Non-invasive functional testing in 2014 · Non-invasive functional testing in 2014, CAD diagnosis...
Transcript of Non-invasive functional testing in 2014 · Non-invasive functional testing in 2014, CAD diagnosis...
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Non-invasive functional testing
in 2014
Bjarne Nørgaard
Department Cardiology B
Aarhus University Hospital Skejby,
Disclosures: Research grants:
Edwards and Siemens
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Non-invasive functional testing in 2014
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Montalescot G, EHJ 2013
Non-invasive functional testing in 2014
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Non-invasive functional testing in 2014
• Is non-invasive functional testing
diagnostic accurate?
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Non-invasive functional testing in 2014, CAD diagnosis
ESC guidelines. Eur Heart J 2013
Montalescot G, EHJ 2013
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2684 patients suspected of CAD
6 y fu
Hard event:● Cardiac death (1%),
● AMI (0.6%)
● Coronary revasc or
coronary stenosis >75% (6%)
Leischick R, Int J Cardiol 2007
Non-invasive functional testing in 2014, CAD diagnosis
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Berman DS , J Nucl Cardiol 2007
Non-invasive functional testing in 2014, CAD diagnosis
●101 patients with left main CAD
(>50%), RCA/LAD/Cx >70%
● No prior MI or revasc.
● Exercise or adenosine gated
sestambi SPECT
N= 101 11 28 37 25
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Berman DS , J Nucl Cardiol 2007
Non-invasive functional testing in 2014, CAD diagnosis
●101 patients with left main CAD
(>50%), RCA/LAD/Cx >70%
● No prior MI or revasc.
● Exercise or adenosine gated
sestambi SPECT
● MPI high risk: myocardium stress
>10% or 5-10% + >1 non-perfusion
abnormalities
N= 101 11 28 37 25
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● Almost 400.000 subjects suspected of SAP
● 82% with prior non-invasive testing
Non-invasive functional testing in 2014, ICA gatekeeper
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● Almost 400.000 subjects suspected of SAP
● 82% with prior non-invasive testing
Non-invasive functional testing in 2014, ICA gatekeeper
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● Almost 400.000 subjects suspected of SAP
● 82% with prior non-invasive testing
Non-invasive functional testing in 2014, ICA gatekeeper
Proportion of coronary revascularization
in patients suspected of CAD
(Danish Heart Registry 2006-2011)
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● Selection bias
Non-invasive functional testing in 2014,
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● Selection bias
● The diagnostic specificity of a test declines
with time
Non-invasive functional testing in 2014,
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● Selection bias
● The diagnostic specificity of a test declines with
time
● Publication bias / ”File cabinet” phenomenon
Non-invasive functional testing in 2014,
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Cath CMR
Stress echo
SPECT
eECG
PET
Test validation
Hecht HS, JCCT, 2009
Non-invasive functional testing in 2014,
Validation paradox
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Cath CMR
Stress echo
SPECT
eECG
PET
Test validation
Hecht HS, JCCT, 2009
Clinical evaluation
Non-invasive functional testing in 2014,
Validation paradox
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Non-invasive functional testing in 2014
Image source: http://www.ptca.org/news/2010/0623_FFR.html
1. Hamm et al., EHJ, 2011 2. Tonino et al. N Engl J Med. 2009 Jan
15;360(3):213-24. 3. Pijls, NH et al. J Am Coll Cardiol. 2007 May
29;49(21):2105-11.
Surv
ival
fre
e fr
om
MA
CE*
Days since randomization
Using FFR to guide therapy
resulted in 33% reduction in
the risk of death or major
cardiac events and reduced
cost1,2
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Non-invasive functional testing in 2014
Invasive Fractional Flow Reserve (FFR) has emerged as the gold
standard “bridge” test to determine optimal (medical vs. PCI)
artery-specific therapy
Image source: http://www.ptca.org/news/2010/0623_FFR.html
1. Hamm et al., EHJ, 2011 2. Tonino et al. N Engl J Med. 2009 Jan
15;360(3):213-24. 3. Pijls, NH et al. J Am Coll Cardiol. 2007 May
29;49(21):2105-11.
Surv
ival
fre
e fr
om
MA
CE*
Days since randomization
Using FFR to guide therapy
resulted in 33% reduction in
the risk of death or major
cardiac events and reduced
cost1,2
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Non-invasive functional testing in 2014
Invasive Fractional Flow Reserve (FFR) has emerged as the gold
standard “bridge” test to determine optimal (medical vs. PCI)
artery-specific therapy
Image source: http://www.ptca.org/news/2010/0623_FFR.html
1. Hamm et al., EHJ, 2011 2. Tonino et al. N Engl J Med. 2009 Jan
15;360(3):213-24. 3. Pijls, NH et al. J Am Coll Cardiol. 2007 May
29;49(21):2105-11.
Surv
ival
fre
e fr
om
MA
CE*
Days since randomization
Using FFR to guide therapy
resulted in 33% reduction in
the risk of death or major
cardiac events and reduced
cost1,2
The diagnostic performance of non-invasive
testing modalities should be tested using
FFR as the gold standard
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• Is non-invasive functional testing
diagnostic accurate?
• Does the information from non-invasive
functional testing change outcomes?
Non-invasive functional testing in 2014
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Hachamovitch R, Circulation 2003
Non-invasive functional testing in 2014, Myocardial ischemia and prognosis
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Boden WE, NEJM 2007
Non-invasive functional testing in 2014, Myocardial ischemia and treatment decision
COURAGE study
BARI-2D study
Frye RL, NEJM 2009
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Boden WE, NEJM 2007
Non-invasive functional testing in 2014, Myocardial ischemia and treatment decision
”COURAGE-ischemia”:
Proximal 70% stenosis and ST or
T-wave in resting ECG or
ischemia in stress ECG or imaging
test or at least one proximal 80%
stenosis
”BARI-2D ischemia”:
Proximal 50% stenosis and
positive stress test or
>70% stenosis
and classical angina
Frye RL, NEJM 2009
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• Is non-invasive functional testing diagnostic accurate?
Non-invasive functional testing in 2014, -Conclusion
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• Is non-invasive functional testing diagnostic accurate?
• Does the information from non-invasive functional testing change outcomes?
Non-invasive functional testing in 2014, -Conclusion
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• Is non-invasive functional testing diagnostic accurate?
• Does the information from non-invasive functional testing change outcomes?
8000 patients, randomized to interventional or conservative treatment, moderate-severe ischemia (PET, SPECT,CMR,Echo) at cor-lab reads.
Non-invasive functional testing in 2014, -Conclusion
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Montalescot G, EHJ 2013
Non-invasive functional testing in 2014
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Montalescot G, EHJ 2013
Non-invasive functional testing in 2014
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Non-invasive CAD diagnosis and management
requires understanding of two fundamental questions
Non-invasive functional testing in 2014
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Non-invasive CAD diagnosis and management
requires understanding of two fundamental questions
FUNCTION: Is coronary ischemia
causing my patient’s symptoms?
• Coronary CT Angiography
ANATOMY: Are there narrowings in
the coronary arteries?
Regional differences in
• myocardial blood flow (e.g. SPECT, PET,
CMR) or
• left ventricular wall motion (e.g. stress
echocardiolography)
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Sato A, J Nucl Cardiol 2010
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Sato A, J Nucl Cardiol 2010
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Non-invasive functional testing in 2014, - the future!
Pazhenkottil AP, EHJ 2011
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PET-CT
CT-perfusion
FFRCT
Non-invasive functional testing in 2014, -assessment of anatomy and function in one single test
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Shaw et al, JCCT 2008
3760 patients, followed 2 years for mortality (693 CT, 3067 SPECT). 60% with inter-mediate pretest likelihood of CAD. Mortality rate: 3.2%.
Prognosis, CTA versus MPI
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Vejle HjerteCT center, N =2343
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Vejle HjerteCT center, N =2343
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CTA, -diagnostisk gatekeeper hos ptt. med uafklarede brystsmerter
Adapted from Schuijf JD et al. J Nucl Cardiol 2007;14:604
CTA
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Teknik Varighed
Røntgen, mSv
Spatiale opløselighed
Temporale opløselighed
Fordele Ulemper
Ekko 15-30 min
0 ~ 1mm < 33 msek
Let tilgængelig Non-invasiv -røntgen -kontrast
2-D info Operatør afhængig Afhængig af anatomi /akustiske forhold
cCT < 10 sek 0.5-10 0.4 – 0.5 mm
83-170 msek
Non-invasiv Høj spatial opløselighed
Kun anatomi Røntgen, Kontrast Afhængig af lav og regelmæssig puls
cMR 20-45 min
0 0.7 – 3.0 mm
120-150 msek
Non-invasiv -røntgen -kontrast
Lav tilgængelighed Omstændelig Lav opløselighed Risiko for HR og respirations artefakt
KAG 10-15 min
2-10 0.2 mm < 10 msek
Høj opløselighed 2-D info, Kun ”luminologi” Invasiv, -sjældne men alvorlige komplikationerOperatør afhængig Røntgen, Kontrast
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CTA, prognosis
Motoyamo JACC 2009
N =1059, suspected of CAD F/u 27 months, Reg.: ACS Plaquefeatures: ●Low attenuation ●Positive remodelling
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Gottlieb JACC 2010
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Validation paradox
Cath
CMR
Stress echo
SPECT
eECG
PET
Test validation Clinical evaluation
Stress echo
SPECT
CMR
PET
Hecht HS, JCCT, 2009
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Non-invasive functional testing in 2014
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Non-invasive functional testing in 2014
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Non-invasive functional testing in 2014
Invasive Fractional Flow Reserve (FFR) has emerged
as the gold standard “bridge” test to determine
optimal (medical vs. PCI) artery-specific therapy
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Non-invasive functional testing in 2014
The diagnostic performance of non-
invasive testing modalities should be
tested using FFR as the gold standard
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Berman DS , J Nucl Cardiol 2007
Non-invasive functional testing in 2014, CAD diagnosis
●101 patients with left main CAD
(>50%), RCA/LAD/Cx >70%
● No prior MI or revasc.
● Exercise or adenosine gated
sestambi SPECT
● MPI high risk: myocardium stress
>10% or 5-10% + >1 non-perfusion
abnormalities
N= 101 11 28 37 25