MPS + CTA in patient with atypical chest pain · Which test can be used to evaluate chest pain in...
Transcript of MPS + CTA in patient with atypical chest pain · Which test can be used to evaluate chest pain in...
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MPS + CTA in patient
with atypical chest pain
F. Mut, J. Vitola
Nuclear Medicine Service, Asociacion Española
Montevideo, Uruguay
Quanta Diagnostico Nuclear
Curitiba, Brazil
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• 59 yo woman, HTN, Dyslipidemia, DM, limited exercise
capacity (Framingham: high risk for CAD due to DM).
• Atypical chest pain for the past 6 months.
• Total Cholesterol = 190; HDL = 40; LDL = 88 (on statins).
• Glucose: 0.93, HbA1C = 6.7 % (on insulin + metformin).
Clinical history
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What is the probability of CAD by
Diamond & Forrester criteria ?
a) Very low.
b) Low.
c) Intermediate.
d) High.
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What is the probability of CAD by
Diamond & Forrester criteria ?
a) Very low.
b) Low.
c) Intermediate.
d) High.
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Probability of CAD (Diamond & Forrester)
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Which test can be used to evaluate chest pain in this
patient with intermediate probability of CAD by Diamond &
Forrest but a high risk of CAD events by Framingham ?
a) Treadmill test.
b) MPI using SPECT.
c) Non invasive CT angiography.
d) a, b and c are appropriate options.
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Which test can be used to evaluate chest pain in this
patient with intermediate probability of CAD by Diamond &
Forrest but a high risk of CAD events by Framingham ?
a) Treadmill test.
b) MPI using SPECT.
c) Non invasive CT angiography.
d) a, b and c are appropriate options.
• Treadmill test is Class I indication in this setting; MPS is
Class I, and CT angiography is Class IIa, while invasive
angiography is Class IIb.
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Dypiridamole MPS
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How do you interpret the MPS findings ?
a) Definitely normal
b) Probably normal
c) Definitely abnormal
d) Equivocal
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How do you interpret the MPS findings ?
a) Definitely normal
b) Probably normal
c) Definitely abnormal
d) Equivocal
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What would you do next to define
if this patient has CAD ?
a) Cardiac MRI.
b) Invasive angiograph.
c) CT angiography.
d) Nothing, she has CAD.
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What would you do next to define
if this patient has CAD ?
a) Cardiac MRI.
b) Invasive angiograph.
c) CT angiography.
d) Nothing, she has CAD.
• A second non-invasive imaging procedure is indicated in a
patient with low or intermediate risk of CAD when the first
method is not conclusive.
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Appropriateness criteria for CTA
Source: Taylor A et al; ACCF/SCCT/ACR/AHA/ASE/ASNC/SCAI/SCMR 2010 Appropriate Use Criteria for
Cardiac Computed Tomography. Circulation published online Oct 25, 2010;
*
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Coronary CT angiography
• Normal; CAC = 0 Agatston
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What is this patient risk of CAD events after functional
(MPS) and anatomical (CTA) evaluation?
a) Low risk.
b) Intermediate risk.
c) High risk.
d) Very high risk.
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What is this patient risk of CAD events after functional
(MPS) and anatomical (CTA) evaluation?
a) Low risk.
b) Intermediate risk.
c) High risk.
d) Very high risk.
• Normal CTA is associated with very low risk of cardiac
events due to the high NPV of the method.
• MPS is equivocal but no definite perfusion defects are
observed.
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• MPS investigates the pathophysiological consequences of luminal obstructive CAD, while CTA indicates the presence, extent and location of coronary atherosclerosis.
• For pratical purposes, CTA excludes CAD (high NPV).
• A negative CTA implies no need of MPS on follow-up.
• A positive CTA (if performed initially) implies the need for a MPS for short-term prognosis and eventual revascularization, because of low PPV.
• Combined anatomical and functional assessment may allow improved risk stratification.
Teaching points
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• Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical
diagnosis of coronary-artery disease. N Engl J Med 1979; 300:1350–8.
• Dorbala S, Hachamovitch R, Di Carli MF. Myocardial perfusion imaging and
multidetector computed tomographic coronary angiography: appropriate for all
patients with suspected coronary artery disease? J Am Coll Cardiol 2006;
48:2515–7.
• van Werkhoven JM, Schuijf JD, Gaemperli O, et al. Prognostic value of multislice
computed tomography and gated single-photon emission computed tomography
in patients with suspected coronary artery disease. J Am Coll Cardiol 2009;
53:623–32.
• Scholte AJ, Roos CJ, van Werkhoven JM. Function and anatomy: SPECT-MPI
and MSCT coronary angiography. Eurointervention 2010; 6 (Suppl G):G94-G100.
• Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/
SCAI/STS Guideline for the diagnosis and management of patients with stable
ischemic heart disease. J Am Coll Cardiol 2012; 60:2564-603.
Bibliography