NIRS Imaging Can Detect the Vulnerable Patient An
NIRS Imaging Can Detect the Vulnerable Patient: An Update on the Latest Data Ryan D Madder, MD, FACC Section Chief, Interventional Cardiology Medical Director, Cardiac Cath Lab Frederik Meijer Heart & Vascular Institute Spectrum Health & Clinical Associate Professor of Medicine Michigan State University College of Human Medicine Grand Rapids, Michigan
Disclosures I have received research support from Infraredx.
Madder et al. J Am Coll Cardiol Intv. 2013; 6(8): 838 -846
Summary of NIRS Max. LCBI 4 mm in ACS Culprit Lesions Study ACS N AUC for culprit Sensitivity identification of by Max. LCBI 4 mm max. LCBI 4 mm ≥ 400 Specificity of Max. LCBI 4 mm ≥ 400 JACC Intv. 2013; 6: 838 -846 STEMI 20 0. 90 85% 95% ATVB. 2016; 36: 1010 -1015 STEMI 75 0. 83 64% 85% NSTEMI 43 0. 87 64% 94% 0. 79 39% 90% CCI. 2015; 86: 10141021 UA 38
Vulnerable Plaque vs Vulnerable Patient Large LRP stented segment Will this lesion cause a site-specific event? Vulnerable Plaque Is this lesion a marker of a patient who is at higher risk of CV events? Vulnerable Patient
NIRS Detects Vulnerable Patients: The ATHEROREMO-NIRS Study • NIRS imaging in nonculprit artery in 203 patients with stable angina or ACS • Cumulative 1 -year MACE was 4 -fold higher in patients with an LCBI equal to and above the median value of 43. 0 • adjusted hazard ratio: 4. 04; 95% confidence interval: 1. 33 to 12. 29; p = 0. 01). Oemrawsingh, et al. J Am Coll Cardiol 2014; 64: 2510– 8
NIRS Detects Vulnerable Patients: The ORACLE-NIRS Registry Danek et al. Cardiovasc Revasc Med 2016 [E-pub ahead of print]
Spectrum NIRS-IVUS Registry ¡ Single-center, prospective observational registry of patients undergoing NIRSIVUS imaging ¡ All patients followed for a total duration of 5 years ¡ Follow-up phone calls made at 6 months, 1 year, and then annually for occurrence of MACE January 2012 to September 2016 Enrolled 500 Patients
Spectrum NIRS-IVUS Registry: Interim Analysis for Patient Vulnerability January 2012 to April 2014 167 patients NIRS-IVUS imaging & ≥ 1 year of follow-up Does a large LRP detected by NIRS in a non-stented segment of the target vessel identify vulnerable patients? Excluded Prior CABG (7) Referred for CABG (17) Uninterpretable NIRS (15) NIRS only in stent (7) 121 patients included in this analysis Stented segment
Baseline characteristics N = 121 Index presentation N = 121 STEMI 45 (37. 2) Non-STEMI 18 (14. 9) Age 62. 5 ± 11. 2 Male 83 (68. 6) BMI 30. 2 ± 29. 3 Unstable angina 40 (33. 1) 53 ± 12 Stable symptoms 18 (14. 9) N = 121 Ejection fraction Hypertension 70 (57. 9) Diabetes 24 (19. 8) Discharge meds History of smoking 79 (65. 3) Aspirin 119 (98. 3) Dyslipidemia 70 (57. 9) P 2 Y 12 inhibitor 111 (91. 7) Beta-blocker 110 (90. 9) Chronic kidney disease 7 (5. 8) LDL-C 107 ± 38 ACEI/ARB 86 (71. 1) HDL-C 44 ± 15 Statin 115 (95. 0)
NIRS Detects Vulnerable Patients: The Spectrum NIRS-IVUS Registry Max. LCBI 4 mm ≥ 400 in non-stented segment in the target artery at baseline was significantly associated with subsequent MACCE: HR 10. 2 (95% CI 3. 4– 30. 6) p<0. 001 Madder et al. Eur Heart J Cardiovasc Img 2016; 17: 393 -399
NIRS Detects Vulnerable Patients: The Spectrum NIRS-IVUS Registry Madder et al. Eur Heart J Cardiovasc Img 2016; 17: 393 -399
Increased Lipid Burden In a Non-Target Vessel is Associated with Future Patient-level MACE Max. LCBI 4 mm Values Cumulative Multivariable Model MACE HR (95%CI) Incidence P-value Quartile 1 0 -83 14. 7% Ref Quartile 2 Quartile 3 84 -227 27. 9% 2. 11 (0. 96 -4. 60) 0. 062 228 -360 34. 3% 3. 09 (1. 41 -6. 74) 0. 005 ≥ 360 38. 6% 3. 58 (1. 67 -7. 70) 0. 001 Quartile 4 ATHEROREMO-NIRS & IBIS-3 -NIRS: Schuurman et al. EHJ 2017; 0: 1 -8
Increased Lipid Burden In a Non-Target Vessel is Associated with Future Patient-level MACE Max. LCBI 4 mm in a non-culprit vessel is associated with MACE at 4 years ATHEROREMO-NIRS & IBIS-3 -NIRS: Schuurman et al. EHJ 2017; 0: 1 -8
NIRS Detects Vulnerable Patients: The Lipid Rich Plaque Study • An international, multicenter, prospective cohort study • Enrolled >1, 500 patients who underwent multivessel NIRS-IVUS imaging between February 2014 and March 2016 • Co-primary hypothesis #1: there will be an association between largest max. LCBI 4 mm value in each patient and patient-level MACE NCT 02033694
# of Yellow Plaques by Angioscopy Identifies Vulnerable Patients • 552 patients underwent angioscopy at baseline • Followed for subsequent ACS Ohtani et al. JACC. 2006; 47: 2194 -200
LRP by OCT Identifies Vulnerable Patients • LRP in nonculprit region of target vessel predicts future cardiac events • Cumulative rate of NC-MACE was almost 3 -fold higher in patients with nonculprit LRP than in those without LRP Xing, L. et al. J Am Coll Cardiol. 2017; 69(20): 2502– 13.
Necrotic Core Size of Advanced Coronary Lesions by Histopathology J Am Coll Cardiol 2007; 50: 940– 9
Can NIRS Identify TCFA? Recent Evidence from Inaba et al. 450 • NIRS vs histopathology in 54 autopsied hearts. • 271 IVUS-defined lesions were evaluated 350 max. LCBI 4 mm • 80% had a cardiovascular cause of death. 400 p=0. 0003 300 250 200 150 100 50 0 Inaba et al. Am J Cardiol 2017; 119: 372 -378 Adaptive Pre. Th-CFA intimal fibroathermoa thickening TCFA
Can NIRS Identify TCFA? Recent Evidence from Inaba et al. • Optimal threshold max. LCBI 4 mm for identifying TCFA was 323 (AUC 0. 84) • Specificity = 85% Inaba et al. Am J Cardiol 2017; 119: 372 -378
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