ΠΑΝΟΣ ΚΟΡΚΟΝΙΚΗΤΑΣ ΚΑΡΔΙΟΛΟΓΟΣ Γ.Ν.ΝΕΑΣ ΙΩΝΙΑΣ ΚΩΝΣΤΑΝΤΟΠΟΥΛΕΙΟ

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1 ΠΑΝΟΣ ΚΟΡΚΟΝΙΚΗΤΑΣ ΚΑΡΔΙΟΛΟΓΟΣ Γ.Ν.ΝΕΑΣ ΙΩΝΙΑΣ ΚΩΝΣΤΑΝΤΟΠΟΥΛΕΙΟ

2 ! "##$%& (%) µ*$+, %-. /%*0+1%1)%µ+2, µ+3 4" %3 /. /+ 432*1$)+ *#)2%2 %-. /52 "/ %)$"6%Galenica

By the definition used for Stable CAD, insufficient blood flow may be manifest by ischemia, angina or both. Therefore angina may not be present with Stable CAD.

3 By the definition used for Stable CAD, insufficient blood flow may be manifest by ischemia, angina or both. Therefore angina may not be present with Stable CAD. Examples of stable coronary artery disease include the following: Prior myocardial infarctions Prior revascularization Angiographically proven coronary atherosclerosis Non-invasive evidence of myocardial ischemia

6 In patients without prior CAD, MPI is considered appropriate only in those who: (1) are at high cardiovascular heart disease risk based on standard Adult Treatment Panel (ATP) III criteria; (2) are at high cardiovascular heart disease risk with a moderately abnormal ( ) CACS by non-contrast CT; or (3) have a severely abnormal CACS (>400) in whom silent myocardial ischemia is known to be prevalent.

7 Detection of Ischemia in Asymptomatic Diabetics (DIAD) Study 1123 ασθενείς Απεικόνιση της αιµάτωσης του µυοκαρδίου (SPECT) Θεραπευτική φροντίδα χωρίς screening 7%$%(+8+9:545 #)%5 ;$.2)%

8 Αποτελέσµατα της µελέτης

13 Modified from Gimelli et al, J Nucl Med 2009;50:546-53

STABLE CORONARY ARTERY DISEASE Normal MPS in patients with intermediate to high likelihood of CAD predicts a very low event rate ( 1%/year), leading to a negative predictive value 99%.

14 STABLE CORONARY ARTERY DISEASE Normal MPS in patients with intermediate to high likelihood of CAD predicts a very low event rate ( 1%/year), leading to a negative predictive value 99%. Abnormal MPS in patients with intermediate to high likelihood of CAD increases the annualized event rate by a factor of 7, and the risk of events is related to the severity of perfusion abnormalities (from 3% annual death or MI with mild to moderate perfusion defects up to 7% in patients with severe perfusion abnormalities

15 STABLE CORONARY ARTERY DISEASE In patients with a number of risk factors (diabetes, dyslipidaemia, hypertension) low event rates extend for at least 2 years. Functional data from ECG-gated SPECT are additional prognostic indicators with LVEF after stress 45% or ESV 70mL indicating an adverse outcome even in the presence of mild inducible perfusion abnormalities. Markers of LV dysfunction are more efficient in the prediction of death, whereas markers of ischaemia are better predictors of ischemic events such as reccurent chest pain and non-fatal infraction

In patients with stable ischemic heart disease, myocardial perfusion imaging may be sometimes regarded as an unnecessary, or even redundant investigation.

19 In patients with stable ischemic heart disease, myocardial perfusion imaging may be sometimes regarded as an unnecessary, or even redundant investigation. But the number of resting echos doubled and nuclear stress tests tripled in the 10-year span, according to the study published online in Circulation: Cardiovascular Quality and Outcomes.

21 Overall Survival Number at Risk 1.0 PCI + OMT OMT Hazard ratio: % CI ( ) P = Years

Ischemia Change in Stable Coronary Artery Disease is an Independent predictor of Death and Myocardial Infarction J Am Coll Cardiol Img. 2012;5(7):715-724.

single-photon emission computed tomography (MPS) scans between September 1993 and June 2009 within a median of 12 months (*) were included in the study.

26 Ischemia Change in Stable Coronary Artery Disease is an Independent predictor of Death and Myocardial Infarction J Am Coll Cardiol Img. 2012;5(7): Study Population and Design A total of 1,425 consecutive patients with angiographically documented coronary artery disease (CAD) who underwent 2 serial myocardial perfusion single-photon emission computed tomography (MPS) scans between September 1993 and June 2009 within a median of 12 months (*) were included in the study. Patients were included in the percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) group on the basis of the first revascularization procedure occurring within 60 days of the first MPS scan. MT = medical therapy.

From: Ischemia Change in Stable Coronary Artery Disease Is an Independent Predictor of Death and Myocardial Infarction J Am Coll Cardiol Img. 2012;5(7):715-724.

27 From: Ischemia Change in Stable Coronary Artery Disease Is an Independent Predictor of Death and Myocardial Infarction J Am Coll Cardiol Img. 2012;5(7): Percentage of Patients With Worsening Ischemia ( 5%) In the MT group, 15.6% of patients had worsening ischemia of 5%, compared with 6.2% in the PCI group and 6.7% in the CABG group. The proportion of patients with 5% ischemia worsening was significantly greater in the MT group compared with the PCI or CABG group (p < ).

28 Ischemia Change in Stable Coronary Artery Disease Is an Independent Predictor of Death and Myocardial Infarction J Am Coll Cardiol Img. 2012;5(7): Kaplan-Meier Curve of Patients With 5% Versus <5% Ischemia Worsening There was a significant difference in Kaplan-Meier event rates (p < ) between patients with 5% ischemia worsening and those with <5% ischemia worsening. Patients were followed for a median of 5.8 years.

29 Algorithm for Revascularization to Improve Survival of Patients With SIHD* *Colors correspond to the ACCF/AHA Classification of Recommendations and Levels of Evidence Table.

baseline SPECT ischemia within the COURAGE trial did not predict cardiac events in the overall cohort nor did the addition of PCI to OMT reduce cardiac events, even when the analysis was confined to

31 baseline SPECT ischemia within the COURAGE trial did not predict cardiac events in the overall cohort nor did the addition of PCI to OMT reduce cardiac events, even when the analysis was confined to patients with moderate to severe ischemia. Baseline stress myocardial perfusion imaging results and outcomes in patients with stable ischemic heart disease randomized to optimal medical therapy with or without percutaneous coronary intervention Leslee J. Shaw, PhD, Am Heart J 2012;164:243-50

32 The current results suggest that less than optimal quality or experience may reduce or obviate the clinical value of an imaging modality. It is also possible that clinical history data may have influenced the nuclear interpretation resulting in an overestimated severity of ischemia.

33 The recently funded National Institutes of Health- NationalHeart, Lung, and Blood Institute sponsored ISCHEMIA trial that will compare treatment effectiveness for patients with SIHD with quantitatively derived estimates of moderate to severe ischemia is necessary to answer this question, affecting millions of patients with SIHD

34 vs

35 The Randomized Evaluation of Patients with Stable Angina Comparing Utilization of Diagnostic Examinations (RESCUE) is a multi-center randomized, controlled trial responding to the need for comparative analysis of these imaging technologies and the role of OMT in clinical care. A total of 4300 patients will be randomized to CCTA or SPECT MPI/ICA for diagnostic assessment of angina at up to 80 institutions internationally.

Βιωσιµότητα Μια σηµαντική µερίδα ασθενών µε επηρεασµένη λειτουργικότητα αριστερής κοιλίας έχουν στοιχεία βιωσιµότητας και παρουσιάζουν βελτίωση στη λειτουργία της µετά από

36 Βιωσιµότητα Μια σηµαντική µερίδα ασθενών µε επηρεασµένη λειτουργικότητα αριστερής κοιλίας έχουν στοιχεία βιωσιµότητας και παρουσιάζουν βελτίωση στη λειτουργία της µετά από θεραπεία επαναιµάτωσης Οι ασθενείς µε ενδείξεις βιωσιµότητας που υπόκειται σε θεραπεία επαναιµάτωσης έχουν καλύτερη επιβίωση σε σχέση µε αυτούς που αντιµετωπίζονται φαρµακευτικά.

41 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)

42 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.

moderate household, yard, or recreational work and most activities of daily living) and have no

46 Noninvasive Testing in Known SIHD: Asymptomatic (or Stable Symptoms) *Patients are candidates for exercise testing if they are capable of performing at least moderate physical functioning (i.e., moderate household, yard, or recreational work and most activities of daily living) and have no disabling comorbidity. Patients should be able to achieve 85% of age-predicted maximum heart rate.

47 Follow-Up Noninvasive Testing in Patients With Known SIHD: New, Recurrent or Worsening Symptoms, Not Consistent With Unstable Angina

48 Follow-Up Noninvasive Testing in Patients With Known SIHD: New, Recurrent, or Worsening Symptoms Not Consistent with UA

49 Algorithm for Risk Assessment of Patients With SIHD* *Colors correspond to the ACCF/AHA Classification of Recommendations and Levels of Evidence Table.

50 Algorithm for Risk Assessment of Patients With SIHD (cont.)* *Colors correspond to the ACCF/AHA Classification of Recommendations and Levels of Evidence Table.

51 ΣΥΜΠΕΡΑΣΜΑΤΑ Το σπινθηρογράφηµα µυοκαρδίου είναι µια καλά τεκµηριωµένη µέθοδος για την διάγνωση της ΣΝ σε ασυµπτωµατικούς ασθενείς µε δείκτες υψηλού κινδύνου και/ή υψηλό calcium score την εκτίµηση της πρόγνωσης για τους ασθενείς ενδιάµεσου και υψηλού κινδύνου µε σταθερή ΣΝ την παρακολούθηση αυτών που έχουν νέα, επαναλαµβανόµενα ή επιδεινούµενα συµπτώµατα και την ανίχνευση βιώσιµου µυοκαρδιακού ιστού σε αυτούς τους ασθενείς που έχουν ήδη υποστεί ΟΕΜ έτσι ώστε να γίνει καλύτερη χάραξη θεραπευτικής στρατηγικής

55 Myocardial perfusion scintigraphy before non-cardiac surgery MPS has received a class I indication for risk stratification of patients undergoing elective noncardiac surgery.

58 Survival Free of Death from Any Cause and Myocardial Infarction 1.0 Optimal Medical Therapy (OMT) PCI + OMT Hazard ratio: % CI ( ) P = 0.62 Number at Risk Years 7

59 Ischemia Change in Stable Coronary Artery Disease Is an Independent Predictor of Death and Myocardial Infarction J Am Coll Cardiol Img. 2012;5(7): Kaplan-Meier Curve of Patients With 5% Versus <5% Ischemia Improvement There was a significant difference in Kaplan-Meier event rates (p = ) between patients with 5% ischemia improvement and those with <5% ischemia improvement. Patients were followed for a median of 5.8 years.

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