Download Imaging: Which Test is Best?

9/25/2014
Southeast Regional
Heart and Vascular Symposium
for Primary Care Providers
Imaging: Which Test is Best?
William P. Warren, MD, FACC
Common Clinical Problems
• Atrial Fibrillation
• Congestive Heart Failure
• Valvular Heart Disease
CHEST PAIN
Chest Pain Evaluation
Cardiac PET
Treadmill Only Stress
Coronary Calcium Score
Stress Echo
Cardiac MRI
Dobutamine
Echo
Stress MPI
Coronary CTA
Pharm MPI
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MedSolutions
OR Order a Treadmill Only Stress
and avoid MedSolutions
GOOD Imaging is GOOD Patient
Care
How to Choose the Best Imaging Test for the Patient
with Suspected Ischemic Heart Disease
2012 ACC/AHA Guidelines for Stable Ischemic Heart Disease
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Possible Imaging Tests for Patients with Chest Pain
TEST
COST
ADVANTAGES
DISADVANTAGES
TMO
$
Widely Available
False +, Inability to reach target HR
Coronary Calcium
$
“risk factor”
Not for symptomatic pts.
Stress ECHO
$$
No radiation
Limited by obesity, COPD, LBBB, Pacing, WMA
Dobutamine ECHO
$$
Same as Stress ECHO
Same as Stress ECHO
Stress MPI
$$$
Widely Available, streamlined process
Radiation exposure, attenuation artifacts
Pharmacologic MPI
$$$
Regadenoson well tolerated vs. older drugs
Radiation exposure,
attenuation artifacts
Coronary CTA
$$$
High Negative Predictive Value
Insurance coverage, overestimate CAD
Cardiac PET
$$$$
Best sens/specificity,
Lower radiation than MPI
Pharmacologic stress only
Cardiac MRI
$$$$
No radiation
Limited availability,
complicated logistics
How to Choose?
Consider:
– Exercise Capacity
– Baseline EKG
– Pretest Probability of Disease
– Other Patient Specific Factors
Exercise Capacity
• Ability to Perform ADL’s and Moderate
Household Work (~4-5 METS)
• Exercise is the best single predictor of
cardiovascular outcome
• Memorial/CHI able to do 65% of outpatient
MPI tests as exercise tests
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EKG Factors:
• Left Bundle Branch Block
• Ventricular Pacing at Baseline
• Resting ST depressions >0.5mm (ie. LVH
with strain pattern or digoxin effect)
Pretest Probability of Disease
• Clinical Assessment of Cardiac Risk
• Diamond and Foster (age, sex, typical
symptoms)
Other Patient Specific Factors
• Obesity: technically limited ECHO images (Definity
contrast may help)
• Obesity: attenuation artifact for MPI (2 day imaging
protocols may help)
• Obesity: May favor PET imaging (less attenuation
artifact)
• COPD/lung disease: technically limited ECHO images
• COPD/asthma: may lead to bronchspasm with
adenosine (less with regadenoson)
• Orthopedic or age factors limiting exercise may dictate
a pharmacologic test
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Evaluation of Patients with Chest
Pain:
Low Pretest Probability of Disease
EKG
Able to Exercise (4METS)
Best Test
Normal
Yes
TMO
Normal
No
Pharm MPI or Dob ECHO
Abnormal
Yes
Stress MPI or Stress ECHO
Abnormal
No
Pharm MPI or Dob ECHO
LBBB, Ventricular Pacing, Resting WMA, Obesity, or Lung Disease favor Pharm MPI over Dob ECHO
Evaluation of Patients with Chest
Pain:
• Intermediate or High Pretest Probability of
Disease favors Stress ECHO or Stress
MPI over TMO regardless of EKG or ability
to exercise
• Stress ECHO or Stress MPI is indicated if
a prior TMO is equivocal or uninterpretable
(2008/2009 ACC/AHA Guidelines appropriateness score 7-9 out of 9)
Suspected Ischemic Heart Disease:
Patient Focused Summary
• Young person with some risk factors.
Normal EKG. Able to exercise. TMO
• Same young patient who can exercise, but
abnormal EKG. Stress ECHO
• LBBB or Ventricular pacing. Pharm MPI
• Intermediate or High clinical risk. Normal
EKG. Able to exercise.
Stress ECHO or Stress MPI
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Suspected Ischemic Heart
Disease: Patient Focused
Summary
• Obesity, unable to exercise Pharm MPI
• COPD, unable to exercise Pharm MPI
• Older, general debility Pharm MPI
Suspected Ischemic Heart Disease:
Patient Focused Summary
• Anxious Young Person with Family History of CAD
Risk factor assessment +/‐ Calcium Score
• Intermediate Risk ASYMPTOMATIC patient
concerned about statin use
? Calcium Score
• Patient you think had a false positive TMO or other
stress
Medical treatment or Coronary CTA
• Anxious executive willing to pay for the best test to
look for CAD = Medical Rx or Coronary CTA
Medical treatment or Coronary CTA
The Future of Imaging for
Ischemic Coronary Disease
• ECHO: strain imaging for better wall motion assessment
• MPI: new camera technology allows shorter imaging
time and/or lower radiation dose
• MPI: stress only protocols lower radiation dose
• PET: high energy photons with short half life allow more
accurate images with lower total radiation dose
• PET: simplified unit dosing (flurpiridaz)
• Coronary CT: new camera/detector arrays and
combination of perfusion or infarct/viability imaging with
anatomical images
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Thank you.
William P. Warren, MD, FACC
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