the use of cardiac ct and mri in clinical practice
DESCRIPTION
The use of Cardiac CT and MRI in Clinical Practice. Matthew W. Martinez, MD Assistant Professor of Medicine LVPG - Lehigh Valley Heart Specialists Lehigh Valley Health Network Oct. 3, 2009. DISCLOSURE. Relevant Financial Relationship(s) None Off Label Usage None. Learning Objectives. - PowerPoint PPT PresentationTRANSCRIPT
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The use of Cardiac The use of Cardiac CT and MRI in CT and MRI in
Clinical PracticeClinical PracticeMatthew W. Martinez, MDMatthew W. Martinez, MD
Assistant Professor of MedicineAssistant Professor of Medicine
LVPG - Lehigh Valley Heart LVPG - Lehigh Valley Heart SpecialistsSpecialists
Lehigh Valley Health NetworkLehigh Valley Health Network
Oct. 3, 2009Oct. 3, 2009
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DISCLOSUREDISCLOSURERelevant Financial Relationship(s)Relevant Financial Relationship(s)
NoneNone
Off Label UsageOff Label UsageNoneNone
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Learning ObjectivesLearning Objectives
Review basics of cardiac MRI and Review basics of cardiac MRI and CTACTA
Review utility of cardiac CT and MRI Review utility of cardiac CT and MRI in clinical practicein clinical practice
Clinical casesClinical cases
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EchoEchoSPECTSPECT
PETPET MRIMRI
NoninvasiveNoninvasive Tests for the Tests for the Diagnosis of Coronary Diagnosis of Coronary
Artery DiseaseArtery DiseaseTMETTMET
CTCT
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Cardiac MRICardiac MRI
Black-Blood (Spin-Echo) White-Blood
SSFP
Still Images
Morphology
Edema
Cine Imaging
Morphology and function
Delayed Enhancement
Still Images
Delayed Enhancement
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SSFP = 2D echo = 2D echo
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Delayed Enhancement-Delayed Enhancement-MRIMRI Images obtained 10-15 Images obtained 10-15
minutes post-contrast minutes post-contrast (Gd)(Gd)
Normal myocardium – Normal myocardium – Black *Black *
Necrosis/scarring/Necrosis/scarring/inflammation – inflammation – Hyperenhanced Hyperenhanced
Image in Press – Nature of Clinical Practice
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Infarct size by MRI Infarct size by MRI Delayed EnhancementDelayed Enhancement
Abundance of Abundance of validation data in validation data in animal modelsanimal models
Dog with near-Dog with near-transmural infarcttransmural infarct
Visible on SPECT and Visible on SPECT and DE-MRIDE-MRI
3 dogs with 3 dogs with subendocardial subendocardial infarctsinfarcts
Visible on DE-MRI onlyVisible on DE-MRI only
CP1302151-4
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Hyperenhancement PatternsHyperenhancement Patterns
Subendocardial infarctSubendocardial infarct
Transmural infarctTransmural infarct
IschemicIschemic
Mid-wall HEMid-wall HE
Epicardial HEEpicardial HE
NonischemicNonischemic
• Idiopathic dilated cardiomyopathy
• Myocarditis
• Idiopathic dilated cardiomyopathy
• Myocarditis
• Hypertrophiccardiomyopathy
• Right ventricularpressure overload
• Hypertrophiccardiomyopathy
• Right ventricularpressure overload
• Sarcoidosis
• Myocarditis
• Anderson–Fabry disease
• Sarcoidosis
• Myocarditis
• Anderson–Fabry disease
Shah DJ et al: Magnetic resonance of myocardial viabilityShah DJ et al: Magnetic resonance of myocardial viability
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Mass RV Function
Cardiomyopathies
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Cardiac MRICardiac MRI
LVEFLVEF LV massLV mass Wall MotionWall Motion LV ESVLV ESV LV EDVLV EDV LV stroke LV stroke
volumevolume
RV ESVRV ESV RV EDVRV EDV RV Stroke RV Stroke
volumevolume RVEFRVEF
FunctionalFunctional AnalysisAnalysis
Infarct Infarct identificationidentification
Infarct sizeInfarct size ViabilityViability
Tissue Tissue characterizationcharacterization
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CP1210291-8
ImagingImaging
Evaluation of Chest PainEvaluation of Chest Pain
Unstable Hemodynamics and Complications
Unstable Hemodynamics and Complications
PrognosisViability
PrognosisViability
FunctionInfarct sizeFunction
Infarct sizeACS
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Cardiac MRICardiac MRI
LVEFLVEF LV massLV mass Wall MotionWall Motion LV ESVLV ESV LV EDVLV EDV LV stroke LV stroke
volumevolume
RV ESVRV ESV RV EDVRV EDV RV Stroke RV Stroke
volumevolume RVEFRVEF
FunctionalFunctional AnalysisAnalysis
Infarct Infarct identificationidentification
Infarct sizeInfarct size ViabilityViability PrognosisPrognosis
Tissue Tissue characterizationcharacterization
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Case 1Case 157-year-old woman57-year-old woman
Sudden onset of Sudden onset of achy, continuous, achy, continuous, substernal, 8/10 substernal, 8/10 chest painchest pain
Radiating to backRadiating to back Pain came on at Pain came on at
restrest
Cardiac Risk Cardiac Risk FactorsFactors
Never SmokerNever Smoker Hyperlipidemia Hyperlipidemia
(untreated)(untreated) Sedentery LifestyleSedentery Lifestyle
Troponin – 0.56, 0.5 (3h), 0.36 (6h)
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EchocardiogramEchocardiogram
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Cardiac CatheterizationCardiac Catheterization
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Cardiac CatheterizationCardiac Catheterization
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Cardiac MRICardiac MRI
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Cardiac MRICardiac MRI
Acute MI
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Importance of Importance of unrecognized Myocardial unrecognized Myocardial
scarscar Aim: Assess the prognostic Aim: Assess the prognostic
significance of unrecognized significance of unrecognized myocardial scar by MRI in patients myocardial scar by MRI in patients without a history of MIwithout a history of MI
195 patients without known prior 195 patients without known prior MIMI
1) Pts with unknown status of CAD 1) Pts with unknown status of CAD referred for assessment of LV fxn, referred for assessment of LV fxn, scarscar
2) Pts with angiographic CAD 2) Pts with angiographic CAD referred for prediction of referred for prediction of segmental wall motion after segmental wall motion after revascularization (22)revascularization (22)
16 month follow-up16 month follow-upCirculation,
2006
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Case Presentation 2Case Presentation 2 History of Present IllnessHistory of Present Illness
46 year old man presents to ED, 6:30 AM with 46 year old man presents to ED, 6:30 AM with 10/10 chest pain10/10 chest pain Began 4:30 AM - Radiated to left armBegan 4:30 AM - Radiated to left arm No SOB, no n/vNo SOB, no n/v Feeling ill with episodic CP over past 2 weeksFeeling ill with episodic CP over past 2 weeks
Past Medical HistoryPast Medical History Hyperlipidemia at Hyperlipidemia at
health fairhealth fair
MedicationsMedications nonenone
Social HistorySocial History 30 pack year history, 30 pack year history,
currently smokes 1 currently smokes 1 pack/weekpack/week
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Initial ECGInitial ECG
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Angiography ResultsAngiography Results
Troponin Elevation:Troponin Elevation:Baseline 0.44 3 hr 0.48 6 hr 0.49Baseline 0.44 3 hr 0.48 6 hr 0.49
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Cardiac MRICardiac MRI
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Delayed EnhancementDelayed Enhancement
Myocarditis
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Etiologies of Elevations of Etiologies of Elevations of Cardiac TroponinsCardiac Troponins
Plaque rupture Plaque rupture mediated necrosismediated necrosis STEMISTEMI nSTEMInSTEMI
Alterations in Alterations in coronary vasomotor coronary vasomotor tonetone Coronary spasmCoronary spasm Subarachnoid Subarachnoid
hemorrhagehemorrhage Intracranial Intracranial
hemorrhagehemorrhage Apical Ballooning Apical Ballooning
SyndromeSyndrome Transplant Transplant
vasculopathyvasculopathy
Sub-endocardial Sub-endocardial myocyte necrosismyocyte necrosis CHFCHF Hypertensive crisisHypertensive crisis Acute pulmonary Acute pulmonary
embolismembolism Tachycardia-mediated – Tachycardia-mediated –
CHF, Pressure overload CHF, Pressure overload Volume-Pressure overload Volume-Pressure overload
(renal failure, CHF, (renal failure, CHF, fluid fluid resuscitation)resuscitation)
AnemiaAnemia HypotensionHypotension Aortic Stenosis and / or Aortic Stenosis and / or
RegurgitationRegurgitation Hypertrophic Hypertrophic
CardiomyopathyCardiomyopathy Amyloid heart diseaseAmyloid heart disease
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Problem Solving ToolProblem Solving Tool Troponin is extremely sensitive for Troponin is extremely sensitive for
detecting myocardial cell necrosisdetecting myocardial cell necrosis
9-14% of patients who present with ACS 9-14% of patients who present with ACS will have normal or non-significant disease will have normal or non-significant disease on coronary angiographyon coronary angiography
This cohort of patients have been shown to This cohort of patients have been shown to have a poorer prognosis; potentially from have a poorer prognosis; potentially from clinical uncertaintyclinical uncertainty (TACTICS-TIMI-18)(TACTICS-TIMI-18)
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Development of CTDevelopment of CTDevelopment of CTDevelopment of CT
2000 2010 2015
DSCTDSCT128-slice128-slice
20092009
MDCTMDCT320-slice320-slice
20082008
MDCTMDCT4-slice4-slice
19981998
MDCTMDCT16-slice16-slice
20022002
MDCTMDCT40-slice40-slice
20052005
DSCTDSCT64-slice64-slice
20062006
MDCTMDCT8-slice8-slice
20012001
MDCTMDCT64-slice64-slice
20042004
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CT ScanningMinimallyInvasive
Angiography
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Nuclear Cardiac ImagingNuclear Cardiac ImagingDiagnostic AccuracyDiagnostic Accuracy
Imaging Imaging ModalityModality
# of # of StudieStudie
ssPatientPatient
ss Sen. (%)Sen. (%)Spec. Spec. (%)(%)
AccuracAccuracyy
SPECT 99mTc* > 45> 45 ~7,000~7,000 83-8683-86 73-7573-75 83-86%83-86%
CTA* >20>20 ~2,000~2,000 83-9483-94 77-9277-92 89-9289-92
“GOLD” Standard - Angiography
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MDCT in Clinical MDCT in Clinical PracticePractice
A Clinician’s ViewpointA Clinician’s Viewpoint
Gold StandardGold Standard Anomalous coronary vesselsAnomalous coronary vessels Coronary fistula, aneurysmsCoronary fistula, aneurysms
Coronary DiseaseCoronary Disease Great for ruling out CADGreat for ruling out CAD OK (but not great) for disease severityOK (but not great) for disease severity
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High High ProbabilityProbability
Intermediate Intermediate ProbabilityProbability
Low Low ProbabilityProbability
• Typical chest painTypical chest pain
• ECG changes & cardiac enzyme elevationECG changes & cardiac enzyme elevation
• Personal history of CADPersonal history of CAD
““Definite” signs of CAD:Definite” signs of CAD:
Patient PopulationPatient Population
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High High ProbabilityProbability
Intermediate Intermediate ProbabilityProbability
Low Low ProbabilityProbability
• Atypical chest painAtypical chest pain
• Discordant symptoms & stress test resultsDiscordant symptoms & stress test results
High risk factors & negative stress testHigh risk factors & negative stress test
Low risk factors & positive stress testLow risk factors & positive stress test
• Patient reluctant to have a cathPatient reluctant to have a cath
““Indeterminate” signs of CAD:Indeterminate” signs of CAD:
Patient PopulationPatient Population
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High High ProbabilityProbability
Intermediate Intermediate ProbabilityProbability
Low Low ProbabilityProbability
Patient PopulationPatient Population
CTACTA
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High High ProbabilityProbability
Intermediate Intermediate ProbabilityProbability
Low Low ProbabilityProbability
• “ “Worried well”Worried well”
““Doubtful” signs of CAD:Doubtful” signs of CAD:
Patient PopulationPatient Population
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High High ProbabilityProbability
Intermediate Intermediate ProbabilityProbability
Low Low ProbabilityProbability
Patient PopulationPatient Population
? CTA ?? CTA ?
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High High ProbabilityProbability
Intermediate Intermediate ProbabilityProbability
Low Low ProbabilityProbability
Patient PopulationPatient Population
? CTA ?? CTA ?CTACTA
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HistoryHistory 49yr female previously healthy 49yr female previously healthy 6+ months of dyspnea on exertion 6+ months of dyspnea on exertion No personal history of No personal history of
hyperlipidemia, HTN, CAD, smoking, hyperlipidemia, HTN, CAD, smoking, and family history and family history
Currently on no cardiac medicationsCurrently on no cardiac medications BMI = 36.BMI = 36.
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HistoryHistory
Exercise Time: 7.3 minutesExercise Time: 7.3 minutes Test was stopped due to dyspnea and leg Test was stopped due to dyspnea and leg
fatiguefatigue 32,736 (SBP x HR)32,736 (SBP x HR) Stress Echo with an area of anterior ischemia Stress Echo with an area of anterior ischemia
was noted from mid to the basewas noted from mid to the base ECG was negativeECG was negative
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Appropriateness for CTAppropriateness for CT
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References supporting the use of References supporting the use of coronary CTA following equivocal coronary CTA following equivocal
exercise sestamibiexercise sestamibi Schuijf, J., et. al, “Relationship between Noninvasive Coronary Schuijf, J., et. al, “Relationship between Noninvasive Coronary
Angiography with Multi-slice Computed Tomography and Angiography with Multi-slice Computed Tomography and Myocardial Perfusion Imaging” Myocardial Perfusion Imaging” Journal of the American College of Journal of the American College of CardiologyCardiology; December 19, 2006.; December 19, 2006.
Rubinstein, R., et. al, “Usefulness of 64-slice multidetector Rubinstein, R., et. al, “Usefulness of 64-slice multidetector computed tomography in diagnostic triage of patients with chest computed tomography in diagnostic triage of patients with chest pain and negative or nondiagnostic exercise stress test result” pain and negative or nondiagnostic exercise stress test result” American Journal of CardiologyAmerican Journal of Cardiology 2007; 99: 925-929. 2007; 99: 925-929.
Danciu, S., et. al, “Usefulness of multislice computed tomography Danciu, S., et. al, “Usefulness of multislice computed tomography coronary angiography to identify patients with abnormal myocardial coronary angiography to identify patients with abnormal myocardial perfusion stress in whom diagnostic catheterization could be perfusion stress in whom diagnostic catheterization could be avoided” avoided” American Journal of CardiologyAmerican Journal of Cardiology 2007; 100: 1605-1608. 2007; 100: 1605-1608.
Dewey, M., et. al, “Head-to-head comparison of multislice computed Dewey, M., et. al, “Head-to-head comparison of multislice computed tomography and exercise electrocardiography for diagnosis of tomography and exercise electrocardiography for diagnosis of coronary artery disease” coronary artery disease” European Heart JournalEuropean Heart Journal 2007; 28: 2485- 2007; 28: 2485-2490.2490.
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55 y/o womanSubsternal chest discomfort 2 mosEmotion and sometimes exertion
Today 10 min chest and back pain at rest ED
PostmenopausalPrior smoker >15 yrs ago
No FHNo medsMild HTN
Case 2 –chest painCase 2 –chest pain
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Exam: no murmurBP 142/88
Troponin: <.01Creat: 0.8
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Acute chest painWhat do you want to know?
ProbabilityCAD
Risk of acute event
Low/inter
High Angio
LowIntermediate
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What to Do?What to Do?Sestamibi
Stress Echo
Coronary CTA
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CTA vs Standard of Care CTA vs Standard of Care in Chest Painin Chest Pain
Goldstein JACC 2007 49:863-71
Chest painLow risk197 pts
Standard care
Normal Nondiag Severe
MSCT
Stress Nucs
Stress Nucs
HOME HOMEAngio
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Goldstein JACC 2007 49:863-71
CTA – 67% normal and discharged9% severe CAD cath24% needed further eval
Length of stay: lowered by 43%12.5 hrs vs 22.1 hrs
Cost of care: lowered by 15%$1586 vs $1872
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ConclusionsConclusions
Cardiac MRI Cardiac MRI EF, ESV, EDV, RV function, infarct EF, ESV, EDV, RV function, infarct
sizesize ICM vs DCMICM vs DCM ACSACS
Cardiac CTCardiac CT Excellent for exclusion of CAD in low to Excellent for exclusion of CAD in low to
intermediate riskintermediate risk ED patients, “equivocal stress test”ED patients, “equivocal stress test”
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THANK YOU!THANK YOU!