1. 核心脏病学现状与进展 何作祥国家心血管病中心中国医学科学院阜外心血管病医院 www.csnm.com.cnwww.csnc.org.cn 2011 年北京 “ 五洲 ” 心血管病研讨会

2. Imaging in Coronary Artery Disease Changing roles Changing roles Coronary stenosis (coronary angiography, CTA)? Coronary stenosis (coronary angiography, CTA)? myocardial ischemia (SPECT, PET, stress echo) ? myocardial ischemia (SPECT, PET, stress echo) ? Changing strategy Changing strategy

3. Accuracy of Noninvasive Test for Diagnosis of CAD No. of Studies No. of Patients SensitivitySpecificity Exercise ECG 147240476877 Exercise Perfusion Imaging 2287518980 Pharmacological Stress Scintigraphy 11<10008591 Circulation 2000;102:126

5. Gupta et al, 1992

6. 腺苷负荷试验心肌灌注显像多中心临床试验 田月琴, 等, 中华心血管病杂志,2005

7. Aden Rest Aden Rest Aden Rest

8. Can Gated SPECT improve sensitivity for CAD detection?

9. Part 0. Introduction to Nuclear Medicine 9 ECG-GATED MYOCARDIAL PERFUSION

10. Gated SPECT vs. Cine MRI Wang F, et al. Eur J Nucl Med Mol Imaging, 2009

11. Specificity of Stress TI-201 and Tc-99m Sestamibi SPECT for CAD Detection in Women Stenosis  50% (n=51) Stenosis  70% (n=64) p=0.002 p=0.0004 p=0.05 NS p=0.02 NS Adapted from Taillefer et al. J Nucl Med 1996;37:69P. 70.6 86.3 94.1 67.2 84.4 92.2 0 10 20 30 40 50 60 70 80 90100 Tl-201 Tc-99m Sestamibi Gated Tc-99m Sestamibi Specificity (%)

12. Examples of Coronary Artery Scans Normal Condition Moderate Calcification Severe Calcification

13. 0% 0% 2.7% 10.8% 48.3% 0 10 20 30 40 50 011-100101-399>400 EBT Baseline Calcium Score % with +SPECT (n=17)(n=37)(n=93)(n=89)(n=10) 1-10 246 patients all asymptomatic except 34 with atypical CP 58 + 10 years 75% with 2 or more RF He et. al Circulation 2000;101:244-51 EBT Calcium Score and SPECT Thallium Stress Testing

14. Clinical Characteristics (N=706) of Patients who Underwent CTA and SPECT 14 N (%)/average Age56.1±9.9 Male450 (63.7%) Body Mass Index25.1* Diabetes102 (14.4) Hypertension388 (55.0) Hyperlipidemia407 (57.6) Smoking273 (38.7) Family History of CAD165 (23.4) SymptomsAsymptomatic118 (16.7) Atypical chest pain476 (67.4) Typical chest pain112 (15.9)

15. Accuracy of luminal stenosis by coronary CTA for detecting abnormal MPI 15 StenosisSensitivity*Specificity*PPV*NPV** Patients’ Level ≥50%80.256.721.595.1 ≥75%48.490.442.792.2 ≥90%29.798.47390.4 Vascular Level ≥50%69.679.315.897.9 ≥75%40.295.633.696.6 ≥90%22.39954.395.8

16. CTA and SPECT/ CTA for Detection of Hemodynamically Significant Coronary Lesions Rispler JACC 2007; 49: 1059-67 0 50 100 Percent Sens Spec PPV NPV CTASPECT/ CTA 96 99 63 95 31 77

17. PET/CT in CAD Namdar M, et al. JNM 2005

18. Myocardial Infarctions are caused by Low-Grade Stenoses Pooled data from 4 studies: Ambrose et al, 1988; Little et al, 1988; Nobuyoshi et al, 1991; and Giroud et al, 1992. (Adapted from Falk et al.)

19. Risk Stratification Low <1% per year Intermediate 1-3% per year High >3% per year Adapted from Gibbons RJ, et al. J Am Coll Cardiol. 1999;33:2092-2197. Risk of Cardiac Death:

20. Risk Stratification: Noninvasive Testing Markers Amount of infarcted myocardium Amount of jeopardized myocardium Degree of jeopardy

21. Risk Stratification: Noninvasive Testing Markers Left ventricular systolic function

22. Predictors of cardiac mortality factors estimating the extent of LV dysfunction factors estimating the extent of LV dysfunction LVEF LVEF the extent of infarcted myocardium the extent of infarcted myocardium transient ischemic dilation of the LV transient ischemic dilation of the LV and increased lung uptake and increased lung uptake

23. Predictors of the subsequent development of acute ischemic syndromes markers of provocative ischemia markers of provocative ischemia exertional symptoms, exertional symptoms, electrocardiographic changes electrocardiographic changes the extent of reversible perfusion defects the extent of reversible perfusion defects stress-induced ventricular dyssynergy stress-induced ventricular dyssynergy

25. Follow-up Time (Months) 9080706050403020100 Cumulative Event-Free Survival 1.0.9.8.7.6.5 Normal Coronaries Angiographic CAD p=ns Yang MF, NMC, 2006

26. Prognostic value: Perfusion imaging vs. Angiography Patients with a normal stress myocardial perfusion imaging are at low risk for cardiac events (<1% mortality per year), even in the presence of angiographically significant coronary artery stenosis. Patients with a normal stress myocardial perfusion imaging are at low risk for cardiac events (<1% mortality per year), even in the presence of angiographically significant coronary artery stenosis.

27. 2.9 0.3 0.8 2.3 0.5 2.7 2.9 4.2 0.0 1.0 2.0 3.0 4.0 5.0 Event Rate/Year, % Cardiac Death MI Hachamovitch R, et al. Circulation. 1998;97:535-543. Scan Result ** * * Mildly Abnormal Moderately Abnormal Severely Abnormal Normal 2946884455898 Prognosis: MPI Scan Severity Predicts Outcome * P<.001 **P<.01 n SSS <4 4-8 9-13 >13

28. Cardiac Death Rate (%/y) Hachamovitch R, et al. Circulation 1998

29. Enrollment and Outcomes 3,071 Patients met protocol eligibility criteria 2,287 Consented to Participate (74% of protocol-eligible patients) 1,149 Were assigned to PCI group 46 Did not undergo PCI 27 Had a lesion that could not be dilated 1,006 Received at least one stent 784 Did not provide consent - 450 Did not receive MD approval - 237 Declined to give permission - 97 Had an unknown reason 107 Were lost to follow-up 1,149 Were included in the primary analysis 1,138 Were assigned to medical-therapy group 97 Were lost to follow-up 1,138 Were included in the primary analysis

30. Shaw, L. J. et al. Circulation 2008;117:1283-1291 Kaplan-Meier survival for patients by residual ischemia after 6 to 18 months of PCI+OMT or OMT

31. 心肌 SPECT 正常与异常患者的冠 状动脉造影率对比（ N=1053 ） 31 Han PP, et al. Chin J Med 2011 (in press)

32. 心肌灌注显像正常与异常的冠状动脉再 血管化治疗比例（ N=1053 ） 32 P<0.001 Han PP, et al. Chin J Med 2011 (in press)

33. ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization The use of coronary revascularization for patients with acute coronary syndromes and combinations of significant symptoms and/or ischemia was viewed favorably. The use of coronary revascularization for patients with acute coronary syndromes and combinations of significant symptoms and/or ischemia was viewed favorably. Revascularization of asymptomatic patients or patients with low-risk findings on noninvasive testing and minimal medical therapy were viewed less favorably. Revascularization of asymptomatic patients or patients with low-risk findings on noninvasive testing and minimal medical therapy were viewed less favorably. Circulation. 2009;119:1330-1352