Comparison of Non-invasive Techniques for diagnosis of Cardiovascular Diseases.

1. Non-invasive Imaging for Management of
Cardiovascular Diseases
Dr. Muhammad Ayub, FCPS
Diplomate Certification Board of Nuclear Cardiology
Diplomate Board of Cardiovascular Computed Tomography
Department of Cardiovascular Imaging
Punjab Institute of Cardiology Lahore

2. Trends in Imaging

3. Cardiovascular Imaging

4. Comparative spatial resolution
SPECT PET Echo MRI CT
Resolution 7-15 3-10 <1 <1 <1
(mm)
Function Structure

5. Atherosclerosis and Imaging Modalities

6. Accuracy for diagnosis of CAD

7. Parameters Assessed with Various imaging Modalities
LV Perfusion Coronary Viability Valve Radiation
Function Pathology Function Dose
PET + + - + -
SPECT + + - + -
10-25 mSv
Echo + + - + + -
+
IVUS
MSCT + - + _ - 9.3-11.3
mSv
MRI + + _ + + -
Cardiac + + + - + 3-5 mSv
Cath TIMI Flow,
TIMI Blush

8. Applications of Nuclear Cardiology
 Coronary Artery Disease
 Assessment of LV /RV function
 Cardiomyopathy /Myocarditis
 Valvular Heart Disease
 Cardiac Shunts
 Secondary Hypertension
 Pulmonary Hypertension
 Assessment of Cardiac Transplant

9. Nuclear Studies for Diagnosis of CAD

10. Incremental Prognostic Value of MPI
P<.01 P=ns
40.0
35.0 33.5 33.7
P<.01
30.0
25.0
25.0
2 20.0
15.0 P=ns
10.0 7.4
5.1
5.0
0.0
Clinical +Ex Clin Clin All
+Ex +Ex N = 316
NS=not significant +Cath +SPECT
Iskandrian AS, et al. J Am Coll Cardiol. 1993;22:665-670. Reproduced with permission.
Copyright 1993 by the American College of Cardiology.

11. Cardiac CT

12. Applications of Cardiac CT
 Diagnosis of Coronary Artery Disease (intermediate probability)
 Suspected Coronary Anomalies
 Assessment of grafts prior to redo CABG
 Assessment of complex congenital heart disease (difficult echo)
 Suspected Aortic Dissection
 Suspected Pulmonary Embolism
 Assessment of Cardiac masses (difficult echo)
 Assessment of pericardial conditions (difficult echo)
 Assessment of pulmonary veins prior to radiofrequency ablation
 Assessment of coronary veins prior to biventricular pacing

13. CTA Accuracy of MDCT for CAD

14. CTA Limitations
 Rapid (>80 bpm) and irregular HR
 High calcium scores (>800-1000)
 Stents
 Contrast requirements (Cr > 2.0 mg/dl)
 Small vessels (<1.5 mm) and collaterals
 Obese and uncooperative patients
 RADIATION EXPOSURE

15. Cardiac MRI

16. Diagnosis of CAD
MRI Vs SPECT
100% 88% 90% 91% 88% 87%
90%
80% 71%
70% 52% 52%
60%
50%
40%
Sensitivity
30%
Specificity
20%
10%
0%
MRI SSS SRS SDS

17. MR Assessment of Myocardial Viability
N Myocardium
Gd
injection
infarct
1st pass Delayed time
enhancement

18. MRI
 Pros
 No Radiation
 Less Toxic Gadolinium Contrast
 Cons
 Expensive
 Claustrophobic
 Long Acquisition time
 Operator dependant
 Technical Artifacts with 3T
 Problem in patients with metallic prosthesis

19. Diagnostic Testing According to Clinical Need

20. Chest pain syndrome
Intermediate Likelihood for CAD
Resting ECG abnormal or patient not able to Exercise
CTA MPI
Low to Intermediate Intermediate to High
•Stress MPI
CT Angiography •Stress Echo
•Dobutamine MR

21. Evaluation of Chest Pain Syndrome
Equivocal Test
Myocardial Perfusion Imaging CT Coronary Angiography
Equivocal Equivocal
Myocardial Perfusion Imaging CT Coronary Angiography

22. Evaluation of Suspected Coronary Anomalies
 CT Angiography
 MR Angiography
50 years old male underwent CCA for
FC III angina but RCA could not be
engaged
The patient was referred for CT
Angiography for suspected coronary
anomaly

23. Diagnosis of Acute Chest Pain
 Detection of CAD: Symptomatic—Acute Chest Pain
Intermediate pre-test probability of CAD. No ECG changes and serial
enzymes negative
CT Coronary Angiography Resting MPI

24. Assessment of myocardial Viability
 Cardiac MRI
 PET Metabolism/ perfusion
 Thallium 201/Tc-sestamibi SPECT
 Low dose dobutamine echo

25. Assessment of Cardiac Function
 Echocardiography
 Nuclear Studies
 Cardiac MRI
 Cardiac MDCT

26. Assessment of Valvular Function
 Echocardiography
 Cardiac MRI
 Nuclear Studies
 Cardiac CT

27. Assessment of Cardiac Shunts
 Echocardiography
 Nuclear first pass study
 Cardiac MRI
 Cardiac MDCT

28. Assessment of Cardiac Masses
 Echocardiography
 Cardiac MRI
 Cardiac MDCT

29. Assessment of Pericardial Conditions
Echocardiography (TTE; TEE)
Cardiac MRI
Cardiac CT
Echo MDCT MRI

30. Assessment of Complex Congenital
Heart Disease
 Echocardiography
 Cardiac CT
 Cardiac MRI
CT MR

31. Assessment of Pulmonary Venous Anatomy
before Radiofrequency Ablation
 Echocardiography
 CT Angiography

32. Post CABG Assessment
• MPI
• CT Angiography
Noninvasive coronary arterial
mapping, including internal
mammary artery prior to repeat
cardiac surgical
revascularization

33. Suspected Aortic Aneurysm/ Dissection
 Echocardiography
 CT Angiography
 Cardiac MRI
 Structure and Function—
Evaluation of Aortic and
Pulmonary Disease
Evaluation of suspected aortic
dissection or thoracic aortic
aneurysm
A (9)

34. Suspected Pulmonary Embolism
 Echocardiography
 CT Pulmonary Angiography
 Lung Perfusion Ventilation Scan

35. Calcium Deposit (Atherosclerotic patient)
Soft Plaque( CTA, new ligands)
Is there
any one
stop shop?
Perfusion deficit
LV Function
(Rb-82 stress and rest)
Substrate Metabolism
Three (Five) Tests in One Sitting
Courtesy of E. Garcia, Emory U.

36. Conclusions
 No simple Recipe
 Appropriate Usage of all available technologies
according to clinical need

37. Thank you for listening