHO for DD(Pulm. Embol./AorticDiss./Pericardial Eff.)

Hs-Tn > 99°percentile

Hs-Tn <= 99°percentile

ECG hs-Tn Testing (0-3 hours) Clinical/ECG

On-GoingChest Pain

No On-GoingChest Pain

< 20% increaseStable

< 50% increse

Cardiac Imaging/Invasive

SIGNIFICANTHigh ValuesOr Increase

2D-ECHO (Resting WM) (in-patient testing)

2D-ECHO (Resting WM) StressECHO (Stress WM)(in-or-outpatient testing)

Modified from Garg P et al. , Nature Reviews 2016

Acute Coronary SyndromesRole of Echocardiography in Suspected ACS

Garg P et al. , Nature Reviews 2016

Acute Coronary SyndromesRole of Echocardiography in Suspected ACS

Speaker

Acute Coronary SyndromesRole of Echocardiography in Suspected ACS

Speaker

Acute Coronary SyndromesRole of Echocardiography in Suspected ACS

Take Home Messages

2D-ECHO can complement history, ECG, and cardiac biomarkers for timely identification or ruling out of acute coronary syndrome (ACS). It is the first-line imaging test in patients with suspected ACS

ADVANTAGESBedside, widely available, low cost, RCT supported, Strain technique and Contrast ECHO might improve accuracy and prognostic information

Stress ECHO adds diagnostic and prognostic value in patients with suspected ACS (with inconclusive ECG, clinical and biomarkers findings). Exercise ECHO is superior to EET (and similar to exercise MPS) in risk stratification

LIMITATIONSPoor acustic window, contraindications to pharmacological stress, available only in centers with expertise in stress ECHO.

Redrawn from Gould et al Am J Cardiol 1974

2

4

6

EXERCISE Myocardial Oxygen Consumption

Myocardial B

lood

 Flow

Detection of CAD‐IHDImaging

Coronary

Atherosclerosis

Medical TreatmentATS

Obstructive

CAD

Medical TreatmentRevascularization

CAD

Endothelial/Microvascular

Dysfunction

Medical TreatmentRisk Factors

Myocardial

Damage/Dysfunction

Medical TreatmentDevices

Heart Failure

Scar

Stable Ischemic Heart DiseaseRole of Non-Invasive Imaging

Myocardial

Ischemia

Medical TreatmentIschemia

Diagnosis >> Treatment >> Outcome

Endothelial/Microvascular

Dysfunction

ECHO Stress >> CFR

Myocardial

Damage/Dysfunction

ECHO Stress >> Viability

Myocardial

Ischemia

ECHO Stress >> Ischemia

Diagnosis >> Treatment >> Outcome

Stable Ischemic Heart DiseaseRole of Echocardiography

Male 65 yrs – Recent onset Typical AnginaHypercholesterolemia, Hypertension

Is Ischemic Heart Disease causing his SYMPTOMS?

Which is his LIFE RISK?

Which TREATMENT does he require to improve

SYMPTOMS and reduce RISKS?

Which are the MECHANISMS?

Pre-Test Probability of CAD D&F (Genders)

2013 ESC guidelines on the managementof stable coronary artery disease

Stress Echo Lab (Exercise)

2D Echo    

Blood pressure

12‐lead ECG

1 ECG lead(echomonitor)

time (min)0 108642

2550

75 100 125

Watt

Stress Echo (Exercise)

Exercise Stress EchoPositive WM (3 segments)

rest peak

2013 ESC guidelines on the managementof stable coronary artery disease

Hachamovitch R, et al. Circulation. 2003

Revascularization reduces mortality only in the presence of  large  perfusion defects

Non Invasive detection of HIGH RISK CAD Efficacy of Revascularization

2013 ESC guidelines on the managementof stable coronary artery disease

DEFINE RISK

Speaker

Exercise Stress EchoAdditional Prognostic Value over ECG

Marwick TH et al. Circulation 2001

Prospective, multicenter (2 US Centers), observational Study 5375 consecutive patients

Exercise ECG and Echocardiography

Male 65 yrs – Recent onset Typical AnginaHypercholesterolemia, Hypertension

Is Ischemic Heart Disease causing his SYMPTOMS?

Which is his LIFE RISK?

Which TREATMENT does he require to improve

SYMPTOMS and reduce RISKS?

Which are the MECHANISMS?

Yes

Obstructive CAD

High

Revascularization

Female 55 yrs – Atypical AnginaHypertension, Post-traumatic Hip Prothesis

Is Ischemic Heart Disease causing her SYMPTOMS?

Which is her LIFE RISK?

Which TREATMENT does she require to improve

SYMPTOMS and reduce RISKS?

Which are the MECHANISMS?

Pre-Test Probability of CAD D&F (Genders)

2013 ESC guidelines on the managementof stable coronary artery disease

Stress Echo Lab (Pharmacological)

0 6 10 min

DIP 0.84 mg/kg in 6’

TIMELINE

1 lead ECG

12 lead ECG

BP recording

Drugs infusion AMINO 120 mg in 1’ (up to 240 mg in 2’)

CFR‐PW

2D echo

Continuous monitoringand Pulsed recording

Continuous monitoringand Pulsed recording

on the echo‐monitor

Stress Echo (Dipyridamole)

Modified apical 3-chambers

TTE Doppler of mid-distal LAD

rest

hyperemia

CFR= peak vel/rest vel, normal>2

CFR by TTE Doppler

Dipyridamole Stress EchoNegative WM - Abnormal CFR

CFR = 80 / 70 = 1.2

rest peak

CFR > 2

Normal finding

Obstructive CAD ??

CFR <= 2

MicrovascularDisease ??

CFR <= 2

Dipyridamole Stress EchoNegative WM - Abnormal CFR

2013 ESC guidelines on the managementof stable coronary artery disease

Speaker

Prospective, multicenter, observational study

4,313 patientsknown CAD (n 1,547)

suspected CAD (n � 2,766)

High-dose Dip Stress ECHO CFR evaluation of LAD by Doppler

CFR on LAD is a strong and independent

indicator of mortality, over wall motion analysis, in patients with

known or suspected CAD. A negative result confers an annual risk of death <1% in

both patient groups.

(J Am Coll Cardiol Img 2012;5:1079–85)

Dipyridamole Stress EchoAbnormal CFR >> Additional Prognostic Value over WM

Speaker

Dipyridamole Stress EchoAbnormal CFR >> Additional Prognostic Value over WM

Cortigiani L et al. J Am Coll Cardiol Img 2012;5:1079–85

Female 55 yrs – Atypical AnginaHypertension, Post-traumatic Hip Prothesis

Is Ischemic Heart Disease causing her SYMPTOMS?

Which is her LIFE RISK?

Which TREATMENT does she require to improve

SYMPTOMS and reduce RISKS?

Which are the MECHANISMS?

Yes

Microvascular Coronary Disease

Intermediate

Medical

Dorbala S and Shaw LJ, J Nucl Cardiol 2016

2D Echo

Blood pressure

12‐lead ECG

1 ECG lead(echomonitor)

time (min)0 20156        9 10    123  5

510

2030

Dose 

5

1020

3040

ischemia

viability

Stress Echo (Dobutamine)

Speaker

Pharmacological Stress Echo IschemiaAdditional Prognostic Value over Clinical an Functional Variables

Sicari R et al. JACC 2003

Speaker

Dobutamine Stress EchoViability

Speaker

Pharmacological Stress Echo ViabilityAdditional Prognostic Value over Clinical an Functional Variables

Sicari R et al. Am J Cardiol 2003

Speaker

2013 ESC guidelines on the managementof stable coronary artery disease

Speaker

Comparative DIAGNOSTIC performance

Comparative impact on OUTCOME

Comparative COST-EFFECTIVENESS

OPEN ISSUES in STABLE IHDECHO and Non-Invasive Imaging

Taquety VR and Di Carli MFProgress in CV Diseases, 2015

The “Ischemic” CascadeEchocardiography

Sentitivity Specificity

Performance of Diagnostic Tests in TrialsRetrospective or Prospective studies comparing 1 or 2 modalities Patients with ~50% prevalence of disease (>50% stenosis at ICA)

CFc

Coordinator

PET, ICA

ECHO

CTASPECT

ECHO, MRI

PET

EVINCI ConsortiumEU FPVII (HEALTH  2009‐2012) Grant 2.695 KEuro

ESC

65%49 %

29%15%

0

20

40

60

80

D&F  Probability

Genders         Probability

Prevalence         Significant  

CAD

Prevalence       High Risk     CAD

Revascularized20%

Performance of Diagnostic Tests in EVINCI Prospective study comparing all IMAGING modalities Patients with LOW prevalence of disease (>70% stenosis or FFR < 0.8 at ICA)

Neglia D et al., Circulation CVI 2015

0

10

20

30

40

50

60

70

80

90

100

CCTA PET SPECT MRI ECHO

Sensitivity (%)

Specificity (%)

Neglia D et al., Circulation CVI 2015

Performance of Diagnostic Tests in EVINCI Prospective studies comparing all IMAGING modalities Patients with LOW prevalence of disease (>70% stenosis or FFR < 0.8 at ICA)

0

20

40

60

80

100

120

SensSpec

Taquety VR and Di Carli MFProgress in CV Diseases, 2015

0

20

40

60

80

100

120

CCTA SPECT PET Hybrid ECHO CMRwm

SensSpec

Neglia D et al. EVINCI Trial Circulation CVI 2015Liga R et al. EHJ CVI 2016

Metanalyses

EVINCI Trial

Performance of Diagnostic Tests in EVINCI Comparison with recent Metanalyses

Frequent suboptimal imaging protocol: Sub-maximal stresswas reported in 41% of Echo examinations and 23% ofpatients remained on medical therapy

Lack of quantitative measurements: MBF by PET, perfusionby CMR and CFR by TTE-Doppler were not included in the mainanalysis

Population: low prevalence of High Risk CAD

Primary End-Point: did not include criteria for High Risk CAD

EVINCI Study: ECHO Limitations

Neglia D et al., Circulation CVI 2015

The 5 years EVINCI Follow-up will be presented at AHA 2016!

Patients withLow‐IntermediateProbability of CAD

CTCA Stress Imaging  ICA PCI/CABG

OMT 

OMT 

+ +

-

OMT 

-

+

OMT 

-

EVINCI Study: Health-Economic Analysis

The EVINCI H-E Analysis will be presented at AHA 2016!

Exciting advances are occurring faster thanevidence can accumulate and are increasing health care

costs.

A joint effort by all stakeholders, including cardiologists,radiologists, nuclear imaging scientists, professional societies,

policy makers, and industry partners, is required.

The evidence base must be improved in order to evaluate thecomparative cost effectiveness of imaging-based decisionmaking on outcomes, quality of life, cost-effectiveness, and

downstream resource utilization. Shaw LJ, JACC 2010

The Integration of Cardiovascular ImagingNeed for “Discussing” and “Promoting” New Research

Danilo Neglia

Danilo Neglia

The EACVI Team Thanks

Teaching Courses 2016

Nuclear Cardiology in Practice 2016• European Heart House, Nice

November 17-19

Teaching Course Cardiac CT• EuroECHO Congress, Liepzig

December 7

eduCAD WEB & LIVE• www.educad.org• Ekaterinburg – September 23• Pisa – November 21• Minsk – December

Danilo Neglia

EuroEcho-Imaging 20167-10 December 2016 Leipzig,

GERMANY

7-9 May 2017, Vienna AUSTRIA

Call for abstracts & clinical cases15 Sept – 21 Nov 2016

Early registration fee deadline 27 February 2017

ICNC 2017

Speaker

The Integration of Cardiovascular ImagingNeed for a “Integrating Competence” in Cardiac Imaging

Danilo Neglia

Lancellotti P, EHJ 2015

www.educad.org • EVINCI study consortium• ESC‐EACVI• GE healthcare

New Contract EACVI‐GEHC:Health‐Economics, TranslationsOne new case per monthE‐Learning (CME)

Educational tool focused on the appropriateness of  the diagnostic pathway

32000 visits930 users training on eduCAD clinical cases

54%  from European countries27% .com15% .net4% not EuropeanC

EVINCI Study:WEB eduCAD 2016-2017

0

20

40

60

80

100

CTCA‐PET CTCA‐SPECT CTCA‐CMR CTCA‐ECHO

ICA Avoided (TN)

Diagnosis Done (TP)

Diagnosis Lost (FN)

ICA Unuseful (FP)

Number of Patients (over 100 with suspected CAD)

EVINCI Study: Integrated Imaging Strategies

Neglia D et al., Circulation CVI 2015