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Diagnostic Multimodality

• Patients with cardiovascular disease have become

increasing more complex
• It lead to the development of multimodal diagnostic
• It means the integration of several different imaging
The objective of multimodality on diagnostic:
to establish a precise and early diagnosis
of the disease, in order guide treatment
and predict prognosis throughout the
patient’s follow-up
• The development of diagnostic investigations in the
field of cardiovascular disease has been accompanied
by their increased availability in health care facilities
and an increased demand for them.
• Consequently, the number of procedures that patients
undergo has increased markedly.
• This Evolution  “Lost clinical skill” in young
generation, phragmatic approach to new technology.
• The above factors have all contributed to a
significant increase in health care spending
• Cardiovascular imaging techniques being one of the
main reasons for such a trend
Diagnostic MultiModality
• Echocardiography
- M-mode echocardiography
- Contrast echocardiography
- Stress echocardiography
- Dupplex scanner echocardiography
- Color Doppler flow imaging
- Transesofageal echocardiography (TEE)
- 3D echocardiography
- 2D and 3 D speckle tracking echocardiography
2 D and 3 D Echocardiography

(Circ J 2015; 79: 2287–2298)

Speckle Tracking Echocardiography

Thomas H. Marwick et al. JIMG 2009;2:80-84

American College of Cardiology Foundation

Diagnostic MultiModality
• Myocardial Perfusion Scintigraphy
- Myocardial perfusion plannar scintigraphy  single
photon emission-computed tomography (MPSPECT)
has been one of the most important non-invasive
diagnostic cardiac test.
- MPSPECT provides simultaneous assessment of
myocardial perfusion & function in one study.
The Use of MSSPECT
• Diagnosis of CAD and various cardiac abnormalities.
• Identifying location and degree of CAD
• Assessment of viable myocardium in particular
coronary artery territory following acute coronary
• Post intervention revascularization (coronary artery
bypass graft, angioplasty) evaluation of heart.
Diagnostic MultiModality
Cardiac MS-CT
èmultislice CT (MSCT), cardiac CT or cardiovascular CT
èmeasuring parts of the heart/vessels anatomy by
èMSCT systems has allowed imaging of the heart,
while beating, with a level of more detail.
Cardiac MRI

• MRI uses a powerful magnetic field, radio waves and a

computer to produce detailed pictures of the structures
within and around the heart.

• It detect or monitor cardiac disease and to evaluate the

cardiac anatomy and function in patients with CVDs

• Cardiac MRI does not use ionizing radiation to produce

images, and it may provide the best images of the heart
Cardiac MRI
Common conditions for which cardiac MRI is indicated:
• Assessment of myocardial function following myocardial
• Assessment of myocardial viability/hibernation
• Myocarditis
• Cardiomyopathies
• Congenital heart disease
• Valvular disease
• Pericardial disease
• Myocardial tumor
Coronary angiography and PCI
- Invasive procedure to evaluate and treat coronary artery
disease and acute coronary syndrome

- It uses fluoroscopy/radiation

- Current application and development is widely influence

by operator technique and wiring/stent technology
Stent Technology
• Bifurcation and covered stent
Fractional Flow Reserve (FFR)

- FFR, is a guide wire-based procedure that can accurately

measure blood pressure and flow of the coronary artery.

- FFR is done through a standard diagnostic catheter at the

time of a coronary cardiac catheterization.

- The FFR has been shown useful in assessing whether or

not to perform angioplasty or stenting on "intermediate"
blockages (±70% blockade)
• Coronary intravascular ultrasound (IVUS)

- IVUS is an invasive tomographic imaging

modality, providing images of coronary arteries
and other blood vessels.

- Although coronary angiography continues to be

the standard tool to assess the coronary artery
lumen, angiography doesn’t supply direct
information about the plaque & vessel wall.

Normal coronary artery

Plaque with dissection

OCT (Optical coherence tomography)

- OCT is a novel invasive imaging technique that

produces high resolution intracoronary images.
- Its general principle of operation is similar to IVUS,
however OCT uses infrared light, not ultrasound.
- The main applications of the OCT system are:
• Atherosclerotic plaque assessment
• Stent struts coverage and apposition assessment,
and in stent restenosis evaluation
• PCI guide and optimisation
Laboratory medicine and
Point-of-care test (POCT)

- Expanding fast with novel application of new

biomarker (NT-pro BNP, Hs Trop I, ST2, galectin-1)

- Fast result, easy to use (POCT for Troponin I,

POCT for ST2, POCT for Hs CRP)
Application of Multimodality
on Diagnosis

• Cost effectiveness
• International guidelines
• National and Local implementation
• Insurance Coverage
ècomprehensive and precise diagnosis
Treatment Multimodality
Role of Treatment in CVDs:
- curative
- secondary prevention
- long term management
- comprehensive approach
Component of multimodality on
Treatment of CVDs
- Drugs (medications)
- Interventional procedure
- Device implantation
- Operative procedure (corrective / palliative)
- Rehabilitation and exercise
- Psychososial support
- Occupational therapy
Treatment Multimodality
Angina > 20 min,
diaforesis, general

Primary PCI + Temporary

Inferior STEMI with Total AV Block
Intensive care procedure and Intermediate care and continue
medication medication

Follow up and evaluation

Cardiac rehabilitation and
secondary prevention
Stem Cell Therapy
• Stem Cell Tx remains a relative young science
• Most of Clinical Trial were generally small and
• Trial for post infarction HF with mesenchymal stem
cell BM
• However the result were encouraging, the stem cell
tx appears safe
• Study are now expanding to larger spectrum of CV
Application of Multimodality
on Treatment
• Cost effectiveness
• International guidelines
• National and Local implementation
• Insurance Coverage
• Patient willingness and motivation

è comprehensive management of patients

• Cardiologist > >  Great improvement in Life Expectancy
and Q o L
• Depend on : Competency for Early Stages Dx
Novel Tx
Guiding Selection & Evaluating the
Effect of the Tx
Comprehensive Management

• Most of the Advanced in CV Dx on field CV Imaging

• Choosing Single or Combined Modality Imaging
• Important : Value, Benefit, Guidelines,
Cost - Insurance Coverage.
Selamat Mengikuti Jogja
Cardiology Update 2018 !!!