1 / 50

Il tribunale del cardiologo: Processo allo studio della riserva coronarica Avvocato difensore

CardioLucca. “ CARDIOLOGIA E’ PROGRESSO” II° Congresso Tosco-Umbro della FIC Montecatini terme, 14-15 novembre 2007 . Il tribunale del cardiologo: Processo allo studio della riserva coronarica Avvocato difensore. Lauro Cortigiani U.O. Malattie Cardiovascolari

ginata
Download Presentation

Il tribunale del cardiologo: Processo allo studio della riserva coronarica Avvocato difensore

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. CardioLucca “CARDIOLOGIA E’ PROGRESSO” II° Congresso Tosco-Umbro della FIC Montecatini terme, 14-15 novembre 2007 Il tribunale del cardiologo:Processo allo studio della riserva coronarica Avvocato difensore Lauro Cortigiani U.O. Malattie Cardiovascolari Ospedale “Campo di Marte”, Lucca

  2. CardioLucca Effects of coronary stenosis on CFR Maximal flow 4 3 Coronary blood flow 2 Basal flow 1 0 100 60 80 0 40 20 Coronary stenosis % Gould. Am J Cardiol 1974;34:48

  3. CardioLucca Prognostic effect of CFR in patients with 51% to 75% stenosis of the LAD 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 Rigo, for the EPIC-FR. Am J Cardiol 2007;100:1527

  4. CardioLucca Correlation between CFR and LAD stenosis n = 1,243 r = 0.53 p < 0.0001 n = 1,243 r = - 0.53 p < 0.0001 EPIC-FR 2007

  5. CardioLucca Factors affecting the functional significance of coronary artery stenosis • Percent diameter stenosis • Geometry and lenght of the lesion • Minimum diameter and cross-sectional area of the lesion • Size of the vessel proximal and distal to the lesion • Vasoactivity of the lesion • Viable or necrotic state of myocardium • Degree of distal collateral support • Left ventricular hypertrophy • Microvascular disease Folland. Circulation 1994;89:2005(modified)

  6. CardioLucca Relation between LV mass and CFR Intracoronary Doppler Transthoracic Doppler 400 r = 0.85 p < 0.01 r = - 0.85 p < 0.01 r = - 0.57 p < 0.0001 350 300 250 CFR on LAD % increase of CBF with ACh 200 150 100 50 40 60 80 100 120 140 160 180 LV mass index (g/m2) LV mass index (g/m2) Sekiya. Am J Hypertens 2000;13:789 Rigo, Cortigiani. Eur Heart J 2006;27(abs)

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

  8. CardioLucca Techniques of assessing CFR Picano. Stress Echocardiography. 4th ed, 2003

  9. CardioLucca Comparison of CFR on LAD by transthoracic Doppler and intracoronary Doppler flow wire R = 0.88 Mean + 2SD Mean + 2SD Mean Mean - 2SD Caiati. Circulation 1999;99:771

  10. CardioLucca CFR profile with transthoracic Doppler Systole Diastole Velocity (cm/sec) Resting Velocity (cm/sec) Hyperemic Hyperemic Resting diastolic velocity CFR=

  11. CardioLucca Resting Hyperemic 68 32 CFR= = 2.13

  12. 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

  13. CardioLucca Diagnostic value of CFR for LAD disease Sensitivity Specificity % n=18 n=138 n=45 n=53 n=110 n=230 n=1243 Hozumi JACC 1998 Caiati JACC 1999 Pizzuto AJC 2003 Ruscazio JACC 2003 Nohtomi JASE 2003 Rigo AJC 2003 EPIC-FR 2007

  14. CardioLucca Accuracy of CFR <2.0 to assess >70% LAD stenosis in normotensives and hypertensives p = 0.40 p = 0.06 p = 0.28 Normotensives (n = 396) % Hypertensives (n = 847) Sensitivity Specificity Accuracy EPIC-FR 2007

  15. CardioLucca Better value of CFR to assess >70% LAD stenosis 396 Normotensives 847 Hypertensives 1.92 1.97 2.00 2.00 1.92 AUC = 0.89 (0.85-0.91) Sensitivity = 88% Specificity = 79% AUC = 0.90 (0.88-0.92) Sensitivity = 89% Specificity = 82% EPIC-FR 2007

  16. CardioLucca Frequency of reduced CFR on LAD in pts with RCA or LCx disease and <70% LAD stenosis p = 0.15 % n = 968 1-2 vessel (n = 248) 0-vessel (n = 720) EPIC-FR 2007

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

  18. CardioLucca Feasibility and diagnostic value of CFR for RCA disease Sensitivity Specificity Feasibility % % n=81 n=151 n=446 n=81 n=151 n=446 Voci AJC 2002 Takeuchi JASE 2004 Rigo CU 2005 Voci AJC 2002 Takeuchi JASE 2004 Rigo CU 2005

  19. CardioLucca Limitations of CFR as “stand-alone” diagnostic criterion • Only LAD is sampled • Inability to distinguish between macrovascular and microvascular CAD

  20. CardioLucca CFR on LAD adds diagnostic value over wall motion analysis during dipyridamole stress echo Dip 2D Dip 2D + CFR % 5 studies 741 pts Sensitivity Specificity Accuracy Rigo. J Cardiovasc Med 2006;7:472

  21. CardioLucca CardioLucca EPIC-FR: Recruiting Centers 2007 Mestre Rigo Cesena Gherardi Pisa Sicari, Picano Lucca Cortigiani Napoli Galderisi Empoli Gianfaldoni BelgradeDjordjevic-Dikic

  22. 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 Continuous monitoring and Pulsed recording 1 lead ECG 12 lead ECG BP recording On the echo-monitor Continuous monitoring and Pulsed recording

  23. CardioLucca Incremental prognostic value of CFR over wall motion analysis 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 Rigo, for the EPIC-FR. Eur Heart J 2008;(in press)

  24. CardioLucca Annual hard event rate in diabetics and nondiabetics Nondiabetics Diabetics 8.5 Annual hard event rate (%) 6.0 4.7 5,456 pts 2.2 Suspected CAD Known CAD Cortigiani. JACC 2006;47:605

  25. CardioLucca Prognostic value of stress echo result Nondiabetics Diabetics n = 749 p < 0.0001 n = 4,707 p < 0.0001 n = 749 p < 0.0001 n = 4,707 p < 0.0001 Cortigiani. JACC 2006;47:605

  26. CardioLucca Prognostic value of CFR in diabetics and nondiabetics with no inducible ischemia Diabetics Nondiabetics Cortigiani, for the EPIC-FR. JACC 2007;50:1354

  27. CardioLucca Anti-ischemic therapy negatively affects the prognostic value of stress echo SE- / Off therapy (95%) Total mortality (%) SE- / On therapy (88%) SE+ / Off therapy (84%) n = 7,333 SE+ / On therapy (81%) Time (months) Sicari, Cortigiani, Picano. Circulation 2004;109:2428

  28. 100 80 60 40 20 0 0 12 24 36 48 CardioLucca Anti-ischemic therapy does not affect the prognostic value of CFR CFR >2 - Off Therapy (93%) CFR >2 - On Therapy (91%) CFR <2 - Off Therapy (79%) CFR <2 - On Therapy (74%) Infarction-free survival (%) n = 1,506 p < 0.0001 0 12 24 36 48 Time (months) Subjects at risk CFR>2 - Off Therapy 586 369 186 87 27 CFR>2 - On Therapy 369 260 135 54 10 CFR<2 - Off Therapy 262 108 57 24 7 CFR<2 - On Therapy 289 105 40 16 2 Sicari, for the EPIC-FR. Submitted

  29. CardioLucca Characteristics of 1.243 patients EPIC-FR 2007

  30. CardioLucca Multivariable prognostic indicators (death, STEMI, NSTEMI) EPIC-FR 2007

  31. CardioLucca Incremental prognostic value of CFR + 13% + 46% + 279% + 14% Clinical Clinical LVEF Angio Clinical LVEF Clinical LVEF Angio SE Clinical LVEF Angio SE CFR EPIC-FR 2007

  32. CardioLucca Incremental prognostic value of CFR + 2% + 25% + 394% + 14% Clinical Clinical LVEF SE Clinical LVEF Clinical LVEF SE CFR Clinical LVEF SE CFR Angio EPIC-FR 2007

  33. CardioLucca Prognostic value of CFR in pts with and without significant (>70% stenosis) CAD Significant CAD No significant CAD n = 523 p = 0.0007 n = 720 p < 0.0001 327 EPIC-FR 2007

  34. CardioLucca Prognostic implication of CFR assessed on LAD and RCA n = 553 p < 0.0001 EPIC-FR 2007

  35. CardioLucca Frequency of significant CAD according to CFR assessed on LAD and RCA Significant CAD % 553 pts LAD (-) RCA (+) LAD (+) RCA (-) LAD (-) RCA (-) LAD (+) RCA (+) EPIC-FR 2007

  36. CardioLucca Prognostic value of CFR in dilated cardiomyopathy CFR>2 (70%) CFR<2 (22%) n=129 p=0.0001 Subjects at risk CFR>2 CFR>2 CFR<2 CFR<2 Rigo, for the EPIC-FR. Eur Heart J 2006;27:1319

  37. CardioLucca Prognostic value of PET derived CFR in HCM Cecchi. NEJM 2003;349:1027

  38. CardioLucca Doppler echocardiographic derived CFR in HCM • 68 HCM patients (5812 yy; 59% men) • NYHA class I-II • Angiographically normal coronary arteries (n=37) or negativity of stress test and likelihood of CAD <5% (n=31) • High-dose dipyridamole (0.84 mg over 6’) with CFR assessment of LAD • Follow-up: 2213 months Cortigiani, for the EPIC-FR. Submitted

  39. CardioLucca Follow-up events 1 sudden death 1 AMI 4 ICD 6 hospitalizations for heart failure (4 of whom for pulmonary edema) 5 unstable anginas 8 atrial fibrillations 2 syncope 27 events Cortigiani, for the EPIC-FR. Submitted

  40. Cox analysis Cortigiani, for the EPIC-FR. Submitted

  41. CardioLucca Event-rates according to CFR n = 68 p < 0.0001 CFR >2 (79%) CFR <2 (17%) CFR <2 CFR >2 Cortigiani, for the EPIC-FR. Submitted

  42. CardioLucca Functional aspects of coronary circulation Ischemia CFR

  43. Conclusions CFR evaluation of LAD by transthoracic Doppler: • is highly feasible (>90%); • increases the sensitivity of dipyridamole stress echo with only modest loss in specificity; • provides strong and independent prognostic information in patients with known or suspected CAD (including diabetics), additional to that of wall motion analysis and angiographic findings; • if effective to risk stratify patients with dilated and hypertrophic cardiomyopathy.

  44. CardioLucca Coronary anatomic and prognostic CFR conditions Mild-to-Moderate CAD Moderate- to-severe CAD Microvascular disease Normal Coronary angiography Wall motion STRESS CFR ± - + + + Prognostic impact Cortigiani, for the EPIC-FR. JACC 2007;50:1354

  45. CardioLucca Diagnostic value of CFR for LAD disease

  46. CardioLucca Diagnostic value of CFR for RCA disease

  47. CardioLucca CFR and stresses X X X CFR X X EXE ADO DIPY REST DOBU Iskandrian. J Nucl Cardiol 1994:1;94

  48. CardioLucca CFR with vasodilator agents Picano. Stress Echocardiography. 4th ed, 2003

  49. CardioLucca Patients Cortigiani, for the EPIC-FR. Submitted

  50. CardioLucca Causes of reduced CFR in dilated cardiomyopathy LV hypertrophy Increased LV end-diastolic pressure Coronary small vessel disease

More Related