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PIC Heart Talk 2013and EP ConOctober 24 – 26, 2013
Can cardiac imaging improve patient outcome?
Richard Underwood
Professor of Cardiac ImagingImperial College London
Royal Brompton & Harefield Hospitals
Roles of imaging in CAD
• Diagnosis
• Coronary anatomy & function
• Myocardial anatomy & function
• Valve anatomy & function
• Objective assessment of symptoms
• Disease severity & burden
• Acute & chronic risk assessment
• Myocardial viability, stunning & hibernation
• Guiding revascularisation
• Monitoring therapy
Subspecialty Cardiac Imaging
• Echocardiography– Rest– Stress– Specialist (e.g. trans-oesophageal)
• Radionuclide imaging– Myocardial perfusion scintigraphy– Radionuclide ventriculography
• Magnetic resonance imaging
• X-ray computed tomography– Coronary calcium imaging– Coronary angiography
Cardiac Imaging 2011
MPS¹ PET perfn² sEcho² MR perfn¹ Coronary CT¹
0
500
1000
1500
2000
2500
3000
Test
s per
mill
ion
¹ECNC survey²Personal communications
How might imaging influence outcome?
• Avoiding diagnostic false negatives of less sensitive investigations
• Avoiding complications of invasive investigation
• Identifying patients with high but reversible risk
• Preventing intervention if no reversible risk
• Achieving similar outcome without intervention
• Achieving similar outcome at reduced cost
Myocardial perfusion scintigraphy
LVEF 74%
Prognostic value of MPS
• asymptomatic volunteers
• asymptomatic patients withabnormal sECG
• investigation of suspected CAD
• known CAD with stable angina
• after infarction
• after stabilisation of UA
• after revascularisation
• before non-cardiac surgery MPS normal MPS abnormal
0.7%
6.7%
Annual hard event rate
Underwood SR, et al. EJNM 2004; 31; 261-9129 studies , 20963 patients, mean follow-up 28m
Beliefs concerning PCI
Ann Intern Med 2010; 153: 307-13
Studies of ischaemia guided management
• A• BARI-2D• COURAGE• DEFER• ERASE• FAME• GRACE• INSPIRE• OASIS• etc
ACS No ACS0%
20%
40%
60%
80%
100%
84%
42%
85%
52%
MPS Normal care
Pati
en
ts a
dm
itte
d
Death or MI
Stroke Bleed Angina0%
5%
10%
15%
20%
Cath facilities No cath facilities
Relevant outcome studies
Study Topic Design
FAME FFR vs CAG guided PCI Randomised
DEFER PCI vs MT Randomised
Al Housni Ischaemia & PCI response, stable CAD Observational
Hachamovitch
MT vs revasc, stable CAD Observational
COURAGE OMT vs PCI, stable CAD Randomised
INSPIRE MT vs revasc, after MI Randomised
STICH MT vs CABG, impaired LV function Randomised
PARR2 FDG PET vs standard care, impaired LV function Randomised
EMPIRE Cost effectiveness of diagnosis Controlled
END Cost effectiveness of diagnosis Observational
Pijls NHJ et al. JACC 2010; 56: 177-84
FFR guided PCI, FAME 1Surv
ival fr
om
death
or
MI
• 1005 patients
• Multi-vessel disease undergoing PCI
• Randomised to CAG alone or FFR
P = 0.02
Fearon WF, et al. Circ 2010; 122: 2545-50
FFR guided PCI, FAME 2
De Bruyne B. NEJM 2012; 367: 991-10011220 patients, SCAD, FFR <0.8
Death, MI, urgent revasc Death
Stenting insignificant lesions
Pijls NHJ et al. JACC 2007; 49: 2105-11325 patients, elective PCI for intermediate stenosis
5 y
ear
card
iac
death
or
MI
DEFER study
Function v anatomy for symptoms
Al-Housni MB, et al. JNC 2009; 16: 869-77
123 patients, elective PCI
Procedure blinded to MPS
sECG baseline + 6 months
SDS 0
SDS 1-6
SDS >6
Hachamovitch R et al, 2011 doi: 10.1093/eurheartj.ehq50013555 patients, mean f/u 8.7yr, subset with <10% scar
Benefit of revasc vs medical therapy
% myocardium ischaemic
HR
earl
y r
evasc
vs
medic
al
PCI in stable angina
years
Free from death or MINEJM 2007; 356: 1503-16
Quality of LifeNEJM 2008; 359: 677-87
months
Shaw LJ, et al. Circulation 2008; 117:1283-91314 of 2287 patients, stable angina randomised to OMT or
PCI
Events and ischaemia
Events rates by ischaemia reduction
Baseline ischaemia
>10%
Events and ischaemia reduction
Shaw LJ, et al. Circulation 2008; 117:1283-91314 of 2287 patients, stable angina randomised to OMT or
PCI
Management after High Risk MI
• 205 patients, stable after MI
• Stress MPS defect >20%
• Reversible MPS defect >10%
• LVEF >35%
• Randomised to medical Rx or revascularisation
Mahmarian J, et al. INSPIRE trial JACC 2006; 48: 2458-67
Management after High Risk MI
Mahmarian J, et al. INSPIRE trial JACC 2006; 48: 2458-67
STICH trial
Bonow RO, et al. NEJM 2011; 364: 1617-25
HR 0.64 (95% CI 0.48-0.86)P = 0.003 unadjustedP = 0.21 risk adjusted
• 1212 patients with IHD & LVEF <35%
• Randomised to medical Rx or CABG
• 5 year follow-up
• 601 patients underwent viability assessment in non-random fashion
STICH limitations
• Nonrandomised selection of patients for imaging (601 of 1212)
• 72% of imaging referrals after randomisation
• MPS definition of viability: > 11/17 segments with uptake >50%
• Echo definition of viability: > 5/16 segments with abnormal resting function but contractile reserve to dobutamine
Hibernation and outcome
PARR2 study
• 430 patients, suspected CAD, LVEF <35%
• Randomised to FDG imaging or standard care
• Primary outcome cardiac death, MI or admission at 1 yearS
urv
ival fr
ee o
f 1
° outc
om
e
Beanlands RSG et al. JACC 2007; 50: 2002-12
P = 0.15
Perfusion viability mismatch
Beanlands RSG et al. JACC 2007; 50: 2002-12
Revascularisation or workup recommendation if “significant viability”
Hibernation and outcome
PARR2 study
• 430 patients, suspected CAD, LVEF <35%
• Randomised to FDG imaging or standard care
• Primary outcome cardiac death, MI or admission at 1 yearS
urv
ival fr
ee o
f 1
° outc
om
e
Beanlands RSG et al. JACC 2007; 50: 2002-12
P = 0.15
P = 0.019
Post hoc analysis
• 156 patients in PET arm who adhered to PET recommendation
Revasc benefit with extensive hibernation
D'Egidio G . . . Beanlands RGS JACCCI 2009; 2: 1060-8
Death, MI, admission
Cardiac death
>7% hibernationbenefit from revascularisation
PARR2 sub-study
182 patients randomised to PET arm
IHD and LVEF <35%
Hibernation and outcome
Abraham A . . . Beanlands RSG. JNM 2010; 51: 567-74
Ottawa-FIVE sub-study of PARR2
111 patients with:
1 Ready access to FDG
2 Expertise in FDG imaging
3 Integration between imaging,
4 Heart failure and
5 Revascularisation teams
Su
rviv
al fr
ee o
f 1
° outc
om
e
Two year costs (CAD absent)
Strategy 1 2 3 4 Scint Non-scint£0
£200
£400
£600
£800
£1,000
£1,200
£1,400
£1,600
£1,800
Management
Diagnosis
EMPIRE study. Eur Heart J 1999; 20: 157-66
P < 0.0001
P < 0.05P < 0.001
Rapid Access Chest Pain Clinic
• 1522 patients referred Dec 97 to Apr 2000 (630/yr)
• clinical management decisions by SpR with consultant supervision
Male % Female %
Ex-ECG 100 100
MPI 8 5
Angiogram 31 23
Normal angiogram 16 56
Wong Y et al. Heart 2001; 85: 149-152
Conclusion
Randomised controlled trials• Assessment of coronary function improves outcome in PCI
• Ischaemia reduction assessed by MPS improves outcome
• Conservative management after high risk MI identified by MPS has the same outcome as intervention
• FDG PET improves outcome in severe LV dysfunction in an expert centre
Controlled studies• MPS achieves equal diagnostic outcome at lower cost
Observational studies• MPS identifies patients who will benefit symptomatically from
PCI
• Patients with >10% myocardial ischaemia have improved outcome with revascularisation
Imaging & Cardiology
a natural partnership