Transcript Additive value of MPI to Duke treadmill score in outpatients

Prognostic Value of
Myocardial Perfusion Imaging
over Duke Treadmill Score
Ethan Levine, D.O., Regina S. Druz, M.D., FACC
Department of Cardiology, State University of New
York at Stony Brook and St. Francis Hospital
Cardiac Imaging Research Group, Roslyn,
New York
Case History (MC-10/2004)
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45 y/o non-diabetic, non-smoking male without
personal or family history of CAD.
No medical care for the last 15 years
CC: exertional dyspnea for 1 month
Physical Exam:
BP 130/100, HR 93 reg, resp 14
Cor: normal S1 and S2, no murmur
Lungs: no adventitious sounds
Testing (MC-10/2004)
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Pt. underwent treadmill exercise as follows:
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Exercise Duration: 11:30 (Bruce protocol)
Reason for termination: dyspnea (onset @ 9
min)
Max HR 166 bpm (94% APMHR)
Max BP 170/100 mm Hg
ECG (MC-10/2004)
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Rest: Sinus at 73 bpm, incomplete RBBB,
otherwise unremarkable
Peak stress: Sinus at 166 bpm, 2mm ST
depression in III, aVF; ST changes
resolved 1 min into recovery
Exercise Data (MC-10/2004)
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Patient’s Duke Treadmill Score
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11.5 – (5 x 2mm) – (4 X 0) = 1.5
Correlates with 95% 4 year survival (moderate risk) 1
Duke Score = Exercise Duration (min) – (5 X ST deviation (mm) ) – (4 x
angina index) where angina index = 0 for none, 1 for non-limiting and 2 for
limiting angina.
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< -10 = High risk (81% four year survival)
- 10 - +4 = Moderate risk (95% four year survival)
> or = 5 Low risk (99% four year survival)
Imaging (MC-10/2004)
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ADAC Cardio-60 dual-detector system
Raw data acquired over 180º orbit
Simultaneous gadolinium line source attenuation
correction (VantagePro™, Milpitas, CA)
Iterative reconstruction
Gated 16-frame/cycle
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Isotopes: Stress 30.9 mCi 99mTc sestamibi; rest
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3.5 mCi 201Tl
Nuclear Perfusion Imaging (MC-10/2004)
Gated SPECT (MC-10/2004)
play loop)
( double click to
Interpretation of Nuclear Data (MC10/2004)
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Large, severe intensity, reversible anteroseptal and apical defect consistent with
LAD ischemia (SSS=21)
TID suggestive of tight stenosis and/or
multivessel disease
Gated Data: apical, septal and anterior
severe hypokinesis.
Post Stress EF: 46%
Angiography (MC-10/2004)
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95% mid
LAD lesion
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(double click to play
loop)
Angiography (MC-10/2004)
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Trans-septal
RCALAD
collaterals
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( double click to
play loop)
Discussion (MC-10/2004)
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ACC/AHA guidelines recommend stress imaging in patients with an
intermediate treadmill score to allow for further risk stratification, and
guidance in patient management.
This case illustrates incremental benefit from myocardial perfusion imaging
in patients with intermediate Duke treadmill score. The patient had HTN
(unknown to him), but no other significant risk factors other than gender.
His chief complaint was atypical (exertional dyspnea), and his exercise
tolerance was very good. Overall, his pre-test probability of CAD was lowto- intermediate. Duke treadmill score put this patient at an intermediate risk
for cardiac death and myocardial infarction. However, perfusion image data
allowed further risk stratification into a high risk prognostic category.
This case illustrates that the extent of perfusion defects (SSS) and TID
should be used together as markers of severe and/or multi-vessel CAD.
Teaching Points (MC-10/2004)
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The Duke treadmill score is a useful
measure of prognosis in
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outpatients with suspected CAD.
Duke Scores have been shown to be more predictive than clinical
data, in risk stratification of patients with CAD.
The ACC
advises imaging in patients with intermediate treadmill
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scores.
Patients with Intermediate treadmill scores and normal myocardial
perfusion imaging studies have low event rates similar to the
background population. However, severe perfusion defects in the
setting of the same3 intermediate treadmill scores predict event rates
approaching 11%.
References
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1. Mark, DB, Shaw, Linds et al. Prognostic Value of A Treadmill Exercise Score in
Outpatients With Suspected Coronary Artery Disease. N Engl J Med 1991; 325: 84953.
2. Gibbons R, Baladay G, Bricker JT et al. ACC/AHA 2002 Guideline Update for
Exercise Testing: Summary Article. A report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines
(Committee to Update the 1997 Exercise Testing Guidelines). Circulation 2002; 106:
1883-1892
3. Iskander, S and Iskandrian, AE Risk Assesment Using Single Proton Emission
Computed Tomographic Technetium-99m Sestamibi Imaging. J Am Coll
Cardiol1998;32: 57-62
4. Mazzanti Marco, Germano G et al. Identification of Severe and Extensive
Coronary Artery Disease by Automatic Measurement of Transient Ischemic Dilation of
the Left Ventricle in Dual – Isotope Perfusion SPECT. Journal of the American
College of Cardiology. 27(7):1612-20, 1996 Jun