SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of...
Transcript of SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of...
![Page 1: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/1.jpg)
SPECT CT
Current Status and Future Direction
Nuclear Cardiology
BIR
London 25th February 2013
Nik Sabharwal
Consultant Cardiologist
Oxford Heart Centre
No conflict of interest
![Page 2: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/2.jpg)
Contents
• Coronary artery disease
• CT for AC (attenuation correction)
• CT for CAC (Coronary artery calcification)
• CT for CTCA (CT coronary angiography)
• The future?
![Page 3: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/3.jpg)
Spectrum of Coronary Artery Disease
MDCT
MPS/DSE
![Page 4: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/4.jpg)
Where can Nuclear Cardiology help?
• Perfusion
• Function
• Metabolism
• Cellular Injury
• Interstitial dysfunction
• Neurohormonal receptor function
![Page 5: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/5.jpg)
Attenuation correction
• None
• Line source
• CT
![Page 6: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/6.jpg)
AC with CT
• Reliable
• Accurate
• Quality
• Good resolution
• Any isotope
• Any protocol
![Page 7: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/7.jpg)
Coronary artery calcification (CAC)
CAC surrogate for atherosclerosis
CAC represents approx 1/5 overall
atheroma burden
CT best technique for detecting CAC
![Page 8: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/8.jpg)
What does CAC do for you?
Amount of CAC correlates with amount of atheroma
CAC >400 usually indicates significant disease
Distribution of CAC does not correlate with angiographic severity of disease
Most useful in intermediate risk patients
![Page 9: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/9.jpg)
CAC and Framingham in asymptomatic patients Greenland et al. JAMA. 2004;291(2):210-215
Predicted 7-Year Event Rates from Cox
Regression Model for CHD Death or Nonfatal
Myocardial Infarction for Categories of FRS or
CACS
The receiver operating characteristic
curves illustrate FRS alone or plus
coronary artery calcium score
(CACS). Areas under the curves are
0.63 for FRS alone, 0.68 for FRS
plus CACS. P.001 for the comparison
between the 2 areas.
![Page 10: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/10.jpg)
CAC and prognosis
Budoff et al. JACC 2007; 49:1860-70
![Page 11: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/11.jpg)
Limitations of CAC
• Overall low event rates in asymptomatic
• No pharmacological therapy to reduce CAC
• Potential harm from false-positive tests
• Radiation risks in asymptomatic population
• CAC result does not motivate the patient
• Soft plaque not detected
• Stability of plaque not characterised
![Page 12: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/12.jpg)
CT for CAC
• Well established
• Independent prognostic value
• Easy to do
• Early detection of atherosclerosis
• Combined with SPECT?
![Page 13: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/13.jpg)
MPS and CAC
• Normal SPECT with abnormal CAC
• Can predict MVD
• More useful in patients with higher
prevalence of CAD
• DM, elderly
• Increasing CAC = increasing ischaemia
• CAC >400; 20% likelihood of ischaemia
• CAC >100 important in DM, strong FH IHD
![Page 14: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/14.jpg)
SPECT & CAC in pre-op non cardiac surgery
Ghadri et al. JNM 2012; 53:1081–1086
![Page 15: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/15.jpg)
Lung ca. PET/CT incidental finding
Image courtesy of Prof Fergus Gleeson, Oxford
![Page 16: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/16.jpg)
SPECT/CT and PET/CT
![Page 17: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/17.jpg)
CTCA and ischaemia
• CTCA stenosis <50% ≈ normal MPS (NPV >90%)
• CTCA stenosis ≥50% ≠ abnormal MPS (PPV <50%) (Nicol et al. JNC 2008;15:311-8)
• Anatomy and ischaemia are complementary
• Refined plaque scoring techniques likely to be
superior in predicting positive MPS
• Location, distribution, composition etc
![Page 18: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/18.jpg)
CTA and prognosis
Min et al. JACC 2007; 50: 1161-70
![Page 19: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/19.jpg)
CTA and prognosis (2)
CCTA plaque characteristics with potential
prognostic value
Stenosis severity >50% or>70%
intraluminal stenosis
Location Left main, LAD
Composition ‘‘Mixed’’ composition;
low attenuation
density
(<30 Hounsfield units)
Remodeling Positive remodelling
Overall plaque burden Cumulative measure
of plaque extent and
severity
Distribution Cumulative measure
of
plaque diffusivity
![Page 20: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/20.jpg)
Cardiac hybrid imaging in a patient with a single coronary
artery originating from the right sinus of Valsalva
Ghadri et al. EHJ. doi:10.1093/eurheartj/ehr273
![Page 21: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/21.jpg)
Incremental diagnostic accuracy of hybrid SPECT/CT
coronary angiography in a population with an intermediate
to high pre-test likelihood of CAD (n=98)
Schapp et al. EHJ. doi:10.1093/ehjci/jes303
![Page 22: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/22.jpg)
Rapid cardiac hybrid imaging with minimized radiation dose for
accurate non-invasive assessment of ischemic coronary artery disease
Herzog et al. IJC 2011; 153: 10–13
![Page 23: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/23.jpg)
Impact of cardiac hybrid SPECT/CT imaging on choice of
treatment strategy in coronary artery disease (n=318)
Pazhenkottil et al. EHJ. doi:10.1093/eurheartj/ehr232
![Page 24: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/24.jpg)
Prognostic value of cardiac hybrid imaging integrating
SPECT with CCTA (n=355)
Pazhenkottil et al. EHJ. doi:10.1093/eurheartj/ehr047
![Page 25: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/25.jpg)
MPS – Inferior ischaemia
Stress
Rest
![Page 26: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/26.jpg)
Added value of fusion imaging
![Page 27: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/27.jpg)
The Future?
![Page 28: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/28.jpg)
18F –NaF PET and valve disease
• 18F – NaF – novel biomarker of disease activity
• Inflammation and calcification both increased in aortic valve
stenosis compared to controls and with increasing disease severity
• ? target therapies towards calcification
Dweck et al. Circ 2012;125:76-86
![Page 29: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/29.jpg)
Myocardial metabolism
Normal myocardial metabolism
Free fatty acids provide up to 90% ATP
Glycolysis provides the rest
During periods of ischaemia
Myocardial metabolism switches to glucose
Final common pathway
TCA (“Krebs”) cycle
All pathways can be imaged with nuclear
techniques
![Page 30: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/30.jpg)
Glucose metabolism
18F FDG PET
Glucose analogue
Phosphorylated and trapped intracellulary
Preservation of FDG uptake
defines hibernation within hypoperfused
myocardium
patients with advanced CAD
impaired LV function
![Page 31: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/31.jpg)
FFA/TCA metabolism
FFA 123I-BMIPP SPECT
Decreased uptake = ischaemic myocardium
“Ischaemic memory” of remote resolved ischaemia
11C-palmitate PET
TCA 11C-acetate PET
![Page 32: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/32.jpg)
Cellular injury
99mTc-annexin V
Binds to phosphatidylserine (apoptotic cells)
Ongoing research in cardiac transplantation
Uptake associated with ↓LVEF/NYHA in HF
patients
111In-antimyosin
Uptake with loss of sarcolemnal integrity
Allograft rejection, DCM, myocarditis
92% NPV for myocarditis
![Page 33: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/33.jpg)
Noninvasive detection of apoptosis in acute
myocardial infarction using Annexin V
![Page 34: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/34.jpg)
Interstitial dysregulation
Limited potential in myocardial fibrosis
Murine model of 99mTc tracer for MMPs
Angiogenesis more promising
Initiated by VEGF
Modulated by αvβ3 integrin (RGD)
PET/SPECT agents for VEGF / αvβ3 integrin
![Page 35: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/35.jpg)
SPECT and angiogenesis
Late Gd – CMR Tc99m-tetrofosmin Tc99m-RGD
![Page 36: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/36.jpg)
Neurohormonal receptor dysfunction
• Autonomic dysfunction cardiac death
• Increased sympathetic tone is directly linked to
disease progression, prognosis, and risk of
sudden cardiac death (SCD).
• Myocardium that is viable but sympathetically
denervated has a greater propensity for
arrhythmogenesis
• PET • 11C-hydroxyephedrine (11C-HED)
• 11C-epinephrine
![Page 37: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/37.jpg)
Cardiac mIBG
• 123I-mIBG – images sympathetic nerves
• Norepinephrine analogue
• Planar imaging
• Heart/mediastinum ratio calculated
• Lower cardiac uptake = poorer outcome
• Abnormal H/M <1.6
Normal innervation NYHA II NYHA IV
H/M 2.2 H/M 1.7 H/M 1.1
![Page 38: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/38.jpg)
Myocardial Blood Flow (MBF)
• SPECT – CT
• CZT detectors
• Measure MBF/CFR
• “absolute flow”
• No more “balanced ischaemia”
• Reduced uncertainty
• Reduce the need for PET-CT
![Page 39: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/39.jpg)
Summary
• Overview of cardiac SPECT CT
• Evidence
• Diagnosis/Prognosis
• Technological developments
![Page 40: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/40.jpg)
Working together for the patient?
Fraser et al. EHJ 2006: 27: 1750-1753
![Page 41: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/41.jpg)
“Medicine is a science of uncertainty
and art of probability”
Sir William Osler
![Page 42: SPECT CT Current Status and Future Direction Nuclear ... · Myocardial Infarction for Categories of FRS or CACS The receiver operating characteristic curves illustrate FRS alone or](https://reader034.fdocuments.in/reader034/viewer/2022042402/5f11972e39c67b61447ebadd/html5/thumbnails/42.jpg)
Annual Scientific Meeting
Monday 2nd December 2013
NHLI
London
www.bncs.org.uk