Role of noninvasive imaging for diagnosis of secondary hypertension and for assessment of complications of un-controlled hypertension.

1. THE HEART IN HYPERTENSION:
ART AND SCIENCE OF IMAGERY
PROF. DR. MUHAMMAD AYUB, FCPS
DIPLOMATE CBNC; DIPLOMATE CBCCT
CONSULTANT CARDIOVASCULAR IMAGING

2. THE HEART IN HYPERTENSION

3. IMAGING IN HYPERTENSION
• Diagnosis and follow-up of Secondary Hypertension
• Assessment of sequalae of hypertension

4. IMAGING MODALITIES

5. COMPARATIVE SPATIAL RESOLUTION
TECHNIQUE SPECT PET Echo MRI CT
Resolution 6-8mm 3mm 1.2mm 0.9mm 0.4mm
Function Structure

6. LV
Function
Perfusion Coronary
Pathology
Viability Valve
Function
Radiation
Dose
Rb-82 PET + + - + - 3.0 mSv
SPECT + + - + - 10-25 mSv
Echo + + -
+
IVUS
+ + -
MSCT + + + - + 9.3-11.3
mSv
MRI + + _ + + -
Cardiac
Cath
+ +
TIMI Flow,
TIMI Blush
+ - + 3-5 mSv
PARAMETERS ASSESSED WITH
VARIOUS IMAGING MODALITIES

7. ETIOLOGY OF HYPERTENSION
• Essential Hypertension in adults (95%)
• Secondary Hypertension in adults (05%)
• Secondary hypertension in Children (85%)

8. SUSPECTED SECONDARY HYPERTENSION:
NUCLEAR TESTS
Cause NM investigation
Renal parenchymal disease DTPA Renogram, DMSA Scan
Renal Artery Stenosis Captopril Renogram Study
Primary Aldosteronism NP-59 SPECT/CT
Pheochromocytoma I123-MIBG Scan
Hyperthyroidism T3, T4, TSH, Thyroid Scan
Hypothyroidism T4, TSH, Thyroid Scan
Coarctation of Aorta none
Sleep Apnea none
Drugs none

9. RENAL PARENCHYMAL DISEASES
DTPA RENOGRAM DMSA SCAN

10. DIAGNOSIS OF RENOVASCULAR HYPERTENSION
Fibromuscular dysplasia in 20-year-old male
CTA Renal Doppler USG DSA

11. SECONDARY HYPERTENSION: SUSPECTED RENAL ARTERY
STENOSIS
Captopril Renogram Study
Sensitivity=71%Specificity= 75%
BASELINE POST CAPTOPRIL

12. (A) Right adrenal tumor confirmed as pheochromocytoma at surgery.
(B) (B) Anterior (left) and posterior (right) whole-body images of metastatic paraganglioma
Gregory A. Wiseman et al. J Nucl Med 2009;50:1448-1454
SECONDARY HYPERTENSION: SUSPECTED PHEOCHROMOCYTOMA
123I MIBG SCAN
Sensitivity= 77-90%
Specificity= 95-
100%

13. 131I MIBG TREATMENT FOR MALIGNANT
PHEOCHROMOCYTOMA

14. SECONDARY HYPERTENSION: SUSPECTED
ADRENAL CORTICAL TUMOR
NP-59 SPECT/CT IMAGING (ALDOSTERONISM)

15. SECONDARY HYPERTENSION: SUSPECTED COARCTATION OF
AORTA
• ECHOCARDIOGRAPHY
• CARDIAC CT
• CARDIAC MRI
• NO ROLE OF NUCLEAR TECHNIQUES

16. SUSPECTED COARCTATION
ECHOCARDIOGRAPHY

17. SECONDARY HYPERTENSION: SUSPECTED COARCTATION OF AORTA

18. EVALUATION OF SEQUALAE OF
HYPERTENSION
• Assessment for coexisting CAD
• Assessment of LV hypertrophy
• Assessment of Cardiac Function
• Suspected Aortic Dissection in Hypertensive Patient

19. ACCURACY FOR DIAGNOSIS OF CAD
Sensitivity Specificity
Stress Echo 83% 93%
SPECT 83% 77%
PET (Rb-82, N-13) 93% 82%
Coronary CTA 96% 93%
CMR 88% 90%

20. ASSESSMENT OF MYOCARDIAL PERFUSION: STRESS REST MPI

21. ASSESSMENT OF MYOCARDIAL ISCHEMIA:
STRESS ECHOCARDIOGRAPHY
Sensitivity: 83%
Specificity: 93%

22. Manish Motwani. Circulation: Cardiovascular Imaging. Advanced
Cardiovascular Magnetic Resonance Myocardial Perfusion Imaging,
Volume: 6, Issue: 2, Pages: 339-348, DOI:
(10.1161/CIRCIMAGING.112.000193) © 2013 American Heart Association, Inc.
ASSESSMENT OF MYOCARDIAL PERFUSION:
STRESS PERFUSION MRI
Sensitivity: 88%
Specificity: 90%

23. ASSESSMENT OF MYOCARDIAL PERFUSION
MRI Vs SPECT
88% 90%
71%
91%
52%
88%
52%
87%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
MRI SSS SRS SDS
Sensitivity
Specificity

24. ASSESSMENT OF CORONARY ANATOMY
AND MYOCARDIAL ISCHEMIA: CARDIAC CT
Rodrigo J. Cerci. Circulation: Cardiovascular Imaging. Aligning
Coronary Anatomy and Myocardial Perfusion Territories, Volume: 5,
Issue: 5, Pages: 587-595, DOI: (10.1161/CIRCIMAGING.111.970608)

25. ASSESSMENT OF LV HYPERTROPHY:
LEFT VENTRICULAR MASS (A) AND VOLUMES (B):
THREE-DIMENSIONAL ECHOCARDIOGRAPHY

26. ASSESSMENT
OF LV
HYPERTROPHY:
CARDIAC MASS
WITH SPECT
MPI

27. LV MASS BY SPECT: COMPARISON WITH CMR
Linear regression analysis and Bland-Altman plots for comparison of LV mass values obtained
on CMR and on CZT images with either 4DM (Panel A) or ECTb (Panel B)
LVH Criteria:
> 74 g/m2 in
men
and > 63 g/m2
in women.

28. European Heart Journal - Cardiovascular Imaging, Volume 18, Issue 1, January 2017, Pages 95–102,
https://doi.org/10.1093/ehjci/jev357
The content of this slide may be subject to copyright: please see the slide notes for details.
ASSESSMENT OF LV HYPERTROPHY:
CONTRAST-ENHANCED CT ANGIOGRAPHY
STUDY.

29. ASSESSMENT OF LV HYPERTROPHY AND
CARDIAC MASS WITH CMR

30. ASSESSMENT OF CARDIAC FUNCTION
Echocardiography
Cardiac MRI
Nuclear Studies
Cardiac MDCT

31. ASSESSMENT OF CARDIAC FUNCTION
ECHOCARDIOGRAPHY

32. ASSESSMENT OF CARDIAC FUNCTION:
CMR

33. ASSESSMENT OF CARDIAC FUNCTION
GATED MYOCARDIAL PERFUSION SPECT

34. ASSESSMENT OF CARDIAC FUNCTION
MUGA SCAN LV DYSFUNCTION

35. SUSPECTED AORTIC DISSECTION IN
HYPERTENSIVE PATIENT
• Echocardiography
• Cardiac CT

36. SUSPECTED AORTIC DISSECTION IN HYPERTENSIVE
PATIENT WITH COARCTATION OF AORTA

37. CONCLUSIONS:
• Muti-modality imaging is extremely helpful for
diagnosis of etiology of secondary hypertension
and for evaluation of sequalae of uncontrolled
hypertension.
•The knowledge of all imaging modalities is a
great Science but the real Art lies in the right
choice of right technology

38. •Thank you for patient listening