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By Intern 張益維

Roles of Nuclear Cardiology, Cardiac Computed Tomography, and Cardiac Magnetic Resonance: Assessment of Patients with Suspected Coronary Artery Disease J. Nucl. Med. Jan 01, 2006; 47: 74-82. By Intern 張益維. Noninvasive cardiac imaging. Coronary calcium scan Nuclear cardiology

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By Intern 張益維

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  1. Roles of Nuclear Cardiology, Cardiac Computed Tomography, and Cardiac Magnetic Resonance: Assessment of Patients with Suspected Coronary Artery DiseaseJ. Nucl. Med. Jan 01, 2006; 47: 74-82. By Intern 張益維

  2. Noninvasive cardiac imaging • Coronary calcium scan • Nuclear cardiology • Cardiac computed tomography • Cardiac magnetic resonance Roles of Nuclear Cardiology, Cardiac Computed Tomography, and Cardiac Magnetic Resonance: Assessment of Patients with Suspected Coronary Artery DiseaseJ. Nucl. Med. Jan 01, 2006

  3. Who needs noninvasive cardiac imaging test? Nonsymptomatic patients risk stratification Subclinical coronary atherosclerosis cardiac image Aggressive medical management Roles of Nuclear Cardiology, Cardiac Computed Tomography, and Cardiac Magnetic Resonance: Assessment of Patients with Suspected Coronary Artery DiseaseJ. Nucl. Med. Jan 01, 2006

  4. Who needs noninvasive cardiac imaging test- risk stratification • Symptom characteristics, the presence of coronary artery disease risk factors, and ECG findings Roles of Nuclear Cardiology, Cardiac Computed Tomography, and Cardiac Magnetic Resonance: Assessment of Patients with Suspected Coronary Artery DiseaseJ. Nucl. Med. Jan 01, 2006

  5. Low Likelihood: (e.g., 1-14% likelihood) • -Chest pain, "probably not angina" in patients with one or no risk factors, but not diabetes. • -T wave flat or inverted < 1 mm. • -Normal ECG. • Intermediate Likelihood: (e.g., 15-84% likelihood) • -"Definite angina" in patients with no risk factors for CAD. • -"Probable angina" in patients with 1 or more risk factors. • -"Probably not angina" in patients with diabetes or with two or three other risk factors. • -Patients with extracardiac vascular disease. • -ST depression 0.5 to 1 mm. • -T wave inversion of > 1 mm. • High Likelihood: (e.g., 85-99% likelihood) • -Known history of prior MI or CAD. • -"Definite angina" in male > 60 or females > 70. • -Transient hemodynamic or ECG changes during pain. • -ST elevation or depression of > 1 mm. • -Marked symmetrical T wave inversion in multiple leads. UCLA Chest Pain and Acute Coronary Syndrome 2005

  6. Which method is should be used?-Coronary calcium scanning • Vascular calcification has been associated with atherosclerosis since the 1920s (Blankenhorn and Stern) • For many years, the assessment of CAC using fluoroscopy was recognized as providing clinically useful information • The advent of CT provided a technique that was potentially quantifiable, avoiding the subjectivity of fluoroscopy. Roles of Nuclear Cardiology, Cardiac Computed Tomography, and Cardiac Magnetic Resonance: Assessment of Patients with Suspected Coronary Artery DiseaseJ. Nucl. Med. Jan 01, 2006

  7. Which method is should be used?-Coronary calcium scanning • Though CAC measurements were first described using electron beam CT (EBT), investigators are increasingly recognizing that recent-generation multislice CT (MSCT) Roles of Nuclear Cardiology, Cardiac Computed Tomography, and Cardiac Magnetic Resonance: Assessment of Patients with Suspected Coronary Artery DiseaseJ. Nucl. Med. Jan 01, 2006

  8. Which method is should be used?-Coronary calcium scanning • The presence and extent of coronary calcium is expressed by the Agatston coronary calcium score (CCS) 1.Threshold CT density > 130 HU for pixel areas > 1mm2 2.Score each region of interest by multiplying the density score and the area 3.Total coronary calcium score determined by adding up each lesion score for all sequential slices Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol 1990

  9. Which method is should be used?-Coronary calcium scanning • Good: Available for the early detection of coronary atherosclerosis- high sensitivity. • Bad: CAC had lowspecificity—that is, calcification implies atherosclerosis but not necessarily the presence of a stenosis.

  10. Which method is should be used?- Myocardial perfusion scan • Detect a hemodynamically significant anatomic endpoint: flow limiting coronary stenosis • Definition:>=50% diameter stenosis(75% cross-sectional area reduction) • Revascularization with either PCI (percutaneous coronary intervention) or CABG. Roles of Nuclear Cardiology, Cardiac Computed Tomography, and Cardiac Magnetic Resonance: Assessment of Patients with Suspected Coronary Artery DiseaseJ. Nucl. Med. Jan 01, 2006

  11. Which method is should be used?- Myocardial perfusion scan • Patients with an intermediate likelihood of CAD after the analyses of the above factors have been considered the best candidates for stress testing. (ACC/AHA/ASNC guidelines) Roles of Nuclear Cardiology, Cardiac Computed Tomography, and Cardiac Magnetic Resonance: Assessment of Patients with Suspected Coronary Artery DiseaseJ. Nucl. Med. Jan 01, 2006

  12. Low Likelihood: (e.g., 1-14% likelihood) • -Chest pain, "probably not angina" in patients with one or no risk factors, but not diabetes. • -T wave flat or inverted < 1 mm. • -Normal ECG. • Intermediate Likelihood: (e.g., 15-84% likelihood) • -"Definite angina" in patients with no risk factors for CAD. • -"Probable angina" in patients with 1 or more risk factors. • -"Probably not angina" in patients with diabetes or with two or three other risk factors. • -Patients with extracardiac vascular disease. • -ST depression 0.5 to 1 mm. • -T wave inversion of > 1 mm. • High Likelihood: (e.g., 85-99% likelihood) • -Known history of prior MI or CAD. • -"Definite angina" in male > 60 or females > 70. • -Transient hemodynamic or ECG changes during pain. • -ST elevation or depression of > 1 mm. • -Marked symmetrical T wave inversion in multiple leads. UCLA Chest Pain and Acute Coronary Syndrome 2005

  13. Which method is should be used?- Myocardial perfusion scan • Patients with an high likelihood of CAD- Are they of sufficient risk to merit aggressive intervention? • As a consequence, such high-likelihood patients also commonly benefit from MPS Roles of Nuclear Cardiology, Cardiac Computed Tomography, and Cardiac Magnetic Resonance: Assessment of Patients with Suspected Coronary Artery DiseaseJ. Nucl. Med. Jan 01, 2006

  14. Which method is should be used?- Reclassification • Low likelihood: require modifications of coronary risk factors • High likelihood: appropriate referrals for cardiac catheterization depending on the magnitude of inducible ischemia on stress testing Roles of Nuclear Cardiology, Cardiac Computed Tomography, and Cardiac Magnetic Resonance: Assessment of Patients with Suspected Coronary Artery DiseaseJ. Nucl. Med. Jan 01, 2006

  15. Which method is should be used?- Conclusion • Coronary calcium scan • High sensitivity but low sensitiity • Cannot assess hemodynamic condition • Myocardial perfusion scan • High specificity, excellent candidate before invasive cardiac procedure. • Evaluate myocardial perfusion • Only detect hemodynamic significant stenosis Roles of Nuclear Cardiology, Cardiac Computed Tomography, and Cardiac Magnetic Resonance: Assessment of Patients with Suspected Coronary Artery DiseaseJ. Nucl. Med. Jan 01, 2006

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