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Barth imt


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Barth imt

  1. 1. IntroductionIntroductionJacques Barth M.D., Ph.D, FACC, FAHAJacques Barth M.D., Ph.D, FACC, FAHA Professor at W.M Keck School of MedicineProfessor at W.M Keck School of Medicine University of Southern California, LosUniversity of Southern California, Los Angeles, CaliforniaAngeles, California • Expert in preventive cardiology ,Expert in preventive cardiology , endocrinology and image processingendocrinology and image processing Pioneer in the development of ultrasoundPioneer in the development of ultrasound technology to assess cardiovascular risktechnology to assess cardiovascular risk Senior Scientist for NASA’s NationalSenior Scientist for NASA’s National Research Council at the Jet PropulsionResearch Council at the Jet Propulsion LaboratoryLaboratory Involved in Image Laboratories inInvolved in Image Laboratories in Amsterdam, Rotterdam, Vancouver andAmsterdam, Rotterdam, Vancouver and Los AngelesLos Angeles CORE Laboratory for Pharma, State ,CORE Laboratory for Pharma, State , Federal and International studiesFederal and International studies
  2. 2. Evolution IMTEvolution IMT measurement 1986-2005.measurement 1986-2005. Vulnerable PlaquesVulnerable Plaques Myths and issuesMyths and issues Reporting 2005Reporting 2005
  3. 3. Normal Arterial WallNormal Arterial Wall Tunica adventitia Tunica media Tunica intima Endothelium Subendothelial connective tissue Smooth muscle cell Internal elastic membrane Elastic/collagen fibres External elastic membrane
  4. 4. Blood Flow Features atBlood Flow Features at Carotid BifurcationCarotid Bifurcation  This figure depicts the region of flow separation with formation of secondary vortices.  While flow remains laminar and mainly unidirectional in the high- shear flow-divider area, a very low-shear area is present on the lateral wall of the internal carotid artery.  This area is where plaques are most likely to form and where blood flow accelerates with each cardiac cycles.
  5. 5. 19861986
  6. 6. 19921992 Edge-Contour DetectionEdge-Contour Detection
  7. 7. Intima-Medial Thickness ChangeIntima-Medial Thickness Change Colestipol-Niacin Therapy and Placebo over 48 m - CLAS StudyColestipol-Niacin Therapy and Placebo over 48 m - CLAS Study Time (months) • Placebo •Active medication Intima Media Thickness (mm)
  8. 8. IMT HeartScan vs. Caliper IMTIMT HeartScan vs. Caliper IMT Observer 1 1.00 0.5 1.000 0.5 0 n=50 r =.95 Standard Deviations: Observer 1 = 4.05 Observer = 12.45 p < 0.01 Observer 1 Observer2IMTThickness r =.63 Observer2IMTThickness 1.000 0.5 n=50
  9. 9. 1997 Prosound (PCI)1997 Prosound (PCI) Patient StudiesPatient Studies
  10. 10. IMT Triage - Utah ProjectIMT Triage - Utah Project N = 556 A 137 (25 %) B 206 (37%) C 105 (19%) D 82 (15%) Of the 556 E 13 (4%) AA p<50 Percp<50 Perc BB p=75-95 Percp=75-95 Perc CC >ULN>ULN RR 2-3RR 2-3 (Average Risk 1.5)(Average Risk 1.5) DD RR 4-6RR 4-6 EE RR 6-10RR 6-10 (Average Risk 2.7)(Average Risk 2.7)
  11. 11. Patient Compliance:Patient Compliance: An Illusion?An Illusion?
  12. 12. Personal Image N=210Personal Image N=210 Hypertension(n)Hypertension(n) HypercholesterolemiaHypercholesterolemia Smoking (n)Smoking (n) Weight Loss (kg)Weight Loss (kg) QIMT values (mm)QIMT values (mm) ±± SD;SD; *p<0.05,*p<0.05, **p<0.01 ;**p<0.01 ; Barth JD , Am J Cardiol 2001Barth JD , Am J Cardiol 2001 IMT HeartscanIMT Heartscan Efficacy StudyEfficacy Study Baseline 1 2 months Y N 88 14 /44** 21/44 108 10/54 ** 18/54 42 13/21** 19/21 87 9.5 1 0.790 0.777** 0.790 ±0.070 ± 0.062 ± 0.067
  13. 13. Impact of Picture on ComplianceImpact of Picture on Compliance  Cap test with microchipsCap test with microchips  30 tablets, once a day; after 30 days a pill count;30 tablets, once a day; after 30 days a pill count; Results:Results: without picturewithout picture with picturewith picture 40%40% 76%76%
  14. 14. C h i l d r e n :C h i l d r e n : VulnerableVulnerable and oftenand often forgotten groupforgotten group
  15. 15. Ultrasound Imaging AssessmentUltrasound Imaging Assessment Carotid Artery as a Predictor of Diabetes Susceptibility inCarotid Artery as a Predictor of Diabetes Susceptibility in Adolescent Ethnic Population GroupsAdolescent Ethnic Population Groups PARAMETERPARAMETER HispanicHispanic CaucasianCaucasian  Males and femalesMales and females N=118N=118 N=94N=94  Average age yearsAverage age years 15.015.0 15.915.9  % E from Fat (>30%)% E from Fat (>30%) 89 %89 % 77%77%  % Dietary Cholesterol(>300 mg/d)% Dietary Cholesterol(>300 mg/d) 51%51% 53%53%  Serum LDL- Cholesterol(>100 mg/dl)Serum LDL- Cholesterol(>100 mg/dl) 37%37% 19%19%  HDL-Cholesterol(<40 mg/dl)HDL-Cholesterol(<40 mg/dl) 18%**18%** 10%10%  Glucose (>100 mg/dl)Glucose (>100 mg/dl) 8%**8%** 4%4%  BMI (>30 kg/m²)BMI (>30 kg/m²) 53%*53%* 36%36%  QIMT (μ±sd)QIMT (μ±sd) 522±017* 539±021522±017* 539±021  Plaques in Diabetics (n)Plaques in Diabetics (n) 4/7**4/7** 0/50/5 E = Energy BMI = Body Mass Index ** p<0.01, * p<0.05E = Energy BMI = Body Mass Index ** p<0.01, * p<0.05
  16. 16. IMT HeartScanIMT HeartScan:: TheThe mostmost sensitive Marker of Insulinsensitive Marker of Insulin ResistanceResistance BMI>30 (n=27;7-17 y)BMI>30 (n=27;7-17 y) BMI <25 (n=13;7-17 y)BMI <25 (n=13;7-17 y) FBSFBS 92.492.4 79.479.4 mg/dl p<0.0005mg/dl p<0.0005 HbAc1HbAc1 5.075.07 5.255.25 NSNS InsulinInsulin 20.020.0 7.87.8 µµU/mlU/ml p<0.0005p<0.0005 HOMAHOMA 4.544.54 1.931.93 p<0.001p<0.001 [ HOMA: Homeostasis Model Assessment (IR) ][ HOMA: Homeostasis Model Assessment (IR) ] Conclusions:Conclusions:  IMT vs INS value r = 0.855IMT vs INS value r = 0.855 p<0.001p<0.001  IMT vs BMI value r = 0.570IMT vs BMI value r = 0.570 p<0.01p<0.01
  17. 17. Plaque Vulnerability:Plaque Vulnerability: What does it mean for the clinician?What does it mean for the clinician?
  18. 18. ZoeZoeXPXP 20052005 InternetInternet EnabledEnabled
  19. 19. PCIPCI HeartScanHeartScan™™ MeasurementMeasurement VariabilityVariability  Three operators measured FAR WALL IMTThree operators measured FAR WALL IMT using the PCI standardized procedureusing the PCI standardized procedure  Intra-operator and inter-operator intra-classIntra-operator and inter-operator intra-class correlations both were 0.97correlations both were 0.97  Coefficients of variation within readers wasCoefficients of variation within readers was 3.0% and between readers was 3.1%3.0% and between readers was 3.1%
  20. 20. About the TechnologyAbout the Technology Physician writes referral prescription for IMT HeartScan Certified ultrasound tech performs 15 min IMT HeartScan test. Data is wirelessly sent to IMT HeartScan server Software measures the IMT thickness. Interactive database generates report. Lesion assessments for size, number and vulnerability Physician and patient receive IMT HeartScan report online in less than one hour.
  21. 21.  Central Laboratory  Satellite Offices  US HeartScan Locations 20052005
  22. 22. Carotid IMT standardizationCarotid IMT standardization  Image Acquisition:Image Acquisition: SOP / PCI as published in AJC;SOP / PCI as published in AJC; Now online acquisition via DIVONow online acquisition via DIVO  Image Transport:Image Transport: Dedicated Secured FTP; HIPAADedicated Secured FTP; HIPAA compliantcompliant  Image Analysis:Image Analysis: Cross-sectional and longitudinalCross-sectional and longitudinal imaging during cardiac cycle; Automated analyses ofimaging during cardiac cycle; Automated analyses of ROI / IMT, plus lesion imaging for carotid tree;ROI / IMT, plus lesion imaging for carotid tree;  Data Reporting:Data Reporting: Individualized per patient for CCA,Individualized per patient for CCA, Lesions, and Tissue typing; Interactive database andLesions, and Tissue typing; Interactive database and automatic storage includedautomatic storage included
  23. 23. How Accurate isHow Accurate is ZoeZoeXPXP ??  Typically the field of view (ultrasound windowTypically the field of view (ultrasound window size) is 40x40 mm, which covers 200x200 pixels.size) is 40x40 mm, which covers 200x200 pixels.  The system calibration is 0.2 mm/pixel and eachThe system calibration is 0.2 mm/pixel and each pixel can be measured to a 10th.pixel can be measured to a 10th.  Bottom line: ZoeXP can measure to an accuracyBottom line: ZoeXP can measure to an accuracy of 0.02 mm orof 0.02 mm or 20 microns20 microns..  The software can measure up to 1/10 of a pixel !!The software can measure up to 1/10 of a pixel !!
  24. 24. PCIPCI HeartScanHeartScan™™ Database AdvantageDatabase Advantage  Contains over 40,000 individualsContains over 40,000 individuals  Age range 2-90 years (incl. 2000 children)Age range 2-90 years (incl. 2000 children)  Average follow-up ~ 6 yearsAverage follow-up ~ 6 years  Different ethnic groups representedDifferent ethnic groups represented  Cross-sectional & longitudinal images are savedCross-sectional & longitudinal images are saved  Demographics are separately savedDemographics are separately saved  Lesion images are savedLesion images are saved  Other miscellaneous parameters are savedOther miscellaneous parameters are saved  SQL interactive formatSQL interactive format  Third party supervision Database monitoringThird party supervision Database monitoring
  25. 25. IMT issues still to be settled . . .IMT issues still to be settled . . .  Acquisition / reportingAcquisition / reporting protocol?protocol?  Data storage?Data storage?  Caliper vs (semi)Caliper vs (semi) automatic analysis?automatic analysis?  Lesions & IMT measures?Lesions & IMT measures?  Min, max, or averageMin, max, or average measurement?measurement?  Normograms?Normograms? ZoeXP SOPZoeXP SOP HIPAA compliantHIPAA compliant dual serversdual servers Digital, fully automaticDigital, fully automatic with remote capabilitywith remote capability Both lesionsBoth lesions andand IMTIMT Min, max,Min, max, andand averageaverage MenMen andand women; Ethnicitywomen; Ethnicity [ Part 1 ][ Part 1 ] PCIPCI HeartScan™HeartScan™ AdvantageAdvantage PCIPCI HeartScan™HeartScan™ AdvantageAdvantage PCIPCI HeartScan™HeartScan™ AdvantageAdvantage PCIPCI HeartScan™HeartScan™ AdvantageAdvantage PCIPCI HeartScan™HeartScan™ AdvantageAdvantage PCIPCI HeartScan™HeartScan™ AdvantageAdvantage
  26. 26.  ReproducibilityReproducibility requirements?requirements?  One vs multiple frames?One vs multiple frames?  ECG or other requiredECG or other required add-on tests?add-on tests?  Location in the carotid treeLocation in the carotid tree for analyses?for analyses?  Acceptance of procedure?Acceptance of procedure? 3% inter + 3.1% intra3% inter + 3.1% intra Full cardiac cycleFull cardiac cycle NoneNone X and longit CCA,X and longit CCA, bulb, internalbulb, internal YesYes YesYes IMT issues still to be settled . . .IMT issues still to be settled . . . [ Part 2 ][ Part 2 ] PCIPCI HeartScan™HeartScan™ AdvantageAdvantage PCIPCI HeartScan™HeartScan™ AdvantageAdvantage PCIPCI HeartScan™HeartScan™ AdvantageAdvantage PCIPCI HeartScan™HeartScan™ AdvantageAdvantage PCIPCI HeartScan™HeartScan™ AdvantageAdvantage PCIPCI HeartScan™HeartScan™ AdvantageAdvantage
  27. 27. Report Print-out # 1 Report Print-out # 2
  28. 28. Additional InformationAdditional Information Tel: 1-866-430-scanTel: 1-866-430-scan