72 22 30
1985
Conductance Vessels flow Vessels<
- Shear stress
conductance vessel
Exercise and Adenosine SPECT in the Patient with Angina
SPECT,PET ACC/AHA/ASNC Guideline 2003 Dicarli JNM 2007;48:783
SPECT, PET SPECT N=1135 DVD 75% TVD 69% N=688 TVD 29% N=143 TVD 10% PET N= DVD 56% LM/TVD 50% AJC 1991;67:2D AJC 1991;70:14 JACC 2003;42:64 JNM 2007;48:349
Kern, M. J ACC2010;55:173
Bayse incremental value
Brown Circulation 1991;83:363 Berman,Hachamovitch Circulation 1996;93:905 JACC 2003;41:1329 Circulation 2003;107:2900 Mayo Clinic Circulation 1999;100:2140 JACC 2005;45:43 Mahmarian JACC 2010;55:221 DM END JACC 1999;33:2448,661 EMPIRE Eur Heat J 1999;20:157 G.K. G.K..
J ACCESS SSS
IHD IHD IHD Shaw JNC 2004;11:171
Plaque CAG
CASS 12
Log Hazard ratio for Revascularization vs Medical Therapy as a Function of % Myocardium Ischemia Circulation 2003;107:2900
QGS 12 10 8 6 4 2 0 0 20 40 60 80 100
1967 CABG(on pomp) 1977 PTCA CASS, VA, EUROPEAN 1980 s Aspin/Heparin BARI,EAST, GABRI, GABI 1990 s blocker / ACEI/ Statin Off pomp CABG Bare Metal Stents MASSII,COURAGE, BARI2D 2005-2009 2010- Drug Eluting Stents Clopidogrel ART-II,ERICA-II SYNTAX FREEDOM,CARDIA PROMOTING HEARTH
/ / viability /
evidence CABG vs * PTCA vs ACIP Pilot study Circulation 1997 SWISS II trial JAMA 2007 PTCA vs stents PCI vs * CABG
entry bias, selection bias crossover
Occluded Artery Trial (OAT) NEJM 2006;355:2395-2407 viability PCI vs SWISS II JAMA 2007;297:1985 PCI vs COURAGE NEJ M 2007;356:1503 Circulation 2008;117:1283 PCI vs MPI DIAD Diabetic Care 2004;27:1954 vs JAMA 2009;301:1547 BARI2D NEJ M 2009;360:2503 vs.
Optimal Medical Therapy with or without PCI for Stable Coronary Disease (COURAGE Trial) JNC 2006;13:685
COURAGE Trial Baseline Clinical and Angiographic Characteristic PCI N=1149 N=1138 CAG SVD 361(31) 343(30) DVD 446(39) 439(39) TVD 341(30) 353(31) proximal LAD 360(31) 417(37) LVEF(%) 61 11 61 10 NEJM 2007;356:1503
Optimal Medical Therapy with or without PCI for Stable Coronary Disease (COURAGE Trial) Kaplan-Meier Survival Curves NEJM 2007;356:1503
Optimal Medical Therapy with or without PCI for Stable Coronary Disease (COURAGE Nuclear substudy) JNC 2006;13:685
Comparison of inducible ischemia with MPS pretreatment and after 6 to 18 months of OMT with or without PCI Circulation 2008;117:1283
6-18 PCI+ 0%, 1% to 4.9%, 5% to 9.9%, >=10% Kaplan-Meier Circulation 2008;117:1283
2 MPI + + HbA1c <7.0% insulin providing agents vs insulin sensitizing agents (sulfonylurea, meglitinides, insulin) (biguanides, thiazolidinediones)
BARI D NEJ M 2009;360:2503
CT Curved multiplanar reconstructions and multiple-intensity projection Circulation 2007;115:1464
Correlation between quantitative coronary angiography (QCA) and 64-slice CTA measurements of diameter stenosis in diseased coronary artery segments 0.625mm 3mm 23% 77% Circulation 2007;115:1464
CT FFR Meijboom, JACC 2008;52:636
myocardial fractional flow reserve FFR Adenosine Kern, M. J ACC2010;55:173
SPECT Kern, M. J ACC2010;55:173
JACC 2007;49:2105
PCI DEFER 0.66%/Y JACC 2007;49:2105
JACC 2007;50:1171
CT CT soft plaque) remodeling Motoyama. JACC 2007;50:319
CT SPECT/PET UCG Shaw, JACC Img 2009;2:524
CT D Blooming 320 CT
Gold Standard Gold Standard SPECT CAG 80 90% >50% 65 75% CAG IVUS MLD r=0.34 IVUS SPECT MLA 4mm 2 6mm 2 LMT FFR SPECT <0.75 CTA CAG >50%DS 96% >50% 90% IVUS MLA r=0.88
Gold Standard FFR SPECT IVUS CAG CT
CT SPECT/CT
Berman JNM 2006
Comparative effective research The Study of Myocardial Perfusion and Coronary Anatomy Imaging Roles in CAD SPARC)
The Study of Myocardial Perfusion and Coronary Anatomy Imaging Roles in CAD SPARC)
Imaging Based Medicine CAG Cardiac CT Cardiac MRI G-SPECT Contrast UCG Cardiac MRI Cardiac CT