ΗΜΑΝΣΙΚΔ ΜΔΛΔΣΔ ΣΗΝ ΠΤΡΗΝΙΚΗ ΚΑΡΓΙΟΛΟΓΙΑ

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1 ΗΜΑΝΣΙΚΔ ΜΔΛΔΣΔ ΣΗΝ ΠΤΡΗΝΙΚΗ ΚΑΡΓΙΟΛΟΓΙΑ Πάνος Κορκονικήηας Καρδιολόγος Γ.Ν.Νέας Ιωνίας Κωνζηανηοπούλειο Σεμινάρια Ομάδων Εργαζίας ηης Ελληνικής Καρδιολογικής Εηαιρείας Θεζζαλονίκη 2012

3 Overall Survival PCI + OMT OMT Hazard ratio: % CI ( ) P = Years 5 6 Number at Risk 7

5 εκαληηθέο πξόζθαηεο κειέηεο

8 Imaging heart failure

9 123 I-mIBG Cardiac Imaging Studied in Japan and Europe for 2 decades as a marker of prognosis in heart failure The lower the uptake, the poorer the outcome Limitations of prior studies 1.Single-center experiences 2. No standardization of uptake analysis methodology 3. Diagnostic criteria and endpoints were not always prospectively established

12 BLOOD VESSEL NERVE TERMINAL NE VMAT NE NET1 a2c SYNAPTIC CLEFT a + b receptors COMT NE NMN EFFECTOR mibg mibg enters the synaptic cleft and is taken up into the neuron by NET With heart disease, there may be reduction in the number of presynaptic neurons and the function of the NET, resulting in decreased uptake of mibg.

13 METHODS

21 Endpoint Analyses

22 All-cause Mortality vs BNP (Median 140) & H/M BNP<140 & H/M 1.60 Survival Probability BNP>140 & H/M 1.60 BNP<140 & H/M<1.60 BNP>140 & H/M<1.60* Time (days) *p=0.024 vs BNP>140 & H/M 1.60

23 All-cause Mortality vs LVEF & H/M LVEF 30%, H/M 1.60* Survival Probability LVEF<30%, H/M 1.60** LVEF 30%, H/M<1.60 LVEF<30%, H/M<1.60 Time (days) *p=0.006 vs LVEF 30%, H/M<1.60 **p=0.023 vs LVEF<30%, H/M<1.60

Three Patients with NYHA Class II HF and LVEF between

25 Three Patients with NYHA Class II HF and LVEF between 20-25%. Patient 1 has highly elevated BNP (>1000) BNP in patients 2 and 3 is normal (<100) H/M=0.96 Died at 8 mo HF Progression H/M=1.38 Died at 8 mo, SCD (No ICD) H/M=1.67 No event Based upon the results of ADMIRE-HF, 2-year cardiac mortality risk for patient 1 is 10 times that of patient 3.

26 Ο ξπζκόο έθπιπζεο MIBG (washout rate) είλαη ν πην ηζρπξόο πξνγλωζηηθόο δείθηεο ζε αζζελείο κε θαξδηαθή αλεπάξθεηα Η θαξκαθεπηηθή αληηκεηώπηζε θαίλεηαη πωο κπνξεί λα είλαη απνηειεζκαηηθή όηαλ H/M είλαη δηαηεξεκέλν ελώ washout rate απμεκέλν

28 Βηωζηκόηεηα Μηα ζεκαληηθή κεξίδα αζζελώλ κε επεξεαζκέλε ιεηηνπξγηθόηεηα αξηζηεξήο θνηιίαο έρνπλ ζηνηρεία βηωζηκόηεηαο θαη παξνπζηάδνπλ βειηίωζε ζηε ιεηηνπξγία ηεο κεηά από ζεξαπεία επαλαηκάηωζεο Οη αζζελείο κε ελδείμεηο βηωζηκόηεηαο πνπ ππόθεηηαη ζε ζεξαπεία επαλαηκάηωζεο έρνπλ θαιύηεξε επηβίωζε ζε ζρέζε κε απηνύο πνπ αληηκεηωπίδνληαη θαξκαθεπηηθά.

31 How much viability is enough????

35 In the subset of 601 patients in the trial who had myocardial viability imaging, those with viable myocardium were not less likely to die than those without viable myocardium after adjustment for baseline variables (37% versus 51%,P=0.21)

37 Findings from the STICH (Surgical Treatment for IsChemic Heart failure) study suggest that the outcomes of patients with ischemic heart disease and a reduced left ventricular ejection fraction are unaffected by whether they show viable myocardium on imaging.

Cumulative Event-Free Survival (%) Results from What s the Optimal Method for Ischemia Evaluation in WomeN (WOMEN)s Trial 100% 98% p=0.59 96% 94% HR: 1.3 (0.

39 Cumulative Event-Free Survival (%) Results from What s the Optimal Method for Ischemia Evaluation in WomeN (WOMEN)s Trial 100% 98% p= % 94% HR: 1.3 ( ) (17 Confirmed 1 0 Endpoints) 92% ECG ECG+MPS 90% 0 0,1 0,2 0,3 0,4 0,5 0,6 0,7 0,8 0,9 1 1,1 1,2 1,3 1,4 1,5 1,6 1,7 1,8 1,9 2 Time to Follow-up (in years)

Copyright 2012 American College of Cardiology Foundation. Restrictions may apply.

47 Conclusions Overall, noninvasive studies had only a modest impact on the clinical management of patients referred for clinical testing. Although post-imaging use of cardiac catheterization and medical therapy increase in proportion to the degree of abnormal study results, the frequency of catheterization and medication use suggest possible undertreatment of higher-risk patients. Compared with stress MPI, catheterization referral rates and subsequent need for revascularization are greater after CCTA, but the rates of medication use are similar.

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