Comparative definitions for moderate-severe ischemia in stress nuclear, echocardiography, and magnetic resonance imaging

CMR First-Pass Perfusion for Suspected Inducible Myocardial Ischemia

Cardiovascular magnetic resonance (CMR) has evolved from a pioneering research tool to an established noninvasive imaging method for detecting inducible myocardial perfusion deficits. In this consensus document, experts of different imaging techniques summarize the existing body of evidence regarding CMR perfusion as a viable complement to other established noninvasive tools for the assessment of perfusion and discuss the advantages and pitfalls of the technique. A rapid, standardized CMR perfusion protocol is described, which is safe, clinically feasible, and cost-effective for centers with contemporary magnetic resonance equipment. CMR perfusion can be recommended as a routine diagnostic tool to identify inducible myocardial ischemia.

Stress Echocardiography in Stable Coronary Artery Disease

PURPOSE OF REVIEW

Stress echocardiography (SE) is a well-established technique for the diagnosis and risk stratification of patients with known or suspected coronary artery disease (CAD). This review article summarizes the status of SE in CAD, including testing protocols, clinical efficacy and current use of newer technologies: myocardial perfusion, strain imaging, three-dimensional echocardiography and adjunctive carotid ultrasonography.

RECENT FINDINGS

Recent major findings in SE include the clinical value of myocardial perfusion imaging in multicentre studies, as well as when added to left ventricular (LV) wall motion assessment in clinical service. Additionally, SE has been shown to be more cost-effective than exercise ECG in patients with low-intermediate pre-test probability of CAD. Adjunctive atherosclerosis imaging by carotid ultrasonography (CU) to ischaemia testing by SE provides synergistic prognostic value, equivalent to hybrid imaging by PET-CT. Despite the development of newer and more expensive imaging modalities, SE remains the cornerstone for the assessment of CAD and has excellent clinical efficacy, is safe and is cost-effective.

Simple six-item clinical score improves risk prediction capability of stress echocardiography

Objectives

To assess the value of a simple score integrating non-ischaemia-related variables in expanding the wall motion abnormalities risk power during stress echocardiography (SE).

Methods

Study includes 14 279 patients who underwent SE for evaluation of coronary artery disease. All-cause death was the end point. Patients were randomly divided into the modelling and validation group of equal size. In the modelling group, multivariate analysis was conducted using clinical, rest and SE data, and a score was obtained from the number of non-ischaemia-related independent prognostic predictors. The score prognostic capability was compared in both groups.

Results

During a median follow-up of 31 months, 1230 patients died: 622 (9%) in the modelling and 608 (9%) in the validation group (p=0.68). Independent predictors of mortality were ischaemia at SE (HR 1.77, 95% CI 1.49 to 2.12; p<0.0001) and six other parameters: age>65 years, wall motion at rest, diabetes, left bundle branch block, anti-ischaemic therapy and male sex. Risk score resulted prognostically effective in the modelling and validation groups, both with and without inducible ischaemia subset. When risk score was included in the multivariate analysis, besides ischaemia at SE it was the only independent predictor of mortality in the modelling (HR 1.70, 95% CI 1.60 to 1.82; p<0.0001), in the validation (HR 1.77, 95% CI 1.65 to 1.90; p<0.0001) and in the overall group (HR 1.73, 95% CI 1.66 to 1.82; p<0.0001).

Conclusions

Simple clinical variables may be able to optimise SE risk stratification.

The elusive role of myocardial perfusion imaging in stable ischemic heart disease: Is ISCHEMIA the answer?

The assessment of ischemia through myocardial perfusion imaging (MPI) is widely accepted as an index step in the diagnostic evaluation of stable ischemic heart disease (SIHD). Numerous observational studies have characterized the prognostic significance of ischemia extent and severity. However, the role of ischemia in directing downstream SIHD care including coronary revascularization has remained elusive as reductions in ischemic burden have not translated to improved clinical outcomes in randomized trials. Importantly, selection bias leading to the inclusion of many low risk patients with minimal ischemia have narrowed the generalizability of prior studies along with other limitations. Accordingly, an ongoing randomized controlled trial entitled ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) will compare an invasive coronary revascularization strategy vs a conservative medical therapy approach among stable patients with moderate to severe ischemia. The results of ISCHEMIA may have a substantial impact on the management of SIHD and better define the role of MPI in current SIHD pathways of care.

Comparative effectiveness of coronary CT angiography vs stress cardiac imaging in patients following hospital admission for chest pain work-up: The Prospective First Evaluation in Chest Pain (PERFECT) Trial

BACKGROUND

Because the frequency of cardiac event rates is low among chest pain patients following either performance of coronary CT angiography (CCTA) or stress testing, there is a need to better assess how these tests influence the central management decisions that follow from cardiac testing. The present study was performed to assess the relative impact of CCTA vs stress testing on medical therapies and downstream resource utilization among patients admitted for the work-up of chest pain.

METHODS

The admitted patients were randomized in a 1:1 ratio to either cardiac imaging stress test or CCTA. Primary outcomes were time to discharge, change in medication usage, and frequency of downstream testing, cardiac interventions, and cardiovascular re-hospitalizations. We randomized 411 patients, 205 to stress testing, and 206 to CCTA.

RESULTS

There were no differences in time to discharge or initiation of new cardiac medications at discharge. At 1 year follow-up, there was no difference in the number of patients who underwent cardiovascular downstream tests in the CCTA vs stress test patients (21% vs 15%, P = .1) or cardiovascular hospitalizations (14% vs 16%, P = .5). However, there was a higher frequency of invasive angiography in the CCTA group (11% vs 2%, P = .001) and percutaneous coronary interventions (6% vs 0%, P < .001).

CONCLUSIONS

Randomization of hospitalized patients admitted for chest pain work-up to either CCTA or to stress testing resulted in similar discharge times, change in medical therapies at discharge, frequency of downstream noninvasive testing, and repeat hospitalizations. However, a higher frequency of invasive coronary angiography and revascularization procedures were performed in the CCTA arm. (ClinicalTrials.gov number, NCT01604655.).

Magnetic resonance Adenosine perfusion imaging as Gatekeeper of invasive coronary intervention (MAGnet): study protocol for a randomized controlled trial

Background

Current guidelines for the diagnosis and management of patients with stable coronary artery disease (CAD) recommend functional stress testing for risk stratification prior to revascularization procedures. Cardiac magnetic resonance imaging (CMR) is a modality of choice for stress testing because of its capability to detect myocardial ischemia sensitively and specifically. Nevertheless, evidence from randomized trials evaluating a CMR-based management of stable CAD patients in comparison to a more common angiography-based approach still is limited.

Methods/design

Patients presenting themselves with symptoms indicating a stable CAD and a class I or IIa indication for diagnostic coronary angiography are prospectively screened and enrolled in the study. All subjects receive a basic cardiological work-up and guideline-directed medical therapy. A 1:1 randomization in two groups is being performed. Patients in group 1 undergo diagnostic coronary angiography and subsequent revascularization according to current guidelines. Subjects in group 2 undergo adenosine stress CMR and in case of myocardial ischemia are sent to coronary angiography. Follow-up is planned for 3 years. During this time, the number of primary endpoints (defined as cardiac death and non-fatal myocardial infarction) and unplanned invasive procedures will be documented. Furthermore, symptom burden and quality of life will be assessed by use of the Seattle Angina Questionnaire. Sample size is calculated to prove non-inferiority of the CMR-based approach.

Discussion

In case this study is able to accomplish its aim to prove non-inferiority of the CMR-based management in patients with stable CAD; the importance of this emerging modality may further increase.

Trial registration

ClinicalTrials.gov, identifier: NCT02580851. Registered on 14 October 2015. Unique Protocol ID: 237/11

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2101-6) contains supplementary material, which is available to authorized users.

Assessment of stable coronary artery disease by cardiovascular magnetic resonance imaging: Current and emerging techniques

Coronary artery disease (CAD) is a leading cause of death and disability worldwide. Cardiovascular magnetic resonance (CMR) is established in clinical practice guidelines with a growing evidence base supporting its use to aid the diagnosis and management of patients with suspected or established CAD. CMR is a multi-parametric imaging modality that yields high spatial resolution images that can be acquired in any plane for the assessment of global and regional cardiac function, myocardial perfusion and viability, tissue characterisation and coronary artery anatomy, all within a single study protocol and without exposure to ionising radiation. Advances in technology and acquisition techniques continue to progress the utility of CMR across a wide spectrum of cardiovascular disease, and the publication of large scale clinical trials continues to strengthen the role of CMR in daily cardiology practice. This article aims to review current practice and explore the future directions of multi-parametric CMR imaging in the investigation of stable CAD.

Value of the coronary artery disease consortium rule in patients with acute chest pain and negative troponins referred for exercise stress testing

OBJECTIVE

To assess the value of the pretest probability (PTP) of coronary artery disease (CAD) for predicting stress testing results and coronary events in patients with acute chest pain and negative troponins.

PATIENTS AND METHODS

A total of 3527 patients without a history of CAD referred to our chest pain unit with suspected acute coronary syndromes, nondiagnostic ECGs, and negative troponin levels underwent exercise stress testing. PTP was estimated with the CAD consortium prediction rule, and was categorized as low (<15%), low-intermediate (15-65%), intermediate-high (66-85%), and high (>85%). The endpoints were the presence of signs of inducible myocardial ischemia on stress testing and the occurrence of coronary events within 6 months.

RESULTS

The probability of exercise-induced myocardial ischemia was 2.6, 12.6, 42.9, and 82.1% in patients with low, low-intermediate, intermediate-high, and high PTP, respectively (Ptrend<0.001). The cumulative rate of coronary events within 6 months was also significantly lower in patients with low PTP of CAD (0.8%) than in those with low-intermediate (6.9%), intermediate-high (32.5%), or high PTP (66.7%) (Ptrend<0.001). Per 10% increment in PTP of CAD, the adjusted odds ratios for inducible myocardial ischemia and coronary events within 6 months were, respectively, 1.71 (95% confidence interval: 1.61-1.85) and 1.87 (95% confidence interval: 1.74-2.01).

CONCLUSION

PTP was associated strongly with the likelihood of exercise-induced myocardial ischemia and coronary events in patients with suspected acute coronary syndromes and negative troponins. The yield of stress testing in the subset of patients with low PTP was very low.

The assessment of ischaemic burden: validation of a functional jeopardy score against cardiovascular magnetic resonance perfusion imaging

AIMS

This study assesses the relationship between classical anatomical jeopardy scores, functional jeopardy scores (combined anatomical and haemodynamic data), and the extent of ischaemia identified on cardiovascular magnetic resonance (CMR) perfusion imaging.

METHODS AND RESULTS

In 42 patients with stable angina and suspected coronary artery disease (CAD), CMR perfusion imaging was performed. Fractional Flow Reserve (FFR) was measured in vessels with ≥50 % stenosis. The APPROACH and BCIS jeopardy scores were calculated based on QCA results with both a 70 % (APP₇₀ and BCIS₇₀) and a 50 % stenosis (APP₅₀, and BCIS₅₀) used as the threshold for significance, as well as after integration of FFR and compared with the extent of ischaemia identified on CMR. The correlation between the extent of ischaemia measured by CMR and the anatomical jeopardy scores was moderate (APPROACH: r = 0.58; BCIS: r = 0.48, p = 0.001). Integrating physiological information improved this significantly to r = 0.82, p = 0.0001 for APPROACH and r = 0.82, p = 0.0001 for BCIS scores (z-statistic = -2.04, p = 0.04; z-statistic = -2.63, p = 0.009). In relation to CMR, the APPROACH and BCIS scores overestimated the volume of ischaemic myocardium by 29.2 and 25.2 %, respectively, which was reduced to 12.8 and 12 % after integrating functional data.

CONCLUSIONS

Anatomical and functional jeopardy scores overestimate ischaemic burden when compared to CMR. Integrating physiological information from FFR to generate a functional score improves ischaemic burden estimation.

Left ventricular ejection fraction and presence of myocardial necrosis assessed by cardiac magnetic resonance imaging correctly risk stratify patients with stable coronary artery disease: a multi-center all-comers trial

BACKGROUND

Cardiac magnetic resonance imaging (CMR) has become a diagnostic modality that allows for prognostic risk stratification in various cardiac diseases. CMR derived detection of myocardial necrosis by late gadolinium enhancement (LGE) and assessment of left ventricular functional parameters such as left-ventricular ejection fraction (LVEF) have been proven to be significantly associated with outcome and prognosis. Our study focusses on the validation of specific thresholds for these parameters in a multi-center daily all-comers cohort of stable coronary artery disease (CAD) patients.

METHODS

Multi-center data from tertiary high-volume CMR centers were pooled. Patients referred for viability testing for known or suspected CAD were enrolled. Functional parameters of both ventricles and myocardial necrosis were assessed. The primary endpoint was defined as cardiac death and non-fatal myocardial infarction. A multi-model approach was used for the evaluation of the predictive power of several LVEF thresholds and LGE.

RESULTS

The study cohort consisted of 2422 patients. Median age was 66 years; 25.9 % were female. Median follow-up was 2.86 years. During the follow-up period, 187 primary endpoints occurred. On multi-model testing, optimal thresholds for LVEF could be defined at ≤50 and ≤35 %. The addition of LGE as categorical variable further lead to a significant improvement of each risk prediction model, whilst quantification of LGE affection had no additional prognostic impact.

CONCLUSION

LVEF thresholds at ≤50 and ≤35 % in combination with the assessment of LGE presence allows for excellent discrimination between low, mid and high prognostic risk in stable CAD.

Prognostic Determinants of Coronary Atherosclerosis in Stable Ischemic Heart Disease

Risk stratification in patients with stable ischemic heart disease is essential to guide treatment decisions. In this regard, whether coronary anatomy, physiology, or plaque morphology is the best determinant of prognosis (and driver an effective therapeutic risk reduction) remains one of the greatest ongoing debates in cardiology. In the present report, we review the evidence for each of these characteristics and explore potential algorithms that may enable a practical diagnostic and therapeutic strategy for the management of patients with stable ischemic heart disease.

Transient Ischemic Dilatation during Stress Echocardiography: An Additional Marker of Significant Myocardial Ischemia

AIM

Left ventricular (LV) transient ischemic dilatation (TID) is not clear how it relates to inducible myocardial ischemia during stress echocardiography (SE).

METHODS AND RESULTS

Eighty-eight SEs were examined from the site certification phase of the ISCHEMIA Trial. LV end-diastolic volume (EDV) and end-systolic volume (ESV) were measured at rest and peak stages and the percent change calculated. Moderate or greater ischemia was defined as ≥3 segments with stress-induced severe hypokinesis or akinesis. Optimum cut points in stress-induced percent EDV and ESV change that identified moderate or greater myocardial ischemia were analyzed. Analysis from percentage distribution identified a > 13% LV volume increase in EDV or a > 9% LV volume increase in ESV as the optimum cutoff points for moderate or greater ischemia. Using these definitions for TID, there were 27 (31%) with TIDESV and 12 (14%) with TIDEDV . By logistic regression analysis and receiver operating characteristic curves, the percent change in ESV had a stronger association with moderate or greater myocardial ischemia than that of EDV change. Compared to those without TIDESV , cases with TIDESV had larger extent of inducible wall-motion abnormalities, lower peak stress LVEF, and higher likelihood of moderate or grater ischemia. For moderate or greater myocardial ischemia detection, TIDESV had a sensitivity of 46%, specificity of 83%, positive predictive value of 70%, and negative predictive value of 64%.

CONCLUSION

Transient ischemic dilatation by SE is a marker of extensive myocardial ischemia and can be used as an additional marker of higher risk.

Troponin levels within the normal range and probability of inducible myocardial ischemia and coronary events in patients with acute chest pain

BACKGROUND/OBJECTIVES

Patients with suspected acute coronary syndromes and negative cardiac troponin (cTn) levels are deemed at low risk. Our aim was to assess the effect of cTn levels on the frequency of inducible myocardial ischemia and subsequent coronary events in patients with acute chest pain and cTn levels within the normal range.

METHODS

We evaluated 4474 patients with suspected acute coronary syndromes, nondiagnostic electrocardiograms and serial cTnI levels below the diagnostic threshold for myocardial necrosis using a conventional or a sensitive cTnI assay. The end points were the probability of inducible myocardial ischemia and coronary events (i.e., coronary death, myocardial infarction or coronary revascularization within 3 months).

RESULTS

The probability of inducible myocardial ischemia was significantly higher in patients with detectable peak cTnI levels (25%) than in those with undetectable concentrations (14.6%, p<0.001). These results were consistent regardless of the type of cTnI assay, the type of stress testing modality, or the timing for cTnI measurement, and remained significant after multivariate adjustment (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.21-1.79, p<0.001). The rate of coronary events at 3 months was also significantly higher in patients with detectable cTnI levels (adjusted OR 2.08, 95% CI 1.64-2.64, p<0.001).

CONCLUSIONS

Higher cTnI levels within the normal range were associated with a significantly increased probability of inducible myocardial ischemia and coronary events in patients with suspected acute coronary syndromes and seemingly negative cTnI.

Microvascular ischemia in hypertrophic cardiomyopathy: new insights from high-resolution combined quantification of perfusion and late gadolinium enhancement

BACKGROUND

Microvascular ischemia is one of the hallmarks of hypertrophic cardiomyopathy (HCM) and has been associated with poor outcome. However, myocardial fibrosis, seen on cardiovascular magnetic resonance (CMR) as late gadolinium enhancement (LGE), can be responsible for rest perfusion defects in up to 30% of patients with HCM, potentially leading to an overestimation of the ischemic burden. We investigated the effect of left ventricle (LV) scar on the total LV ischemic burden using novel high-resolution perfusion analysis techniques in conjunction with LGE quantification.

METHODS

30 patients with HCM and unobstructed epicardial coronary arteries underwent CMR with Fermi constrained quantitative perfusion analysis on segmental and high-resolution data. The latter were corrected for the presence of fibrosis on a pixel-by-pixel basis.

RESULTS

High-resolution quantification proved more sensitive for the detection of microvascular ischemia in comparison to segmental analysis. Areas of LGE were associated with significant reduction of myocardial perfusion reserve (MPR) leading to an overestimation of the total ischemic burden on non-corrected perfusion maps. Using a threshold MPR of 1.5, the presence of LGE caused an overestimation of the ischemic burden of 28%. The ischemic burden was more severe in patients with fibrosis, also after correction of the perfusion maps, in keeping with more severe disease in this subgroup.

CONCLUSIONS

LGE is an important confounder in the assessment of the ischemic burden in patients with HCM. High-resolution quantitative analysis with LGE correction enables the independent evaluation of microvascular ischemia and fibrosis and should be used when evaluating patients with HCM.

Stress echocardiography: what is new and how does it compare with myocardial perfusion imaging and other modalities?

Cardiovascular disease is a leading cause of morbidity and mortality, and noninvasive strategies to diagnose and risk stratify patients remain paramount in the evaluative process. Stress echocardiography is a well-established, versatile, real-time imaging modality with advantages including lack of radiation exposure, portability, and affordability. Innovative techniques in stress echocardiography include myocardial contrast echocardiography, deformation imaging, three-dimensional (3D) echocardiography, and assessment of coronary flow reserve. Myocardial perfusion imaging with single-photon emission computed tomography (SPECT) or positron emission tomography (PET) are imaging alternatives, and stress cardiac magnetic resonance imaging and coronary computed tomography (CT) angiography, including CT perfusion imaging, are emerging as newer approaches. This review will discuss recent and upcoming developments in the field of stress testing, with an emphasis on stress echocardiography while highlighting comparisons with other modalities.

The value of core lab stress echocardiography interpretations: observations from the ISCHEMIA Trial

BACKGROUND

Stress echocardiography (SE) is dependent on subjective interpretations. As a prelude to the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) Trial, potential sites were required to submit two SE, one with moderate or severe left ventricular (LV) myocardial ischemia and one with mild ischemia. We evaluated the concordance of site and core lab interpretations.

METHODS

Eighty-one SE were submitted from 41 international sites. Ischemia was classified by the number of new or worsening segmental LV wall motion abnormalities (WMA): none, mild (1 or 2) or moderate or severe (3 or more) by the sites and the core lab.

RESULTS

Core lab classified 6 SE as no ischemia, 35 mild and 40 moderate or greater. There was agreement between the site and core in 66 of 81 total cases (81%, weighted kappa coefficient [K] =0.635). Agreement was similar for SE type - 24 of 30 exercise (80%, K = 0.571) vs. 41 of 49 pharmacologic (84%, K = 0.685). The agreement between poor or fair image quality (27 of 36 cases, 75%, K = 0.492) was not as good as for the good or excellent image quality cases (39 of 45 cases, 87%, K = 0.755). Differences in concordance were noted for degree of ischemia with the majority of discordant interpretations (87%) occurring in patients with no or mild LV myocardial ischemia.

CONCLUSIONS

While site SE interpretations are largely concordant with core lab interpretations, this appears dependent on image quality and the extent of WMA. Thus core lab interpretations remain important in clinical trials where consistency of interpretation across a range of cases is critical.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01471522.

Stable coronary artery disease: revascularisation and invasive strategies

Stable coronary artery disease is the most common clinical manifestation of ischaemic heart disease and a leading cause of mortality worldwide. Myocardial revascularisation is a mainstay in the treatment of symptomatic patients or those with ischaemia-producing coronary lesions, and reduces ischaemia to a greater extent than medical treatment. Documentation of ischaemia and plaque burden is fundamental in the risk stratification of patients with stable coronary artery disease, and several invasive and non-invasive techniques are available (eg, fractional flow reserve or intravascular ultrasound) or being validated (eg, instantaneous wave-free ratio and optical coherence tomography). The use of new-generation drug-eluting stents and arterial conduits greatly improve clinical outcome in patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). PCI is feasible, safe, and effective in many patients with stable coronary artery disease who remain symptomatic despite medical treatment. In patients with multivessel and left main coronary artery disease, the decision between PCI or CABG is guided by the local Heart Team (team of different cardiovascular specialists, including non-invasive and invasive cardiologists, and cardiac surgeons), who carefully judge the possible benefits and risks inherent to PCI and CABG. In specific subsets, such as patients with diabetes and advanced, multivessel coronary artery disease, CABG remains the standard of care in view of improved protection against recurrent ischaemic adverse events.

The Prevalence of Clinically Significant Ischemia in Patients Undergoing Percutaneous Coronary Intervention: A Report from the Multicenter Registry

Background

Myocardial perfusion scintigraphy (MPS) plays an important role in the evaluation and quantification of myocardial ischemia, and those with significant ischemia (SI) benefit most from revascularization procedures. This study aimed to identify the clinical factors and anatomical features associated with SI in patients with stable ischemic heart disease (SIHD).

Methods and Results

Data were analyzed from 4197 SIHD patients undergoing percutaneous coronary intervention (PCI). Ischemia was based on MPS findings prior to PCI, with SI defined as an ischemic region of more than 10% of the total left ventricular area. Logistic regression analysis was performed to identify any clinical factors associated with SI. MPS was used to evaluate 1070 (25.5%) patients pre-procedurally. Patients with a history of heart failure, stroke, or anginal symptoms with Canadian Cardiovascular Society class 2 or more were more likely to have SI (odds ratio [OR] 1.63, p = 0.025, OR: 1.85, p = 0.009, and OR: 1.49, p = 0.003, respectively). When angiographic variables were considered, a proximal left anterior descending artery (pLAD) lesion was the sole factor associated with SI (OR: 1.45, p = 0.012). Importantly, those with SI had more in-hospital complications (p = 0.006), most notably post-PCI infarcts (p = 0.008).

Conclusions

Patients’ background data, such as stronger anginal symptoms or a pLAD lesion, were associated with SI. Patients with SI must be treated with PCI to improve their long-term prognosis; however, procedure-related complications happen more frequently in SI patients than in non-SI patients. Physicians must give their full attention when performing the PCI procedure in SI patients to minimize their complication rate.

Finding the Gatekeeper to the Cardiac Catheterization Laboratory: Coronary CT Angiography or Stress Testing?

Functional capacity is a robust predictor of clinical outcomes, and stress testing is used in current practice paradigms to guide referral to invasive coronary angiography. However, invasive coronary angiography is driven by ongoing symptoms, as well as risk of adverse outcomes. The limitations of current functional testing-based paradigms might be avoided by using coronary computed tomographic angiography (CCTA) for exclusion of obstructive coronary artery disease. The growth of CCTA has been supported by comparative prognostic evidence with CCTA and functional testing, as well as radiation dose reduction. Use of CCTA for physiological evaluation of coronary lesion-specific ischemia may facilitate evaluation of moderate stenoses, designation of the culprit lesion, and prediction of benefit from revascularization. The potential of CCTA to serve as an effective gatekeeper to invasive coronary angiography will depend, in part, on the adoption of these new developments, as well as definition of the benefit of detecting high-risk plaque for guiding the management of selected patients.

Temporal changes in the use and results of exercise echocardiography

AIMS

Limited data are available regarding changes over time in referral patterns and outcomes of non-invasive cardiac stress testing. Our aim was to evaluate the temporal changes in the use and results of exercise echocardiography in our area of reference.

METHODS AND RESULTS

A total of 12 339 patients referred to our unit for exercise echocardiography between 1997 and 2012 were included. We divided the 16-year period into four quadrennia and evaluated the changes in clinical data, results of the tests, referrals for invasive management and outcomes. We observed a gradual decrease in the frequency of detection of myocardial ischaemia from 35.3% in1997-2000 to 25.4% in 2009-12 (P < 0.001). There was also a progressive increase in the prevalence of cardiovascular risk factors and in the frequency of non-ischaemic chest pain and dyspnoea, while the proportion of patients with prior myocardial infarction and non-interpretable electrocardiograms declined. The rate of referral to coronary angiography within 6 months decreased from 24.8% in 1997-2000 to 19.6% in 2009-12 (P < 0.001), but the rate of coronary revascularization remained almost unchanged (13.1 to 11.7%, P for the trend = 0.16). We also observed a progressive decrease in the 1-year mortality rate from 3.4 to 1% (P < 0.001).

CONCLUSION

Over a 16-year period, there was a gradual decrease in the frequency of myocardial ischaemia among patients referred to our unit for exercise echocardiography, which was parallel to changes in their clinical profile. However, this was not accompanied by a significant reduction in the rate of coronary revascularization.

Update on ischemic heart disease and intensive cardiac care

This article summarizes the main developments reported in 2014 on ischemic heart disease, together with the most important innovations in intensive cardiac care.

Update on cardiac imaging techniques 2014

In this article, we review the contributions of the most important imaging techniques used in cardiology, reported in 2014. Echocardiography remains the cornerstone for diagnosing and monitoring valvular heart disease, and there has been a continuing effort to improve quantification of this condition and obtain prognostic parameters for follow-up. The study of regional myocardial function is anchored in the diagnosis of subclinical ventricular dysfunction, and 3-dimensional transesophageal echocardiography has become the perfect ally in interventional procedures for structural heart disease. Cardiac magnetic resonance imaging and cardiac computed tomography are the focus of most publications on cardiac imaging in ischemic heart disease, reflecting their consolidated use in clinical practice. Nuclear medicine excels in the study of myocardial viability after interventional treatment of acute coronary syndromes and its performance is validated in the diagnosis of ischemic heart disease.