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Myocardial Perfusion Imaging Myocardial Perfusion Imaging and Coronary Calcium Scoring:and Coronary Calcium Scoring:Complimentary or CompetitiveComplimentary or Competitive

Myocardial Perfusion Imaging Myocardial Perfusion Imaging and Coronary Calcium Scoring:and Coronary Calcium Scoring:Complimentary or CompetitiveComplimentary or Competitive

David Wolinsky MD FACC MASNCDavid Wolinsky MD FACC MASNCSection Head Nuclear Cardiology,Section Head Nuclear Cardiology,

Cleveland Clinic FloridaCleveland Clinic FloridaImmediate Past President Immediate Past President ,,

American Society Nuclear CardiologyAmerican Society Nuclear Cardiology

DisclosuresDisclosuresDisclosuresDisclosures

•• Speaker Speaker –– AstellasAstellas PharmaPharma•• Consultant Consultant ––AstellasAstellas PharmaPharma•• Steering Committee Steering Committee ––Adenosine Adenosine

TherapeuticsTherapeutics•• Immediate Past President ASNCImmediate Past President ASNC

DiscussionDiscussionDiscussionDiscussion

•• Anatomy Anatomy vsvs PhysiologyPhysiology•• Long term Long term vsvs Short Term Risk Short Term Risk

Assessment Value of MPI Assessment Value of MPI •• The patient with veryThe patient with very high Calcium high Calcium

ScoreAssessmentScoreAssessment Positive Family Positive Family HistoryHistory

•• Assessing Incidental Coronary CalciumAssessing Incidental Coronary Calcium•• PET PerfusionPET Perfusion

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Cardiac Testing Cardiac Testing –– What What ;Why?;Why?

Cardiac Testing Cardiac Testing –– What What ;Why?;Why?

The Value of Noninvasive The Value of Noninvasive TestingTesting

The Value of Noninvasive The Value of Noninvasive TestingTesting

TraditionalTraditional•• Determine cause of Determine cause of

symptoms symptoms •• Diagnose diseaseDiagnose disease•• Define treatment Define treatment •• Risk StratifyRisk Stratify

Modern ParadigmModern Paradigm

Shaw JACC Imaging 2010

No One Pair of Shoes for ALL No One Pair of Shoes for ALL OccasionsOccasions

No One Pair of Shoes for ALL No One Pair of Shoes for ALL OccasionsOccasions

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Anatomic Anatomic vsvs Functional ImagingFunctional ImagingAnatomic Anatomic vsvs Functional ImagingFunctional Imaging

Courtesy Leslee Shaw PhD

Calcium Score Calcium Score vsvs MPIMPICalcium Score Calcium Score vsvs MPIMPI

Calcium ScoreCalcium Score

•• Anatomic TestAnatomic Test•• Defines atherosclerosisDefines atherosclerosis•• Long term risk associated Long term risk associated

with increasing CAC scorewith increasing CAC score•• Used in assessing Used in assessing

Asymptomatic patientsAsymptomatic patients•• Combined with CCTA, Combined with CCTA,

PET,SPECT for symptomatic PET,SPECT for symptomatic patientspatients

•• Guideline to medical therapy Guideline to medical therapy or further noninvasive or further noninvasive testingtesting

MPIMPI

•• Physiologic testPhysiologic test•• Short term risk (2 Short term risk (2 yryr) )

very low with negative very low with negative test test

•• Risk stratifies Risk stratifies symptomatic patientssymptomatic patients

•• Gatekeeper to invasive Gatekeeper to invasive studiesstudies

•• Proven management Proven management chronic CADchronic CAD

Diagnostic Accuracy MPIDiagnostic Accuracy MPIDiagnostic Accuracy MPIDiagnostic Accuracy MPI

Shaw Jl Nuc Card 2012

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Prognostic Value Normal MPIPrognostic Value Normal MPIPrognostic Value Normal MPIPrognostic Value Normal MPI

Shaw Jl Nuc Card 2012

Stress MPI and RiskStress MPI and RiskStress MPI and RiskStress MPI and Risk

Hachamovitch Jl Nuc Card 2005 Shaw Jl Nuc Card 2012

SPECT SPECT vsvs PETPETSPECT SPECT vsvs PETPET

SPECTSPECT•• Readily availableReadily available•• Extensive AUCExtensive AUC•• Extensive Outcomes Extensive Outcomes

data based on stress data based on stress resultsresults

•• Data on Medical Data on Medical vsvsRevascularization Revascularization therapytherapy

•• Exercise stress dataExercise stress data•• Raw Spinning Data Raw Spinning Data

PETPET•• Less available , $$$$$Less available , $$$$$•• No specific AUCNo specific AUC•• Limited outcomes dataLimited outcomes data•• Only pharm stressOnly pharm stress•• Attenuation CorrectionAttenuation Correction•• Lower radiationLower radiation•• Less trainingLess training•• Coronary flow reserveCoronary flow reserve•• Less likely to be Less likely to be

covered by insurance covered by insurance

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What is What is InterelationshipInterelationshipBetween MPI and Calcium Between MPI and Calcium

ScoreScore

What is What is InterelationshipInterelationshipBetween MPI and Calcium Between MPI and Calcium

ScoreScore

Prognosis MPIPrognosis MPIPrognosis MPIPrognosis MPI

Shaw JNC 2012

Multimodality AUCMultimodality AUCMultimodality AUCMultimodality AUC

http://dx.doi.org/10.1016/j.jacc.2013.11.009

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Sequential TestingSequential TestingSequential TestingSequential Testing

http://dx.doi.org/10.1016/j.jacc.2013.11.009

Relationship CAC and IschemiaRelationship CAC and IschemiaPredominantly symptomatic Predominantly symptomatic ptspts

Intermediate pretest riskIntermediate pretest risk

Relationship CAC and IschemiaRelationship CAC and IschemiaPredominantly symptomatic Predominantly symptomatic ptspts

Intermediate pretest riskIntermediate pretest risk

Schenker et al Circulation. 2008;117:1693-1700.)

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Ability CAC to Predict Ability CAC to Predict IschemiaIschemia

Ability CAC to Predict Ability CAC to Predict IschemiaIschemia

Risk StratificationRisk Stratification-- Hard EventsHard EventsRisk StratificationRisk Stratification-- Hard EventsHard Events

Schenker et al

Absolute Stratification by MPI

Relative Stratification by CAC

ConclusionConclusionConclusionConclusion•• PET can achieve effective risk stratification for PET can achieve effective risk stratification for

major cardiac events with good discrimination major cardiac events with good discrimination between high and low risk patients in patients between high and low risk patients in patients with intermediate pretest riskwith intermediate pretest risk

•• Two year risk stratification with MPI provides an Two year risk stratification with MPI provides an appropriate warranty period for a normal scan appropriate warranty period for a normal scan and appropriate risk that justifies further therapy and appropriate risk that justifies further therapy in abnormal scans (Await ISCHEMIA)in abnormal scans (Await ISCHEMIA)

•• CAC can define long term risk. It can help CAC can define long term risk. It can help determine which is the most appropriate determine which is the most appropriate functional test to do. It may also help refine ris k functional test to do. It may also help refine ris k of subsequent testingof subsequent testing

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The Patient with Very High Calcium The Patient with Very High Calcium ScoreScore-- Greater than 1000Greater than 1000

The Patient with Very High Calcium The Patient with Very High Calcium ScoreScore-- Greater than 1000Greater than 1000

•• Concern that with severe extensive Concern that with severe extensive coronary disease that stress testing coronary disease that stress testing would provoke balanced ischemia and would provoke balanced ischemia and false negative stress testfalse negative stress test

•• Triple vessel disease Triple vessel disease vsvs left main CADleft main CAD•• Ancillary markers Ancillary markers –– ECG, TID may helpECG, TID may help

LVGLVGLVGLVG

•• 47 47 yoyo malemale•• HTN, FHX, Active tobacco (30HTN, FHX, Active tobacco (30--40 pack40 pack--

years), Poor diet , History carotid years), Poor diet , History carotid stenosis.stenosis.

•• On On PravacholPravachol•• Calcium Score 2057Calcium Score 2057•• SOB climbing 15 stairs . No chest PainSOB climbing 15 stairs . No chest Pain•• Normal ECGNormal ECG

LVGLVGLVGLVG

•• Intermediate to high riskIntermediate to high risk•• Referred for MPIReferred for MPI•• 11.9 METS No chest pain.11.9 METS No chest pain.•• No ECG changesNo ECG changes•• Normal Perfusion Rest Normal Perfusion Rest ––stress studystress study•• No TIDNo TID•• Normal EFNormal EF

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LVGLVGLVGLVG

LVGLVGLVGLVG

What is His Risk?What is His Risk?

Pilot Study Pilot Study –– NonconclusiveNonconclusive Unusual Unusual FindingFinding

Pilot Study Pilot Study –– NonconclusiveNonconclusive Unusual Unusual FindingFinding

Yuoness Eur J Nucl Med Mol Imaging (2015) 42:1542–1550

Relatively uncommon finding

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Does presence of Significant CAC Does presence of Significant CAC modify risk of normal MPImodify risk of normal MPI

Does presence of Significant CAC Does presence of Significant CAC modify risk of normal MPImodify risk of normal MPI

•• CAC increases pretest likelihood of CAC increases pretest likelihood of having ischemia (having ischemia (Baye’sBaye’s Theorem)Theorem)

•• Is their a difference in prognosis Is their a difference in prognosis between patients followed with CAC between patients followed with CAC and normal MPI and patients followed and normal MPI and patients followed with normal MPI?with normal MPI?

Rozanski JACC Vol. 49, No. 12, 2007 :1352–61

CAC did not modify MPICAC did not modify MPIbased riskbased risk

CAC did not modify MPICAC did not modify MPIbased riskbased risk

Patients with CAC did not have increased risk with normal scan

Presence of CAC did not change risk based on clinical and MPS alone

Evaluation of the Patient with Evaluation of the Patient with PostivePostive Family HistoryFamily History

Evaluation of the Patient with Evaluation of the Patient with PostivePostive Family HistoryFamily History

“Doc . I want all the tests done . My “Doc . I want all the tests done . My best friend just died. My father had a best friend just died. My father had a heart attack at 58. I want everything. heart attack at 58. I want everything.

I have great insurance . They will I have great insurance . They will cover everything. Do it all!”cover everything. Do it all!”

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Family History CADFamily History CADFamily History CADFamily History CAD

•• Framingham does not include +Framingham does not include +FHxFHx•• FHxFHx cannot be quantitated cannot be quantitated •• There is no data supporting advanced There is no data supporting advanced

imaging stress testing in this imaging stress testing in this population.population.

•• Can CAC be a surrogate for +FHX and Can CAC be a surrogate for +FHX and help determine high risk patients ?help determine high risk patients ?

•• Does CAC modify risk stratification of Does CAC modify risk stratification of MPI in these patient ?MPI in these patient ?

Family History CAD Family History CAD Family History CAD Family History CAD •• There is an There is an asssociationasssociation between between

premature CAD and presence of CAC.premature CAD and presence of CAC.•• CAC provides long term risk CAC provides long term risk

stratification.stratification.•• There is no data to suggest CAC There is no data to suggest CAC

modifies short short term mortality risk modifies short short term mortality risk in these patients beyond the general in these patients beyond the general population population

•• Many of these patient have too low a Many of these patient have too low a risk profile at time they are studiedrisk profile at time they are studied

Nasir Circ 2007. Knapper and Shaw Heart 2016

PETPETPETPET

•• Do it RightDo it Right•• Bad PET is not a substitute for Bad Bad PET is not a substitute for Bad

SPECTSPECT•• PET is not a substitute for SPECT if the PET is not a substitute for SPECT if the

patient can exercise and has good patient can exercise and has good imaging characteristicsimaging characteristics

•• PET’s true value is not improved images PET’s true value is not improved images but coronary flow reserve (CFR) but coronary flow reserve (CFR)

•• Doing CFR is not easyDoing CFR is not easy

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PET PerfusionPET Perfusion--RbRbPET PerfusionPET Perfusion--RbRb

Courtesy Wael Jaber MD

Abnormal PET PerfusionAbnormal PET PerfusionAbnormal PET PerfusionAbnormal PET Perfusion

Courtesy Wael Jaber MD

PETPET--CT Attenuation CorrectionCT Attenuation CorrectionPETPET--CT Attenuation CorrectionCT Attenuation Correction

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Coronary Flow ReserveCoronary Flow ReserveCoronary Flow ReserveCoronary Flow Reserve

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Reclassification with CFRReclassification with CFRReclassification with CFRReclassification with CFR

Courtesy Leslee Shaw PhD

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SummarySummarySummarySummary

•• SPECT and PET MPI are valuable tools for SPECT and PET MPI are valuable tools for assessing coronary physiology and determining assessing coronary physiology and determining ischemic burden. ischemic burden.

•• They are most appropriately used in assessing They are most appropriately used in assessing intermediate to high risk symptomatic patients.intermediate to high risk symptomatic patients.

•• CAC assesses the presence of preclinical CAC assesses the presence of preclinical atherosclerosis and long term riskatherosclerosis and long term risk

•• Though often used in different populations, when Though often used in different populations, when combined in appropriate patients they are combined in appropriate patients they are complementary to fine tune short term risk complementary to fine tune short term risk

I have a simple view of Calcium I have a simple view of Calcium ScoreScore-- We Need We Need DrDr NasirNasir

I have a simple view of Calcium I have a simple view of Calcium ScoreScore-- We Need We Need DrDr NasirNasir

Segmental rest perfusion measurements ranged from 0.8 to 0.9 mL/min/g of tissue, while hyperemic measurements ranged from 3.1 to 3.3 mL/min/g of tissue. Myocardial perfusion reserve measurements ranged from 3.3 to 3.6.

Thank you

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