The document discusses the role of cardiac imaging in assessing patients with coronary artery disease (CAD). It provides examples of how cardiac imaging with techniques like myocardial perfusion scintigraphy (MPS), positron emission tomography (PET), and magnetic resonance imaging (MRI) can influence patient outcomes. Randomized controlled trials show that imaging-guided management and assessment of ischemia can improve outcomes compared to usual care. Imaging also enables equal diagnostic outcomes at lower cost compared to invasive procedures. Overall, cardiac imaging is presented as having a natural partnership with cardiology for evaluating CAD and guiding treatment.

1. PIC Heart Talk 2013
and EP Con
October 24 – 26, 2013

2. Can cardiac imaging improve patient
outcome?
Richard Underwood
Professor of Cardiac Imaging
Imperial College London
Royal Brompton & Harefield Hospitals

3. Roles of imaging in CAD
• Diagnosis
• Coronary anatomy & function
• Myocardial anatomy & function
• Valve anatomy & function
• Objective assessment of symptoms
• Disease severity & burden
• Acute & chronic risk assessment
• Myocardial viability, stunning & hibernation
• Guiding revascularisation
• Monitoring therapy

4. Subspecialty Cardiac Imaging
• Echocardiography
– Rest
– Stress
– Specialist (e.g. trans-oesophageal)
• Radionuclide imaging
– Myocardial perfusion scintigraphy
– Radionuclide ventriculography
• Magnetic resonance imaging
• X-ray computed tomography
– Coronary calcium imaging
– Coronary angiography

5. Cardiac Imaging 2011
3000
2500
2000
1500
1000
500
0
MPS¹ PET perfn² sEcho² MR perfn¹ Coronary
CT¹
Tests per million
¹ECNC survey
²Personal communications

6. How might imaging influence outcome?
• Avoiding diagnostic false negatives of less sensitive
investigations
• Avoiding complications of invasive investigation
• Identifying patients with high but reversible risk
• Preventing intervention if no reversible risk
• Achieving similar outcome without intervention
• Achieving similar outcome at reduced cost

7. Myocardial perfusion scintigraphy
LVEF 74%

8. Prognostic value of MPS
• asymptomatic volunteers
• asymptomatic patients with
abnormal sECG
• investigation of suspected CAD
• known CAD with stable angina
• after infarction
• after stabilisation of UA
• after revascularisation
• before non-cardiac surgery
Annual hard event rate
0.7%
6.7%
MPS normal MPS abnormal
Underwood SR, et al. EJNM 2004; 31; 261-91
29 studies , 20963 patients, mean follow-up 28m

9. Beliefs concerning PCI
Ann Intern Med 2010; 153: 307-13

10. Studies of ischaemia guided management
• A
• BARI-2D
• COURAGE
• DEFER
• ERASE
• FAME
• GRACE
• INSPIRE
• OASIS
• etc
Cath facilities No cath facilities
84%
42%
85%
52%
100%
80%
60%
40%
20%
0%
ACS No ACS
Patients admitted
MPS Normal care
20%
15%
10%
5%
0%
Death or
MI
Stroke Bleed Angina

11. Relevant outcome studies
Study Topic Design
FAME FFR vs CAG guided PCI Randomised
DEFER PCI vs MT Randomised
Al Housni Ischaemia & PCI response, stable CAD Observational
Hachamovitch MT vs revasc, stable CAD Observational
COURAGE OMT vs PCI, stable CAD Randomised
INSPIRE MT vs revasc, after MI Randomised
STICH MT vs CABG, impaired LV function Randomised
PARR2 FDG PET vs standard care, impaired LV function Randomised
EMPIRE Cost effectiveness of diagnosis Controlled
END Cost effectiveness of diagnosis Observational

12. FFR guided PCI, FAME 1
Pijls NHJ et al. JACC 2010; 56: 177-84
Survival from death or MI
• 1005 patients
• Multi-vessel disease
undergoing PCI
• Randomised to CAG
alone or FFR
P = 0.02
Fearon WF, et al. Circ 2010; 122: 2545-50

13. FFR guided PCI, FAME 2
Death, MI, urgent revasc Death
De Bruyne B. NEJM 2012; 367: 991-1001
1220 patients, SCAD, FFR <0.8

14. Stenting insignificant lesions
Pijls NHJ et al. JACC 2007; 49: 2105-11
325 patients, elective PCI for intermediate stenosis
5 year cardiac death or MI
DEFER study

15. Function v anatomy for symptoms
123 patients, elective PCI
Procedure blinded to MPS
sECG baseline + 6 months
Al-Housni MB, et al. JNC 2009; 16: 869-77
SDS 0
SDS 1-6
SDS >6

16. Benefit of revasc vs medical therapy
% myocardium ischaemic
Hachamovitch R et al, 2011 doi: 10.1093/eurheartj.ehq500
13555 patients, mean f/u 8.7yr, subset with <10% scar
HR early revasc vs medical

17. PCI in stable angina
years
Free from death or MI
NEJM 2007; 356: 1503-16
Quality of Life
NEJM 2008; 359: 677-87
months

18. Events and ischaemia
Shaw LJ, et al. Circulation 2008; 117:1283-91
314 of 2287 patients, stable angina randomised to OMT or PCI

19. Events rates by ischaemia reduction
Baseline
ischaemia
>10%
Events and ischaemia reduction
Shaw LJ, et al. Circulation 2008; 117:1283-91
314 of 2287 patients, stable angina randomised to OMT or PCI

20. Management after High Risk MI
• 205 patients, stable after MI
• Stress MPS defect >20%
• Reversible MPS defect >10%
• LVEF >35%
• Randomised to medical Rx or
revascularisation
Mahmarian J, et al. INSPIRE trial JACC 2006; 48: 2458-67

21. Management after High Risk MI
Mahmarian J, et al. INSPIRE trial JACC 2006; 48: 2458-67

22. STICH trial
Bonow RO, et al. NEJM 2011; 364: 1617-25
HR 0.64 (95% CI 0.48-0.86)
P = 0.003 unadjusted
P = 0.21 risk adjusted
• 1212 patients with IHD
& LVEF <35%
• Randomised to medical
Rx or CABG
• 5 year follow-up
• 601 patients underwent
viability assessment in
non-random fashion

23. STICH limitations
• Nonrandomised selection of patients for imaging (601 of
1212)
• 72% of imaging referrals after randomisation
• MPS definition of viability: > 11/17 segments with uptake >50%
• Echo definition of viability: > 5/16 segments with abnormal
resting function but contractile reserve to dobutamine

24. Hibernation and outcome
PARR2 study
• 430 patients, suspected CAD,
LVEF <35%
• Randomised to FDG imaging or
standard care
• Primary outcome cardiac death,
MI or admission at 1 year
Survival free of 1° outcome
Beanlands RSG et al. JACC 2007; 50: 2002-12
P = 0.15

25. Perfusion viability mismatch
Revascularisation or workup recommendation if “significant viability”
Beanlands RSG et al. JACC 2007; 50: 2002-12

26. Hibernation and outcome
PARR2 study
• 430 patients, suspected CAD,
LVEF <35%
• Randomised to FDG imaging or
standard care
• Primary outcome cardiac death,
MI or admission at 1 year
Survival free of 1° outcome
Beanlands RSG et al. JACC 2007; 50: 2002-12
P = 0.15
P = 0.019
Post hoc analysis
• 156 patients in PET arm who
adhered to PET recommendation

27. Revasc benefit with extensive hibernation
Death, MI, admission
Cardiac death
D'Egidio G . . . Beanlands RGS JACCCI 2009; 2: 1060-8
PARR2 sub-study
182 patients randomised to PET arm
IHD and LVEF <35%
>7% hibernation
benefit from revascularisation

28. Hibernation and outcome
Ottawa-FIVE sub-study of PARR2
111 patients with:
1 Ready access to FDG
2 Expertise in FDG imaging
3 Integration between imaging,
4 Heart failure and
5 Revascularisation teams
Abraham A . . . Beanlands RSG. JNM 2010; 51: 567-74
Survival free of 1° outcome

29. Two year costs (CAD absent)
£1,800
£1,600
£1,400
£1,200
£1,000
£800
£600
£400
£200
£0
Management
Diagnosis
Strategy 1 2 3 4 Scint Non-scint
EMPIRE study. Eur Heart J 1999; 20: 157-66
P < 0.0001
P < 0.05
P < 0.001

30. Rapid Access Chest Pain Clinic
• 1522 patients referred Dec 97 to Apr 2000 (630/yr)
• clinical management decisions by SpR with consultant
supervision
Male % Female %
Ex-ECG 100 100
MPI 8 5
Angiogram 31 23
Normal angiogram 16 56
Wong Y et al. Heart 2001; 85: 149-152

31. Conclusion
Randomised controlled trials
• Assessment of coronary function improves outcome in PCI
• Ischaemia reduction assessed by MPS improves outcome
• Conservative management after high risk MI identified by MPS has
the same outcome as intervention
• FDG PET improves outcome in severe LV dysfunction in an expert
centre
Controlled studies
• MPS achieves equal diagnostic outcome at lower cost
Observational studies
• MPS identifies patients who will benefit symptomatically from PCI
• Patients with >10% myocardial ischaemia have improved outcome
with revascularisation

32. Imaging & Cardiology
a natural partnership