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Utilità dello studio ecocardiografico della doppia coronaria

CardioLucca. ANMCO Toscana 2008 “Il divenire clinico in cardiologia” Firenze, 31 ottobre 2008. Utilità dello studio ecocardiografico della doppia coronaria. Lauro Cortigiani U.O. Malattie Cardiovascolari Ospedale “Campo di Marte”, Lucca. CardioLucca.

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Utilità dello studio ecocardiografico della doppia coronaria

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  1. CardioLucca ANMCO Toscana 2008 “Il divenire clinico in cardiologia” Firenze, 31 ottobre 2008 Utilità dello studio ecocardiografico della doppia coronaria Lauro Cortigiani U.O. Malattie Cardiovascolari Ospedale “Campo di Marte”, Lucca

  2. CardioLucca Event-rate in 7,107 nondiabetics and 1,630 diabetics accordingto stress echoresults Men Women Nondiabetics Diabetics Nondiabetics Diabetics p=0.48 p=0.57 p=0.03 p=0.007 p<0.0001 p=0.41 p=0.97 p=0.76 Annual hard event rate % SE (+) SE (-) SE (-) SE (+) SE (+) SE (-) SE (-) SE (+) Suspected CAD Known CAD Suspected CAD Known CAD Cortigiani. Am J Med 2009;(in press)

  3. CardioLucca Functional aspects of coronary circulation Ischemia Regionalfunction CFR Coronary flow

  4. CardioLucca Subendocardial flow and systolicthickening 1.0 1.0 0.5 0.5 Ipokinesia Normalized systolic wall thickening Akinesia 0 0 1.0 1.0 Dyskinesia 0.5 0.5 - 0.3 - 0.3 Normalized subepicardial blood flow Normalized subendocardial blood flow Gallagher. Am J Physiol 1984;16:727

  5. CardioLucca Extentoftransmural ischemia and systolicthickening 40 13 dogs LAD or LCxocclusion 827 echosegments p < 0.001 15 p < 0.001 Systolic thickening (%) p = ns 535 84 81 69 40 18 0 1-20 21-40 41-60 61-80 81-100 Infarct thickness (%) Lieberman. Circulation 1981;63:739

  6. CardioLucca Amountofischemicmyocardium and systolicfunction 100 100 Wall thickening abnormalities Wall motion abnormalities Sensitivity (%) 30 10 Largeinfarcts (18-51% LV mass) 14 dogs Smallinfarcts (1-6% LV mass) 10 dogs Pandian. Am J Cardiol 1985;55:551

  7. CardioLucca Tests off therapy (59%) n = 1,130 Tests on therapy (41%)

  8. CardioLucca 91 p = 0.01 65 Sensitivity (%) Off therapy On therapy

  9. CardioLucca SE- / Off therapy (95%) Total mortality (%) SE- / On therapy (88%) SE+ / Off therapy (84%) n= 7,333 SE+ / On therapy (81%) Time (months)

  10. CardioLucca Controls CAD CFR CFR * p<0.05 vs baseline; ** p<0.05 vs baseline

  11. CardioLucca CFR >2 - Off Therapy CFR >2 - On Therapy CFR <2 - Off Therapy n = 1,779 p < 0.0001 CFR <2 - On Therapy CFR >2 - Off Therapy CFR >2 - On Therapy CFR <2 - Off Therapy CFR <2 - On Therapy

  12. CardioLucca Nitroglycerin- induced vasodilation Flow- dependent dilation Cold pressor test Acetylcholine- induced vasoreactivity p = 0.001 p < 0.001 p = 0.009 p = 0.002 mean FU: 7.7 yy No event Event

  13. CardioLucca Transthoracic Doppler of mid-distal LAD Modified apical 3-chambers

  14. CardioLucca Dipyridamole stress echo with CFR assessment Aminophylline 120 mg in 1’ (up to 240 mg in 2’) Dipyridamole 0.84 mg/kg in 6’ Drugs infusion min 0 6 TIMELINE 10 CFR-PW 2D echo Continuousmonitoring and Pulsedrecording 1 lead ECG 12 lead ECG BP recording On the echo-monitor Continuous monitoring and Pulsed recording

  15. CardioLucca Feasibility of transthoracic Doppler of LAD % n=18 n=138 n=45 n=53 n=110 n=230 n=1544 Hozumi JACC 1998 Caiati JACC 1999 Pizzuto AJC 2003 Ruscazio JACC 2003 Nohtomi JASE 2003 Rigo AJC 2003 Cortigiani JACC 2007

  16. CardioLucca CFR profilewithtransthoracic Doppler Systole Diastole Velocity (cm/sec) Resting Velocity (cm/sec) Hyperemic Hyperemic Resting diastolic velocity CFR=

  17. CardioLucca Normalfinding Resting 68 32 = CFR= 2.13 Hyperemic

  18. CardioLucca LAD stenosis Resting 50 42 = CFR= 1.19 Hyperemic

  19. CardioLucca Microvasculardisease Resting 65 34 = CFR= 1.91 Hyperemic

  20. CardioLucca Dip 2D Dip 2D + CFR % 5 studies 741 pts Sensitivity Specificity Accuracy

  21. CardioLucca 1,145 patientswithknown or suspected CAD 6.3 Angina on effort Inducibleischemia Antischemictherapy CFR on LAD <2.0 3.6 2.8 2.4 8 0 1 2 16 4 Hazard ratio

  22. CardioLucca 100 CFR >2 / DET – 80 CFR <2 / DET – CFR >2 / DET + 60 Event-free survival (%) 40 CFR <2 / DET + n = 1,145 p < 0.0001 20 0 0 6 12 18 24 Months

  23. CardioLucca + 43% + 93% + 44% Clinical Clinical WMSI Clinical WMSI Angio Clinical WMSI Angio CFR

  24. CardioLucca Nondiabetics Diabetics

  25. CardioLucca 100 CFR>2 (86%) 80 60 Infarction-free survival % Spontaneous event-free survival (%) 40 CFR<2 (30%) n = 86 p = 0.0001 20 0 0 12 24 36 Time (months) Subjects at risk CFR>2 39 21 12 5 CFR<2 47 22 6 2

  26. 0 0 12 24 36 48 CardioLucca Prognosticvalueof CFR in patientswithnormal or nearnormalcoronaryarteries 100 CFR>2 (96%) 80 60 CFR<2 (55%) Infarction-free survival (%) 40 n=394 p<0.0001 20 Time (Months) Subjects at risk 307 268 156 66 13 CFR>2 37 15 5 CFR<2 87 68 Sicari, for the EPIC-FR. Am J Cardiol 2009;103:(in press)

  27. CardioLucca Transthoracic Doppler of RCA Modified apical 2-chambers

  28. CardioLucca Diagnosticvalueof CFR for RCA disease Sensitivity Specificity % Voci AJC 2002 Takeuchi JASE 2004 Rigo CU 2005

  29. CardioLucca Feasibilityof CFR for RCA disease % n=81 n=151 n=658 Voci AJC 2002 Takeuchi JASE 2004 Rigo CU 2005

  30. CardioLucca Combinedassessmentof CFR on LAD and RCA. Patientsselection Pts with known or suspected CAD (n=1104) n=58 (5%) Inadequate echo image quality for LAD sampling (n=1046) n=439 (40%) Inadequate echo image quality for RCA sampling (n=607) n=147 (24%) Positive stress echo for inducible ischemia 460 pts Final Study Population Cortigiani, for the EPIC-FR. Submitted

  31. CardioLucca Characteristicsof the studypopulation

  32. CardioLucca Outcomes 77 Median FU: 32 months 38 28 6 5 Death Total events STEMI Late CABG/PCI (>6 months) Pts (n=42) undergoing early (<6 months) CABG/PCI were censored Cortigiani, for the EPIC-FR. Submitted

  33. CardioLucca Multivariableprognosticindicators Death, AMI CFR on LAD <2.0 Diabetesmellitus 12.0 2.0 Death, AMI, late CABG/PCI CFR on LAD <2.0 Resting WMA Diabetesmellitus Antischemictherapy 5.3 3.4 2.2 2.1 12 0 1 4 16 8 Hazard ratio Cortigiani, for the EPIC-FR. Submitted

  34. CardioLucca Event-freesurvivalaccordingto CFR on LAD and RCA 54 Cortigiani, for the EPIC-FR. Submitted

  35. CardioLucca Angiographicallyobstructive (>70%) CAD accordingto CFR on LAD and RCA in 404 patients 50% 12% 3% CFR >2.0 LAD and RCA (7/254) CFR <2.0 LAD or RCA (45/90) CFR <2.0 LAD and RCA (7/60) Cortigiani. Eur Heart J 2008;(abstract)

  36. CardioLucca Conclusions CFR evaluation of either LAD and RCA allows identifying distinct angiographic and prognostic patternsin patients with known or suspected CAD and negative stress echo by wall motion criteria. In particular: 1) preserved CFR in both LAD and RCAis highly predictive of non-obstructive CAD and very favourable outcome; 2) concordant reduction in LAD and RCA is predictive of microvascular disease without obstructive CAD and intermediate prognosis; 3) reduced CFR in LAD is a strong and independent predictor of future events.

  37. CardioLucca awaitingfor CFR on LCx …

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