1. health and fitness
2. disease

MICHAEL POON, MD, FACC, FSCCT
Ambassador
Charles A. Gargano Chair in Advanced Cardiovascular Imaging
Professor of Radiology, Medicine (Cardiology), and Emergency Medicine
Director, Dalio Center for Cardiovascular Wellness and Preventive Research
Director, Advanced Cardiovascular Imaging
Stony Brook University Medical Center

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X-rays
ECHO and Doppler
CT (MDCT and EBCT)
MR
Nuclear (SPECT and PET)
Invasive (Coronary angiography and
Hemodynamics)
Modality
Radiation
Function
Resolution
(mm)
Artifact
Contrast
Sensitivity
Specificity
Anatomy - Coronary Artery Imaging
Invasive
Angiogram
++
++
0.2
+
Iodinated
compound
-
-
64 MDCT
+++
+
0.4
+
Iodinated
compound
93
97
Function – perfusion imaging
SPECT
++
+
10 - 15
+++
Radioactive
tracers
79 – 96
53 – 76
PET
+
-
6 - 10
++
Radioactive
tracers
82 – 97
82 – 100
Contrast
echocardiography
-
++
< 1 (axial)
+++
Microbubbles
-
-
MRI
-
+++
2-3
+
Gadolinium
compound
60 - 90
60 - 100
Higgins and De Roos, ed. Cardiovascular MRI & MRA, 2003 (Modified)
• Large Field of View
• High Contrast
• High Resolution
Black-Blood Coronary Plaque MR
Patient #A
LAD Wall
Patient #B
Patient #C
LAD Wall
RCA Wall
Eccentric (“lipid-rich”)
Concentric (“fibrotic”)
Ectatic (“remodeled”)
Fayad ZA; Fuster V et al. Circ. 2000;102;506-510
Cardiac Structure and Function
Aortic valve disease
Severe Pulmonary Hypertension
S. Kozerke, P. Boesiger, Inst. Biomed. Eng., University and ETH Zurich, Switzerland
Large ASD
Closure of ASD
Mitral Stenosis
Pulmonary Outflow Tract Obstruction
S
C
A
N
P
R
O
T
O
C
O
L
Perfusion
Delayed short
Aortic MRA
Delayed long
MRI
Multislice Spiral CT Coronary Angiography
Detector row collimation
64 - 320 x 0.5 mm
Rotation time
87 to 330 ms
Table feed
6.6 to 8.0 mm/s
Image quality
- IV contrast 40 -120 ml
- ß-blocker < 70 bpm
- 4 to 15 s breathhold
- ECG recording
for prospective retrospective gating
in mid-diastole
Z-axis
Z coverage
10 - 16 cm
Scan time
<1 to 12 s
South Bay Heart Watch: Middle aged,
higher risk
Greenland. JAMA 2004;291:210-215.
St. Francis: Middle aged
PACC Project: Aged 40-50, low risk
Taylor et al, JACC 2005;46:807-814
Rotterdam: Elderly
2-10X  risk
Guerci et al. JACC 2005;46:158
Vliegenthart. Circulation 2005;112:572
• Multi-vessel CAC is
worse:
– Incremental to CAC score
for overall mortality
• Effect even observed at
low calcium scores
J Am Coll Cardiol 2007;49:1860–70
Coronary angiography Vs CCTA
Meta-analysis of 41 articles published between 1997 and 2006
Coronary angiography Vs CCTA
• CCTA is safe and costefficient.
• CCTA is rapid in arriving
the diagnosis.
• Investigational bias –
6640 screened 759
enrolled
• CCTA Median radiation
dose of 12 mSv.
•
MCT: 1392 patients, 929 CCTA, 463 traditional care
March 26, 2012
March 26, 2012
• MCT: 1392 patients, 929 CCTA, 463 traditional care
Conclusion: A CCTA –based strategy for low to intermediate risk patients
presenting with a possible acute coronary syndrome appears to allow the safe,
expedited discharge of patients from the ED of patients who would otherwise
be admitted.
March 26, 2012
• Decrease length of stay in the ED
• Decrease hospital admissions
(12% CCTA vs 47% Standard
Approach)
• Mean CCTA radiation exposure of
11.3 mSv vs 12 mSv SPECT
• More downstream invasive
testing
• No reduction in overall cost of
care.
Study Design:
•
•
•
•
•
•
•
•
Retrospective observational study
Total of 9308 patients with ACP
7/12 daily including weekends and
holidays
CCTA vs Standard of Care
Nearly 1/3 of the CCTA were triple rule
out
Risk matched 784 of CCTA and SOC for
comparison of outcomes
Mean age of 49
Mean number of cardiac risk factor of 1
NORMAL
(0% stenosis)
NONOBSTRUCTIVE
(1‐49% stenosis)
OBSTRUCTIVE
(≥50% stenosis)
1
2
1. Normal Ventricle
2. LV Aneurysm
3. HOCM
4. Pericarditis
3
4
Anomalous Origin RCA
LCA
AO
PA
RCA
Coronary Bypass
LIMA
AO
PA
LA
RV
LAD
LV
Aortic Valves
This image cannot currently be display ed.
Apical thrombus post MI
Patent Ductus Aorta
Michael Poon, Concepción Learra. MDCT of the Pulmonary Veins
Multi-Slice CT in Cardiac Imaging Technical Principles, Imaging Protocols,
Clinical Indications and Future Perspective 2nd Edition, 2005 Bernd Ohnesorge (editor)
Fusion of EP map and MDCT
 Enhanced
External
Counterpulsation Therapy
EECP Operation
Diastolic Inflation
Sequentially inflate three sets of
cuffs at the end of systole
Systolic Deflation
Simultaneously deflate all three
sets of cuffs at the end of diastole
ECG
Normal
Upper Thigh
Cuffs
Upper
Thigh Cuffs
Lower
Thigh Cuffs
EECP
Calf Cuffs
Effects:
Diastolic
Augmentation
Increase
Coronary Perfusion
Lower
Thigh
Cuffs
Calf Cuffs
Effects:
Increase
Venous Return
Increase
Cardiac Output
Systolic Unloading
Reduce Cardiac
Workload
Increase
Cardiac Output
Early (hydraulic) external
counterpulsation machine
1950’s:
-
Kantrowitz Brothers - diastolic augmentation
Sarnoff - LV unloading
Birtwell - combined concepts
Gorlin - defined counterpulsation
1960’s:
- Birtwell & Soroff - Dennis- Osborne - hydraulic external
counterpulsation (Harvard)
1970’s:
- Soroff - cardiogenic shock
- Banas - stable angina
- Amsterdam - acute MI
1980’s:
- Technology innovation - Stony Brook
- China; redeveloped technology- pneumatic system
- Soroff, Hui, Zheng collaboration at Stony Brook
Background: Of 18 patients with chronic angina refractory to medical therapy:
- 8 had 19 prior revascularization attempts
- 7 had 14 prior myocardial infarcts
Methods:
36 one-hour treatment sessions
Pre- and post-treatment thallium treadmill stress tests to
identical exercise times
Separate post-treatment maximal routine treadmill stress test
Results:
All patients reported improvement in anginal symptoms:
- 16 patients (89%) reported no angina during usual activities:
- 12 patients (67%) with resolution of reversible perfusion defects
- 2 patients (11%) with improvement of reversible perfusion defects
- 4 patients (22%) with no change
Lawson WE, Hui JCK, Soroff HS, et al. Efficacy of enhanced external counterpulsation in the treatment
of angina pectoris. Am J Cardiol. 1992;70:859-862.
Noninvasive  Series of 3 cuffs wrapped around calves, lower thighs,
upper thighs and buttocks
procedure:
 Sequential distal to proximal compression upon diastole, and
 Simultaneous release of pressure at end-diastole
Produces:
 Increased diastolic pressure and retrograde aortic flow
 Increased venous return and...
 Systolic unloading, resulting in increased cardiac output
Endothelial Cell Functions
Single layer of cells lining the lumen of all blood vessel
 Vasomotor tone
(vasodilation)
 Permeable barrier
 Antithrombosis
 Anti-inflammation
 Angiogensis: growth
factors
 Antioxidant
Pathophysiology of Endothelial Dysfunction - Process of Atherogenesis
ve Stress, Abnormal metabolism, Low flow state
othelial Dysfunction
Reduced vaso-relaxation nitric oxide
Reduce flow-mediated vasodilatation
Reduced blood flow
Increase systolic blood pressure
Increase arterial stiffness
Vascular Adhesion Molecules
Inflammatory responses
Migrate into sub-endothelial space
Promote smooth muscle cells growth, proliferation, migration
Increase thrombosis/leukocyte adhesion
Intimal Medial thickening
Atherogenesis: Plaque formation
EECP Mechanisms of Action
Improve Endothelial Function
 Vasodilation 
 Intimal Hyperplasia 
emodynamic
Effects
Systolic Unloading
Collateral Development
 Blood flow to ischemic region
 Capillary density 
(cardiac workload)
Diastolic Augmentation
(coronary blood flow)
ncrease Cardiac Output
(organ perfusion)
Improve Neurohormonal Factors
 BNP  and ANP 
 Angiotensin II 
Reduce Arterial Stiffness
 Blood pressure 
 Vascular resistance 
EECP Mechanisms of Action
Hemodynamic Effects of EECP
Increase Cardiac Output
Increase Coronary Perfusion
Diastolic
Augmentation
Improve
Diastolic
Filling
Increase
Venous Return
Systolic
Unloading
Diastolic
Retrograde
Flow
Pressure Gradients
occlusion
Enhance Collateral
Capillary Sprouting
Vasodilatation
Increase Shear Stress on Endothelium
Neurohormonal Release
Increases: NO
Decreases: BNP, ANP,
ET-1, ACE, ANG II
Improve
Endothelial
Function
Release of
Growth
Factors
Angiogenesis
and
Arteriogenesis
the sixth-leading cause of death in the United
States
the only leading cause for which there are no
preventive interventions, cures, or even
means of slowing disease progression
One in three seniors dies with Alzheimer’s or
another dementia
Payments for health and long-term care
services for people with Alzheimer’s and
other dementias will total $203 billion in
2013
CAD plaque
he most common forms of dementia are Alzheimer's
isease (AD) affecting 50-70%, and vascular dementia
VasD) affecting 20-25%.
oth AD and VasD share common cardiovascular risk
actors; including high blood pressure, high
holesterol, and diabetes mellitus
oth have higher rates of occurrence in patients with
ardiovascular diseases, ischemic heart disease, or
ymptoms such as heart failure
P Improves Endothelial function and Vasodilation AJH 2006;19:867-872
eNOs
During EECP Blood flow
200
eNOS protein level (% of
control)
coronary Ultrasound
nary Blood Flow
Circulation 2007
† p< 0.05
versus CHOL
group †
150
culation. 2002;106:1237-1242
Shear stress
*p<
0.05
versus
Control
*
100
p<0.01
N=20
Nitric Oxide Activates eNOs
†
0
Control
CHOL
CHOL +EECP
†
*
†
†
‡
Endothelial cell produce NO
NO crosses intimal to
Smooth Muscular Cells
Baseline 1hr 12hr 24hr36hr1-mo3-mo
27.1±2.6 µmol/L
after after
* p=0.014; †p<0.0001; ‡p=0.002 vs baseline
Release cGMP
Am J Cardil 2006;98:28-30
Smooth Muscle cell relaxation
Vasodilation
m Coll Cardiol 2003;42:2090-5
Vascular resistance 
Effects of EECP on plasma cGMP
ma cGMP (nmol/l)
ated by Brachial Artery
mediated dilation (FMD)
% increase of NOx levels over baseline
50
Eur Heart J 2001;22(16):1451-58
(N=30)
(N=25)
p<0.001
p<0.001
it possible to exercise without sweating?
OTHESIS:
endothelial function may lead to reduction of blood supply, leading to poor
enation and damaged brain cells.
P is a mechanical device that improves blood flow, thereby improving endothelial
on, or micro circulation. EECP treatment has the potential to prevent or reduce
ogression of deterioration of mental status of patients suffering from mild
tive impairment (MCI) due to AD and VasD.
P therapy will be evaluated as a noninvasive intervention for endothelial
nction. Resulting improvements in blood flow to the brain should be evaluated as
tially preventive therapy for patients suffering from mild cognitive impairment
due to AD and VasD.
MCI Protocol Flow Chart
Screening: Patients with Recent Cognitive Decline
Baseline Cognitive Function Tests (CFT): MOCA and Cogstate Test
Consent Form + Baseline CFT Measurement + Endothelial
Function Test (EFT) + PET/MRI
Randomization
EECP vs Control
EECP
at full pressure 220 – 260 mmHg
to 2 hr daily, 5x/wk for 35 hrs to
llowed 2 hr weekly of EECP for 16
s and CFT every 3 months.
Control
Sham EECP at pressure 20 – 40 mmHg for
1 to 2 hr daily, 5x/wk for 35 hrs to be
followed by 2 hr weekly of EECP for 16
weeks and CFT every 3 months.
One EECP and One Sham Continue for another
6 months
One EECP and One Sham Cross Over for another 6
months then repeat CFT + EFT + PET/MRI
20 Sham→ EECP, 20 EECP → Sham, 20 EECP → EECP,
20 Sham - Sham
Translational Research and Imaging