1
|
Miller RJH, Bednarski BP, Pieszko K, Kwiecinski J, Williams MC, Shanbhag A, Liang JX, Huang C, Sharir T, Hauser MT, Dorbala S, Di Carli MF, Fish MB, Ruddy TD, Bateman TM, Einstein AJ, Kaufmann PA, Miller EJ, Sinusas AJ, Acampa W, Han D, Dey D, Berman DS, Slomka PJ. Clinical phenotypes among patients with normal cardiac perfusion using unsupervised learning: a retrospective observational study. EBioMedicine 2024; 99:104930. [PMID: 38168587 PMCID: PMC10794922 DOI: 10.1016/j.ebiom.2023.104930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/24/2023] [Accepted: 12/05/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Myocardial perfusion imaging (MPI) is one of the most common cardiac scans and is used for diagnosis of coronary artery disease and assessment of cardiovascular risk. However, the large majority of MPI patients have normal results. We evaluated whether unsupervised machine learning could identify unique phenotypes among patients with normal scans and whether those phenotypes were associated with risk of death or myocardial infarction. METHODS Patients from a large international multicenter MPI registry (10 sites) with normal perfusion by expert visual interpretation were included in this cohort analysis. The training population included 9849 patients, and external testing population 12,528 patients. Unsupervised cluster analysis was performed, with separate training and external testing cohorts, to identify clusters, with four distinct phenotypes. We evaluated the clinical and imaging features of clusters and their associations with death or myocardial infarction. FINDINGS Patients in Clusters 1 and 2 almost exclusively underwent exercise stress, while patients in Clusters 3 and 4 mostly required pharmacologic stress. In external testing, the risk for Cluster 4 patients (20.2% of population, unadjusted hazard ratio [HR] 6.17, 95% confidence interval [CI] 4.64-8.20) was higher than the risk associated with pharmacologic stress (HR 3.03, 95% CI 2.53-3.63), or previous myocardial infarction (HR 1.82, 95% CI 1.40-2.36). INTERPRETATION Unsupervised learning identified four distinct phenotypes of patients with normal perfusion scans, with a significant proportion of patients at very high risk of myocardial infarction or death. Our results suggest a potential role for patient phenotyping to improve risk stratification of patients with normal imaging results. FUNDING This work was supported by the National Heart, Lung, and Blood Institute at the National Institutes of Health [R35HL161195 to PS]. The REFINE SPECT database was supported by the National Heart, Lung, and Blood Institute at the National Institutes of Health [R01HL089765 to PS]. MCW was supported by the British Heart Foundation [FS/ICRF/20/26002].
Collapse
Affiliation(s)
- Robert J H Miller
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Biomedical Sciences, and Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Cardiac Sciences, University of Calgary and Libin Cardiovascular Institute, Calgary, AB, Canada
| | - Bryan P Bednarski
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Biomedical Sciences, and Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Konrad Pieszko
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Biomedical Sciences, and Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jacek Kwiecinski
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Biomedical Sciences, and Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - Michelle C Williams
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Biomedical Sciences, and Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA; British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Aakash Shanbhag
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Biomedical Sciences, and Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Signal and Image Processing Institute, Ming Hsieh Department of Electrical and Computer Engineering, University of Southern California, Los Angeles, CA, USA
| | - Joanna X Liang
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Biomedical Sciences, and Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Cathleen Huang
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Biomedical Sciences, and Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Tali Sharir
- Department of Nuclear Cardiology, Assuta Medical Centers, Tel Aviv, Israel; Israel and Ben Gurion University of the Negev, Beer Sheba, Israel
| | - M Timothy Hauser
- Department of Nuclear Cardiology, Oklahoma Heart Hospital, Oklahoma City, OK, USA
| | - Sharmila Dorbala
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Marcelo F Di Carli
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Mathews B Fish
- Oregon Heart and Vascular Institute, Sacred Heart Medical Center, Springfield, OR, USA
| | - Terrence D Ruddy
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | | | - Andrew J Einstein
- Division of Cardiology, Department of Medicine and Department of Radiology, Columbia University Irving Medical Center and New York-Presbyterian Hospital, New York, NY, USA
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Edward J Miller
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Albert J Sinusas
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Wanda Acampa
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Donghee Han
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Biomedical Sciences, and Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Damini Dey
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Biomedical Sciences, and Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel S Berman
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Biomedical Sciences, and Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Piotr J Slomka
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Biomedical Sciences, and Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| |
Collapse
|
2
|
Rozanski A, Blumenthal JA, Hinderliter AL, Cole S, Lavie C. Cardiology and lifestyle medicine. Prog Cardiovasc Dis 2023; 77:4-13. [PMID: 37059409 DOI: 10.1016/j.pcad.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 04/09/2023] [Indexed: 04/16/2023]
Abstract
Poor lifestyle habits, such as physical inactivity and poor diets, are highly prevalent within society and even more so among patients with chronic disease. The need to stem poor lifestyle habits has led to the development of a new field of Lifestyle Medicine, whose mission is to prevent, treat, and even reverse chronic diseases through lifestyle interventions. Three fields within Cardiology relate to this mission: Cardiac Rehabilitation, Preventive Cardiology, and Behavioral Cardiology. Each of these three fields have contributed substantially to the reduction of cardiovascular disease (CVD) morbidity and mortality. The historic contributions of these three cardiac fields are reviewed as well as the challenges each of these fields has faced in optimizing the application of lifestyle medicine practices. A shared agenda between Cardiology and the American College of Lifestyle Medicine could further the utilization of behavioral interventions. This review suggests seven steps that could be shared by these organizations and other medical societies. First, there is a need to develop and promulgate the assessment of lifestyle factors as "vital signs" during patient visits. Second, developing a strong partnership between the fields of Cardiology and Physiatry could improve important aspects of cardiac care, including a potential redesign of cardiac stress testing. Third, behavioral evaluations should be optimized at patients' entrée points into medical care since these may be considered "windows of opportunity". Fourth, there is a need to broaden cardiac rehabilitation into inexpensive programs and make this program eligible for patients with risk factors but no known CVD. Fifth, lifestyle medicine education should be integrated into the core competencies for relevant specialties. Sixth, there is a need for inter-societal advocacy to promote lifestyle medicine practices. Seventh, the well-being effects of healthy lifestyle behaviors, such as their impact on one's sense of vitality, should be emphasized.
Collapse
Affiliation(s)
- Alan Rozanski
- Division of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, and the Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
| | - James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, United States of America
| | - Alan L Hinderliter
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Steven Cole
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States of America; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, United States of America
| | - Carl Lavie
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School-the UQ School of Medicine, New Orleans, LA, United States of America
| |
Collapse
|
3
|
Rozanski A, Sakul S, Narula J, Uretsky S, Lavie CJ, Berman D. Assessment of lifestyle-related risk factors enhances the effectiveness of cardiac stress testing. Prog Cardiovasc Dis 2023; 77:95-106. [PMID: 36931544 DOI: 10.1016/j.pcad.2023.03.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 03/13/2023] [Indexed: 03/19/2023]
Abstract
Cardiac stress tests have been widely utilized since the 1960s for the diagnostic and prognostic assessment of patients with suspected coronary artery disease (CAD). Clinical risk is primarily based on assessing the presence and magnitude of inducible myocardial ischemia. However, the primary factors driving mortality risk have changed over recent decades. Factors such as typical angina and inducible ischemia have decreased, whereas the percentage of patients with diabetes, obesity and hypertension have increased. There has also been a marked temporal increase in the percentage of patients who require pharmacologic testing due to inability to perform treadmill exercise at the time of cardiac stress testing and this need has emerged as the most potent predictor of mortality risk in contemporary stress test populations. However, the long-term clinical risk posed by the inability to perform exercise and concomitant CAD risk factors are rarely reflected in the assessment of patients' prognostic risk in cardiac stress test reports. In this review, we suggest that the clinical utility of present-day cardiac stress testing can be improved by developing a more comprehensive assessment that integrates and reports all factors which modulate patients' long-term clinical risk following stress testing. This should include assessment of patients' CAD risk factors, physical activity habits and mobility risks, identification of the reasons why patients could not exercise at the time of cardiac stress testing. In addition, the assessment of four core non-aerobic functional parameters should be considered among patients who cannot exercise: assessment of gait speed, handgrip strength, lower extremity strength, and standing balance.
Collapse
Affiliation(s)
- Alan Rozanski
- Department of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
| | - Sakul Sakul
- Department of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Jagat Narula
- Department of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Seth Uretsky
- Morristown Medical Center, Morristown, NJ, United States of America
| | - Carl J Lavie
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School-the UQ School of Medicine, New Orleans, LA, United States of America
| | - Daniel Berman
- Departments of Imaging and Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| |
Collapse
|
4
|
D'Onofrio G, Kirschner J, Prather H, Goldman D, Rozanski A. Musculoskeletal exercise: Its role in promoting health and longevity. Prog Cardiovasc Dis 2023; 77:25-36. [PMID: 36841491 DOI: 10.1016/j.pcad.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 02/20/2023] [Indexed: 02/27/2023]
Abstract
Resistance training (RT) is an often ignored but essential component of physical health.. The functioning of the musculoskeletal system declines with age, resulting in sarcopenia, loss of muscle strength and power, decrease in muscle flexibility and balance. Other pertinent age-related changes include decline in basal metabolic rate, increase in fat mass, and decrease in bone mineral density. Such primary aging can be accentuated by the concomitant presence of comorbid conditions, such as insulin resistance and diabetes, obesity, inflammatory conditions, and physical inactivity (PI). The latter is often promoted by the presence of musculoskeletal conditions, such as osteoarthritis, back pain, and osteoporosis, which are quite common in society. RT can diminish long-term joint stress, "resist" age-related physiological deterioration and improve health outcomes through its ability to increase muscle strength and mass, balance the distribution of forces within a joint, increase basal metabolic rate and bone density, reduce body fat and cardiac risk factors, enhance endothelial function, and promote cognitive function and psychological well-being. Accordingly, health providers should screen for PI, lack of RT, and mobility risks using short screening questions, and employ simple functional tests, when indicated, to evaluate patients for impairment in gait, muscle strength, flexibility, and balance. This review also provides general principles for initiating and conducting RT and provides general and specific examples of resistance training programs, which should be individualized for patients through the evaluation and guidance by appropriate health providers, physical therapists, and certified trainers.
Collapse
Affiliation(s)
- Gerard D'Onofrio
- Physiatry Department, Hospital for Special Surgery, Department of Rehabilitation Medicine, Weill Cornell Medicine, NY, New York, United States of America
| | - Jonathan Kirschner
- Physiatry Department, Hospital for Special Surgery, Department of Rehabilitation Medicine, Weill Cornell Medicine, NY, New York, United States of America
| | - Heidi Prather
- Physiatry Department, Hospital for Special Surgery, Department of Rehabilitation Medicine, Weill Cornell Medicine, NY, New York, United States of America
| | | | - Alan Rozanski
- Division of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, NY, New York, United States of America.
| |
Collapse
|
5
|
Miller RJH, Huang C, Liang JX, Slomka PJ. Artificial intelligence for disease diagnosis and risk prediction in nuclear cardiology. J Nucl Cardiol 2022; 29:1754-1762. [PMID: 35508795 DOI: 10.1007/s12350-022-02977-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 03/29/2022] [Indexed: 10/18/2022]
Abstract
Artificial intelligence (AI) techniques have emerged as a highly efficient approach to accurately and rapidly interpret diagnostic imaging and may play a vital role in nuclear cardiology. In nuclear cardiology, there are many clinical, stress, and imaging variables potentially available, which need to be optimally integrated to predict the presence of obstructive coronary artery disease (CAD) or predict the risk of cardiovascular events. In spite of clinical awareness of a large number of potential variables, it is difficult for physicians to integrate multiple features consistently and objectively. Machine learning (ML) is particularly well suited to integrating this vast array of information to provide patient-specific predictions. Deep learning (DL), a branch of ML characterized by a multi-layered convolutional model architecture, can extract information directly from images and identify latent image features associated with a specific prediction. This review will discuss the latest AI applications to disease diagnosis and risk prediction in nuclear cardiology with a focus on potential clinical applications.
Collapse
Affiliation(s)
- Robert J H Miller
- Division of Artificial Intelligence in Medicine, Departments of Medicine, Imaging and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Suite Metro 203, Los Angeles, CA, 90048, USA
- Department of Cardiac Sciences, University of Calgary and Libin Cardiovascular Institute, Calgary, AB, Canada
| | - Cathleen Huang
- Division of Artificial Intelligence in Medicine, Departments of Medicine, Imaging and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Suite Metro 203, Los Angeles, CA, 90048, USA
| | - Joanna X Liang
- Division of Artificial Intelligence in Medicine, Departments of Medicine, Imaging and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Suite Metro 203, Los Angeles, CA, 90048, USA
| | - Piotr J Slomka
- Division of Artificial Intelligence in Medicine, Departments of Medicine, Imaging and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Suite Metro 203, Los Angeles, CA, 90048, USA.
| |
Collapse
|
6
|
Sakatani T, Kasahara T, Irie D, Tsubakimoto Y, Matsuo A, Fujita H, Inoue K. Prognostic value of left ventricular mechanical dyssynchrony induced by exercise stress in patients with normal myocardial perfusion single-photon emission computed tomography. J Nucl Cardiol 2022; 29:1-10. [PMID: 33083982 DOI: 10.1007/s12350-020-02389-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 09/17/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Left ventricular mechanical dyssynchrony (LVMD) induced by exercise stress was reported to be clinically useful in detecting multivessel coronary artery diseases. The aim of this study was to compare the prognostic value of LVMD induced by pharmacological stress with that induced by exercise stress. METHODS We retrospectively examined 918 consecutive patients who underwent exercise (N = 310) or pharmacological stress (N = 608) 99mTc-tetrofosmin single-photon emission computed tomography (SPECT) with normal myocardial perfusion. LVMD was evaluated by phase analysis as the indices of phase bandwidth and phase standard deviation (PSD). RESULTS During the follow-up period (2.2 ± 1.9 years), 74 major cardiac events (MCEs) occurred (7 cases of cardiac death, 17 cases of heart failure, and 50 cases of coronary intervention). In global patients, the indices of LVMD on rest images were significantly greater in patients with MCEs (bandwidth (°): 51 ± 31 vs 37 ± 21, P = .001, PSD: 14 ± 9 vs 10 ± 6, P = .001). The exercise stress bandwidth was significantly higher in patients with MCEs (62 ± 37° vs 42 ± 21°, P = .026), as was the pharmacological stress bandwidth (57 ± 35° vs 43 ± 24°, P = .006). Multivariate analysis demonstrated the exercise stress bandwidth to be an independent predictor of MCEs (HR 1.017, CI 1.003 to 1.032, P = .019), but the pharmacological stress bandwidth had no influence on MCEs. CONCLUSIONS LVMD induced by exercise stress was an independent predictor of MCEs in patients with normal perfusion SPECT, whereas that induced by pharmacological stress had no association with further events.
Collapse
Affiliation(s)
- Tomohiko Sakatani
- Department of Cardiology, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi-Cho, Kamigyo-Ku, Kyoto, 602-8026, Japan.
| | - Takeru Kasahara
- Department of Cardiology, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi-Cho, Kamigyo-Ku, Kyoto, 602-8026, Japan
| | - Daisuke Irie
- Department of Cardiology, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi-Cho, Kamigyo-Ku, Kyoto, 602-8026, Japan
| | - Yoshinori Tsubakimoto
- Department of Cardiology, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi-Cho, Kamigyo-Ku, Kyoto, 602-8026, Japan
| | - Akiko Matsuo
- Department of Cardiology, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi-Cho, Kamigyo-Ku, Kyoto, 602-8026, Japan
| | - Hiroshi Fujita
- Department of Cardiology, North Medical Center, Kyoto Prefectural University of Medicine, 481 Otokoyama, Yosano-cho, Kyoto, 629-2261, Japan
| | - Keiji Inoue
- Department of Cardiology, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi-Cho, Kamigyo-Ku, Kyoto, 602-8026, Japan
| |
Collapse
|
7
|
Azarine A, Scalbert F, Garçon P. Cardiac functional imaging. Presse Med 2022; 51:104119. [PMID: 35321846 DOI: 10.1016/j.lpm.2022.104119] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 01/27/2022] [Accepted: 03/11/2022] [Indexed: 01/01/2023] Open
Abstract
During the last 20 years, cardiac imaging has drastically evolved. Positron emission tomography (PET), fast three-dimensional (3D) imaging with the latest generations of echocardiography & multi-detector computed tomography (CT), stress perfusion assessed by magnetic resonance imaging (MRI), blood flow analysis using four-dimensional (4D) flow MRI, all these techniques offer new trends for optimal noninvasive functional cardiac imaging. Dynamic functional imaging is obtained by acquiring images of the heart at different phases of the cardiac cycle, allowing assessment of cardiac motion, function, and perfusion. Between CT and Cardiac MRI (CMR), CMR has the best temporal resolution, which is suitable for functional imaging while cardiac CT provides higher spatial resolution with isotropic data that have an identical resolution in the three dimensions of the space. The latest generations of CT scanners enable whole heart assessment in one beat, offering also an acceptable temporal resolution with the possibility to display the images in a dynamic mode. Another rapidly growing technique using functional and molecular imaging for the assessment of biological and metabolic pathways is the PET using radio-labeled tracers. Meanwhile, the oldest cardiac imaging tool with doppler ultrasound technology has never stopped evolving. Echocardiography today performs 3D imaging, stress perfusion, and myocardial strain assessment, with high temporal resolution. It still is the first line and more accessible exam for the patient. These different modalities are complementary and may be even combined into PET-CT or PET-MRI. The ability to combine the functional/molecular data with anatomical images may implement a new dimension to our diagnostic tools.
Collapse
Affiliation(s)
- Arshid Azarine
- Radiology Department, Groupe Hospitalier Paris Saint-Joseph, 185, Rue Raymond Losserand, 75014, Paris, France.
| | - François Scalbert
- Nuclear Medecine Department, Hôpital Bichat-Claude Bernard, 46 rue Henri Huchard, 75877, Paris, France
| | - Philippe Garçon
- Cardiology Department, Groupe Hospitalier Paris Saint-Joseph, 185, Rue Raymond Losserand, 75014, Paris, France
| |
Collapse
|
8
|
Rozanski A, Berman DS, Iskandrian AE. The imperative to assess physical function among all patients undergoing stress myocardial perfusion imaging. J Nucl Cardiol 2022; 29:946-951. [PMID: 33073319 DOI: 10.1007/s12350-020-02378-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 09/04/2020] [Indexed: 12/31/2022]
Affiliation(s)
- Alan Rozanski
- Department of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, and The Icahn School of Medicine at Mount Sinai, 1111 Amsterdam Avenue, New York, NY, 10025, USA.
| | - Daniel S Berman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ami E Iskandrian
- Division of Cardiovascular Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, USA
| |
Collapse
|
9
|
Rodriguez Lozano P, Bourque JM. Beyond traditional cardiovascular risk factors: Could frailty and other morbidities explain the worse prognosis in patients undergoing pharmacologic stress? J Nucl Cardiol 2022; 29:853-856. [PMID: 33241477 PMCID: PMC8144235 DOI: 10.1007/s12350-020-02441-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 11/03/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Patricia Rodriguez Lozano
- Division of Cardiovascular Medicine and the Cardiac Imaging Center, University of Virginia Health System, 1215 Lee Street, PO Box 800158, Charlottesville, VA, 22908, USA
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA, USA
| | - Jamieson M Bourque
- Division of Cardiovascular Medicine and the Cardiac Imaging Center, University of Virginia Health System, 1215 Lee Street, PO Box 800158, Charlottesville, VA, 22908, USA.
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA, USA.
| |
Collapse
|
10
|
Rozanski A, Gransar H, Hayes SW, Friedman JD, Thomson L, Berman DS. Mortality risk among patients undergoing exercise versus pharmacologic myocardial perfusion imaging: A propensity-based comparison. J Nucl Cardiol 2022; 29:840-852. [PMID: 33047282 DOI: 10.1007/s12350-020-02294-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 06/22/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND The increased risk associated with pharmacologic versus exercise testing is obscured by the higher prevalence of clinical risk factors among pharmacologic patients. Thus, we assessed comparative mortality in a large risk factor-matched group of exercise versus pharmacologic patients undergoing stress/rest SPECT myocardial perfusion imaging (MPI). METHODS 39,179 patients undergoing stress/rest SPECT-MPI were followed for 13.3 ± 5.0 years for all-cause mortality (ACM). We applied propensity-matching to create pharmacologic and exercise groups with similar risk profiles. RESULTS In comparison to exercise patients, pharmacologic patients had an increased risk-adjusted hazard ratio for ACM for each level of ischemia: increased by 3.8-fold (95%CI 3.5-4.1) among nonischemic patients, 2.5-fold (95%CI 2.0-3.2) among mildly ischemic patients, and 2.6-fold (95%CI 2.1-3.3) among moderate/severe ischemic patients. Similar findings were observed among a propensity-matched cohort of 10,113 exercise and 10,113 pharmacologic patients as well as in an additional cohort that also excluded patients with noncardiac co-morbidities. CONCLUSIONS Patients requiring pharmacologic stress testing manifest substantially heightened clinical risk at each level of myocardial ischemia and even when myocardial ischemia is absent. These findings suggest the need to study the pathophysiological drivers of increased risk in association with pharmacologic testing and to convey this risk in clinical reports.
Collapse
Affiliation(s)
- Alan Rozanski
- The Department of Cardiology, Mount Sinai Morningside Hospital and Mount Sinai Heart, 1111 Amsterdam Avenue, New York, 10025, USA.
- Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Heidi Gransar
- Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Sean W Hayes
- Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - John D Friedman
- Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Louise Thomson
- Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Daniel S Berman
- Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| |
Collapse
|
11
|
Mendoza-Ibañez OI, Martínez-Lucio TS, Alexanderson-Rosas E, Slart RH. SPECT in Ischemic Heart Diseases. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00015-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
12
|
Sidhu GS, Hendel RC. The evolution of the prognostic value of regadenoson SPECT myocardial perfusion imaging. J Nucl Cardiol 2021; 28:2808-2811. [PMID: 32468300 DOI: 10.1007/s12350-020-02208-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 05/21/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Gursukhmandeep S Sidhu
- Section of Cardiology, John W. Deming Department of Medicine, Tulane University Heart & Vascular Institute, Tulane University School of Medicine, New Orleans, LA, USA
| | - Robert C Hendel
- Section of Cardiology, John W. Deming Department of Medicine, Tulane University Heart & Vascular Institute, Tulane University School of Medicine, New Orleans, LA, USA.
| |
Collapse
|
13
|
Bailly M, Ribeiro MJ, Angoulvant D. Combining flow and reserve measurement during myocardial perfusion imaging: A new era for myocardial perfusion scintigraphy? Arch Cardiovasc Dis 2021; 114:818-827. [PMID: 34801410 DOI: 10.1016/j.acvd.2021.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 12/25/2022]
Abstract
Myocardial flow reserve represents the ratio of myocardial blood flow between stress and rest, giving functional information about both macrocirculation and microcirculation; it has been reported extensively in positron emission tomography, with an increase in diagnostic performance, providing important prognostic information and being a powerful tool to guide therapy. Advances in single photon emission computed tomography, with the widespread availability of "cadmium zinc telluride" single photon emission computed tomography cameras, raise the question of myocardial flow reserve use in daily clinical practice. In this article, we review the pathophysiology of myocardial blood flow and myocardial flow reserve, and the initial data available from single photon emission computed tomography myocardial blood flow and myocardial flow reserve evaluation; we also discuss potential limitations to the wider implementation of flow evaluation in single photon emission computed tomography.
Collapse
Affiliation(s)
- Matthieu Bailly
- Nuclear Medicine Department, CHR Orleans, 14, Avenue de l'Hôpital, 45100 Orleans, France; UMR 1253, iBrain, Université de Tours, Inserm, 37000 Tours, France.
| | - Maria Joao Ribeiro
- UMR 1253, iBrain, Université de Tours, Inserm, 37000 Tours, France; Nuclear Medicine Department, CHRU Tours, 37000 Tours, France
| | - Denis Angoulvant
- Cardiology Department, CHRU Tours, 37000 Tours, France; EA4245, T2i, Tours University, 37000 Tours, France
| |
Collapse
|
14
|
Abstract
Objective To identify temporal shifts in coronary artery disease (CAD) risk factor profiles, clinical parameters, and corresponding mortality rates among patients referred for radionuclide stress testing over 22 years. Patients and Methods We assessed 39,750 patients with suspected CAD (“diagnostic” patients) and 10,982 patients with known CAD who underwent radionuclide stress testing between January 2, 1991, and December 31, 2012, and were followed up for at least 5 years (median, 12.7 years). Results Among both diagnostic patients and those with known CAD, there was a marked temporal decline in typical angina and myocardial ischemia. However, several risk factors for disease progressively increased, including diabetes, obesity, and hypertension. In addition, the need to perform pharmacological testing in lieu of exercise increased markedly between the first and fourth epochs among both diagnostic patients (from 26.5% [1634 of 6176] to 53.0% [5781 of 10,908]; P<.001) and patients with known CAD (from 31.1% [999 of 3213] to 75.5% [1405 of 1860]; P<.001). The net effect of these competing positive and negative risk factor trends was no change in the adjusted annualized rate of mortality over the temporal span in our study, ranging from 1.57% per year in 1991-1995 to 1.76% per year in 2006-2012 among diagnostic patients and from 2.46% per year to 2.75% per year during the same intervals among patients with known CAD. Conclusion Our findings suggest a marked contemporary shift in the drivers of all-cause mortality among patients undergoing cardiac stress tests away from such factors as typical angina and inducible myocardial ischemia, which are declining in prevalence, and toward such factors as diabetes and an inability to perform exercise, which are increasing in prevalence.
Collapse
|
15
|
Berman DS, Rozanski A. Pharmacologic Stress Testing: Its Roots, Its Impact, and Its Future. J Nucl Med 2020; 61:66S-67S. [PMID: 33293452 DOI: 10.2967/jnumed.120.251298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 06/12/2020] [Indexed: 11/16/2022] Open
Affiliation(s)
- Daniel S Berman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, and Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California; and
| | - Alan Rozanski
- Department of Cardiology, Mount Sinai Morningside Hospital and Mount Sinai Heart, New York, New York
| |
Collapse
|
16
|
Risk stratification and screening for coronary artery disease in asymptomatic patients with diabetes mellitus: Position paper of the French Society of Cardiology and the French-speaking Society of Diabetology. Arch Cardiovasc Dis 2020; 114:150-172. [PMID: 33309203 DOI: 10.1016/j.acvd.2020.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/09/2023]
|
17
|
Mandour Ali M, Aaty A, Abdelfattah A, Allam A. Do we need a new definition for post-stress reduction in LVEF beyond the numerical values? J Nucl Cardiol 2020; 27:1607-1610. [PMID: 31292850 DOI: 10.1007/s12350-019-01799-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 05/13/2019] [Indexed: 10/26/2022]
Affiliation(s)
| | - Ahmed Aaty
- Department of Nuclear Cardiology, Alexandria University, Alexandria, Egypt
| | | | - Adel Allam
- Department of Cardiology, Al-Azhar School of Medicine, Cairo, Egypt
| |
Collapse
|
18
|
Rozanski A, Gransar H, Miller RJH, Hayes SW, Friedman JD, Thomson LEJ, Berman DS. Association between coronary atherosclerotic burden and all-cause mortality among patients undergoing exercise versus pharmacologic stress-rest SPECT myocardial perfusion imaging. Atherosclerosis 2020; 310:45-53. [PMID: 32890806 DOI: 10.1016/j.atherosclerosis.2020.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/26/2020] [Accepted: 07/09/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND AIMS Patients with suspected coronary artery disease who undergo stress SPECT myocardial perfusion imaging (MPI) and require pharmacologic stress are at substantially increased mortality risk compared to those who can exercise. However, the mechanisms underlying this increased risk are not well delineated. To test whether increased atherosclerotic burden accounts for this increased risk, we assessed the association between coronary artery calcium (CAC) scores and mortality risk among patients undergoing exercise versus pharmacologic SPECT MPI. METHODS We assessed all-cause mortality in 2,151 patients, followed for 12.2 ± 3.4 years, after undergoing stress-rest SPECT-MPI and CAC scanning within 3 months of each other. Patients were divided according to their mode of stress testing (exercise or pharmacologic). We further employed propensity analysis to create a subgroup of exercise and pharmacologic subgroups with comparable age, symptoms, and coronary risk factors. RESULTS Despite greater age and worse clinical profiles, pharmacologic and exercise patients had similar CAC scores. However, the hazard ratio (95% CI) for mortality was substantially greater among pharmacologic patients: 2.39 (1.83-3.10). For each level of CAC abnormality, pharmacologic patients had >2-fold increased risk adjusted hazard ratio for all-mortality risk (p < 0.05 for each CAC level). Among propensity-matched exercise versus pharmacologic patients, the same findings were observed. CONCLUSIONS Among patients referred for stress-rest SPECT-MPI and CAC scoring, pharmacologic patients have substantially increased mortality risk compared to exercise patients, despite having comparable levels of coronary atherosclerosis.
Collapse
Affiliation(s)
- Alan Rozanski
- Department of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, and the Icahn School of Medicine at Mount Sinai, New York, NY, USA; Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Heidi Gransar
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Robert J H Miller
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Sean W Hayes
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - John D Friedman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Louise E J Thomson
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel S Berman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| |
Collapse
|
19
|
Valensi P, Henry P, Boccara F, Cosson E, Prevost G, Emmerich J, Ernande L, Marcadet D, Mousseaux E, Rouzet F, Sultan A, Ferrières J, Vergès B, Van Belle E. Risk stratification and screening for coronary artery disease in asymptomatic patients with diabetes mellitus: Position paper of the French Society of Cardiology and the French-speaking Society of Diabetology. DIABETES & METABOLISM 2020; 47:101185. [PMID: 32846201 DOI: 10.1016/j.diabet.2020.08.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/09/2023]
Affiliation(s)
- Paul Valensi
- Unit of Endocrinology Diabetology Nutrition, AP-HP, Jean Verdier hospital, CINFO, CRNH-IdF, Paris 13 University, Sorbonne Paris Cité, Bondy, France
| | - Patrick Henry
- Department of Cardiology, Inserm U942, Lariboisiere Hospital, Assistance Publique - Hôpitaux de Paris, University of Paris, Paris, France.
| | - Franck Boccara
- AP-HP, Hôpitaux de l'Est Parisien, Hôpital Saint-Antoine, Department of Cardiology, Sorbonne Université-Inserm UMR S_938, Centre de Recherche Saint-Antoine, Paris, France
| | - Emmanuel Cosson
- AP-HP, Avicenne Hospital, Paris 13 University, Sorbonne Paris Cité, Department of Endocrinology-Diabetology-Nutrition, CRNH-IdF, CINFO, Bobigny, France; Paris 13 University, Sorbonne Paris Cité, UMR U557 Inserm/U11125 INRAE/CNAM/Université Paris13, Unité de Recherche Epidémiologique Nutritionnelle, Bobigny, France
| | - Gaetan Prevost
- Department of Endocrinology, Diabetes and Metabolic Diseases, Normandie Univ, UNIROUEN, Rouen University Hospital, Centre d'Investigation Clinique (CIC-CRB)-Inserm 1404, Rouen University Hospital, 76000 Rouen, France
| | - Joseph Emmerich
- Service de Médecine Vasculaire, Groupe Hospitalier Paris Saint-Joseph, Université de Paris, Inserm UMR1153-CRESS, 75674 Paris cedex 14, France
| | - Laura Ernande
- Service des explorations fonctionnelles, Hôpital Henri Mondor, AP-HP et Inserm U955, Université Paris-Est Créteil, France
| | - Dany Marcadet
- Centre Coeur et Santé Bernoulli - Cardiologie du sport et Réadaptation Cardiaque, 3, rue Bernoulli, 75008 Paris, France
| | - Elie Mousseaux
- Radiology Department, Hôpital Européen Georges Pompidou & Inserm U 970; Assistance Publique - Hôpitaux de Paris, University of Paris, French Society of Cardiovascular Imaging (SFICV), Paris, France
| | - François Rouzet
- Nuclear Medicine Department, Bichat Hospital, AP-HP Paris - Université de Paris, Laboratory for Vascular Translational Science, Inserm, UMR 1148, 75018 Paris, France
| | - Ariane Sultan
- Physiologie et Médecine Expérimentale du Coeur et des Muscles (PHYMEDEX), U1046 Inserm, UMR9214 CNRS, Université de Montpellier, 34295 Montpellier; Département Endocrinologie, Nutrition, Diabète, Equipe Nutrition, Diabète, CHRU Montpellier, 34090 Montpellier, France
| | - Jean Ferrières
- Department of Cardiology and UMR Inserm 1027, Toulouse Rangueil University Hospital, Toulouse University School of Medicine, Toulouse, France
| | - Bruno Vergès
- Service Endocrinologie-Diabétologie, CHU Dijon - Inserm LNC-UMR 1231, Dijon, France
| | - Eric Van Belle
- Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, Institut Coeur Poumon, Centre Hospitalier Universitaire de Lille, Lille, France; Inserm, U1011, Institut Pasteur de Lille, EGID, Lille, France; Department of Medicine, Université de Lille, Lille, France
| |
Collapse
|
20
|
Rachwan RJ, Mshelbwala FS, Bou Chaaya RG, El-Am EA, Sabra M, Dardari Z, Jaradat ZA, Batal O. Long-term prognosis and predictors of outcomes after negative stress echocardiography. Int J Cardiovasc Imaging 2020; 36:1953-1962. [PMID: 32757119 DOI: 10.1007/s10554-020-01913-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/04/2020] [Indexed: 11/28/2022]
Abstract
Negative stress echocardiography (NSE) is associated with low cardiovascular morbidity and overall mortality. We aimed to determine the clinical and echocardiographic predictors of overall and cardiovascular outcomes following NSE. Patients who underwent SE between 2013 and 2017 were reviewed. Patients with a history of solid organ transplant or being evaluated for transplant, history of end-stage renal or liver disease, and positive SE were excluded. NSE results were divided into negative diagnostic if patient reached target heart rate (THR) and had no wall motion abnormality (WMA) at rest or stress; negative non-diagnostic if patient had no WMA but did not reach THR or if image quality was non-diagnostic; and abnormal non-ischemic if patient had a resting WMA not worsened at stress along with a personal history of coronary artery disease (CAD). New CAD lesion at 1 year was defined as ≥ 50% stenosis on cardiac catheterization. Of 4119 patients with SE, 2575 were included. All-cause mortality rate was 1.1%/year and CAD rate was 3.1%/year. Predictors of all-cause mortality were age, male gender, history of smoking and being selected for dobutamine SE. Predictors of a new CAD lesion at 1 year were male gender, diabetes, personal history of CAD and abnormal non-ischemic SE. We identified clinical and echocardiographic characteristics in a subset of NSE patients who are at higher risk for subsequent adverse events. These characteristics should be accounted for during the clinical interpretation of SE, and patients found at increased risk for morbidity and mortality warrant continued follow-up.
Collapse
Affiliation(s)
- Rayan Jo Rachwan
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Rody G Bou Chaaya
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Edward A El-Am
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mohammad Sabra
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Zeina Dardari
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ziad A Jaradat
- Division of Cardiology, Department of Medicine, Indiana University School of Medicine, 1801 North Senate Boulevard, Indianapolis, IN, USA
| | - Omar Batal
- Division of Cardiology, Department of Medicine, Indiana University School of Medicine, 1801 North Senate Boulevard, Indianapolis, IN, USA.
| |
Collapse
|
21
|
Nappi C, Acampa W, Nicolai E, Daniele S, Zampella E, Assante R, Gaudieri V, Mannarino T, Petretta M, Cuocolo A. Long-term prognostic value of low-dose normal stress-only myocardial perfusion imaging by wide beam reconstruction: A competing risk analysis. J Nucl Cardiol 2020; 27:547-557. [PMID: 30027504 DOI: 10.1007/s12350-018-1373-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 07/10/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND A normal stress myocardial perfusion single-photon emission computed tomography (MPS) is associated with a good clinical outcome. New iterative algorithms, such as wide beam reconstruction (WBR), which improve image interpretation with half-dose or half-time acquisition, have been proposed for cardiac MPS. The aim of this study was to assess the long-term predictive value of a low-dose normal stress-only MPS with WBR using conventional Anger camera in patients with known or suspected coronary artery disease (CAD). METHODS AND RESULTS A total of 2106 patients with known or suspected CAD and normal perfusion at half-dose stress-only MPS protocol were followed for a mean of 6.6 ± 2.7 years. MPS data were reconstructed with WBR iterative algorithm. End-point events were cardiac death or nonfatal myocardial infarction. Noncardiac death was considered the competing event. During follow-up, 149 cardiac events occurred with an annualized event rate of 1.2%. Independent predictors of cardiac events at Cox analysis were age, male gender, diabetes mellitus, previous myocardial infarction and the need for pharmacologic stress testing. At Fine-Gray analysis the cumulative incidence of cardiac events progressively increases with age and in the presence of diabetes for any combination of gender and stress type. Survival tree analysis confirmed that long-term prognosis considerably varies according of risk factors profile. CONCLUSIONS Low-dose normal stress-only WBR MPS has a reliable long-term prognostic value in patients with suspected or known CAD. This finding supports the introduction of such a method into clinical practice with a consistent dose optimization in the interest of patients and exposed staff.
Collapse
Affiliation(s)
- Carmela Nappi
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Wanda Acampa
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
- Institute of Biostructure and Bioimaging, National Council of Research, Naples, Italy
| | | | - Stefania Daniele
- Institute of Biostructure and Bioimaging, National Council of Research, Naples, Italy
| | - Emilia Zampella
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Roberta Assante
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Valeria Gaudieri
- Institute of Biostructure and Bioimaging, National Council of Research, Naples, Italy
| | - Teresa Mannarino
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Mario Petretta
- Department of Translational Medical Sciences, University Federico II, Naples, Italy
| | - Alberto Cuocolo
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy.
| |
Collapse
|
22
|
Rozanski A, Berman D. Optimizing the Assessment of Patient Clinical Risk at the Time of Cardiac Stress Testing. JACC Cardiovasc Imaging 2019; 13:616-623. [PMID: 31326497 DOI: 10.1016/j.jcmg.2019.01.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 01/14/2019] [Accepted: 01/16/2019] [Indexed: 12/21/2022]
Abstract
Due to a marked temporal decline in inducible myocardial ischemia over recent decades, most diagnostic patients now referred for cardiac stress testing have nonischemic studies. Among nonischemic patients, however, long-term risk is heterogeneous and highly influenced by a variety of clinical parameters. Herein, we review 8 factors that can govern long-term clinical risk: coronary risk factor burden; patient symptoms; exercise capacity and exercise test responses; the need for pharmacologic stress testing; autonomic function; musculoskeletal status; subclinical atherosclerosis; and psychosocial risk. To capture the clinical benefit provided by both assessing myocardial ischemia and these additional parameters, the authors propose that a cardiac stress tests report have an additional component beyond statements as to the likelihood of obstructive coronary artery disease and/or magnitude of ischemia. This added component could be a comment section designed to make referring physicians aware of aspects of long-term risk that may influence clinical management and potentially lead to changes in the intensity of risk factor management, frequency of follow-up, need for further testing, or other management decisions. In this manner, the increasingly frequent normal stress test result might more commonly influence treatment recommendations and even patient behavior, thus leading to improvement in patient outcomes even in the setting of normal stress test results.
Collapse
Affiliation(s)
- Alan Rozanski
- Department of Cardiology, Mount Sinai St. Luke's and Mount Sinai Heart, New York, New York.
| | - Daniel Berman
- Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| |
Collapse
|
23
|
Stress Protocol and Myocardial Perfusion Imaging Accuracy. CURRENT CARDIOVASCULAR IMAGING REPORTS 2019. [DOI: 10.1007/s12410-019-9477-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
24
|
Mandour Ali M, Allam AH. The mystery poor prognosticator! Pharmacologic stress MPI prevalence and predictors: Insights from the Middle East. J Nucl Cardiol 2018; 25:1715-1717. [PMID: 29340985 DOI: 10.1007/s12350-017-1157-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 10/24/2017] [Indexed: 11/25/2022]
Affiliation(s)
| | - Adel H Allam
- Cardiology and Cardiovascular Imaging, Al-Azhar University, Cairo, Egypt.
| |
Collapse
|
25
|
Eldirani M, Chehab O, Hassan H, Tamim H, Dakik HA. Variations in the referral patterns to pharmacologic and exercise myocardial perfusion imaging. J Nucl Cardiol 2018; 25:1708-1714. [PMID: 28948527 DOI: 10.1007/s12350-017-1071-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 09/11/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Myocardial perfusion imaging (MPI) is commonly utilized for the non-invasive evaluation of patients with suspected coronary artery disease (CAD). It is either performed with exercise or pharmacologic stress. The objective of this study is to compare the referral patterns and diagnostic findings in patients referred for pharmacologic vs exercise MPI. METHODS AND RESULTS This was a prospective study of 429 consecutive patients who were referred for MPI at the American University of Beirut Medical Center (23% had pharmacologic stress with dipyridamole and 77% had exercise stress testing). Patients referred to pharmacologic stress were older, had a higher percentage of women, and a higher prevalence of diabetes and hypertension. There were more abnormal scans in the pharmacologic stress group (38% vs 20%, P < 0.001), as well as a higher prevalence of ischemia (21% vs 13%, P < 0.001) and impaired left ventricular function with an ejection fraction < 50% (19% vs 7.9%, P < 0.001). The significant predictors for referral to pharmacologic stress by multivariable logistic regression analysis were older age (OR = 2.01 (1.57-2.57), P < 0.001) and diabetes (OR = 2.04 (1.19-3.49), P = 0.009). CONCLUSION Patients referred for pharmacologic stress MPI are at a higher risk than those referred for exercise stress MPI with more CAD risk factors, older age, and a higher prevalence of abnormal MPI findings.
Collapse
Affiliation(s)
- Mahmoud Eldirani
- Division of Cardiology, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Omar Chehab
- Division of Cardiology, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Hussein Hassan
- Division of Cardiology, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Hani Tamim
- Division of Cardiology, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Habib A Dakik
- Division of Cardiology, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon.
| |
Collapse
|
26
|
Gomez J, Golzar Y, Fughhi I, Olusanya A, Doukky R. The significance of post-stress decrease in left ventricular ejection fraction in patients undergoing regadenoson stress gated SPECT myocardial perfusion imaging. J Nucl Cardiol 2018; 25:1313-1323. [PMID: 28181156 DOI: 10.1007/s12350-017-0802-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 01/20/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND The significance of post-stress decrease in left ventricular ejection fraction (LVEF) with regadenoson stress gated SPECT (GSPECT) myocardial perfusion imaging (MPI) has not been studied. METHODS AND RESULTS Consecutive patients who underwent rest/regadenoson stress GSPECT-MPI followed by coronary angiography within 6 months were analyzed. Change in LVEF by GSPECT-MPI was calculated as stress LVEF minus rest LVEF; a significant decrease was tested at 5% and 10% thresholds. In a diagnostic cohort of 793 subjects, LVEF change was not predictive of severe/extensive coronary artery disease (area under the curve, 0.50; 95% confidence interval, 0.44-0.57; P = 0.946). There was no significant difference in the rates of severe/extensive coronary artery disease in patients with or without a decrease in LVEF, irrespective of MPI findings. In an outcome cohort of the 929 subjects followed for 30 ± 16 months, post-regadenoson stress decrease in LVEF was not associated with increased risk of the composite endpoint of cardiac death or myocardial infarction or in the risk of coronary revascularization. CONCLUSIONS In patients selected to undergo coronary angiography following regadenoson stress GSPECT-MPI, a decrease in LVEF after regadenoson stress is not predictive of severe/extensive CAD or adverse clinical outcomes, irrespective of MPI findings.
Collapse
Affiliation(s)
- Javier Gomez
- Division of Cardiology, John H. Stroger, Jr. Hospital of Cook County, 1901 W. Harrison St., Suite # 3620, Chicago, IL, 60612, USA
| | - Yasmeen Golzar
- Division of Cardiology, John H. Stroger, Jr. Hospital of Cook County, 1901 W. Harrison St., Suite # 3620, Chicago, IL, 60612, USA
| | - Ibtihaj Fughhi
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Adebayo Olusanya
- Division of Cardiology, John H. Stroger, Jr. Hospital of Cook County, 1901 W. Harrison St., Suite # 3620, Chicago, IL, 60612, USA
- Division of Cardiology, Rutgers, New Jersey Medical School, Newark, NJ, USA
| | - Rami Doukky
- Division of Cardiology, John H. Stroger, Jr. Hospital of Cook County, 1901 W. Harrison St., Suite # 3620, Chicago, IL, 60612, USA.
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA.
| |
Collapse
|
27
|
Castillo PD, Casanovas N, Santaló M, Narro F, Caresia AP, Barradas A, Bragagnini W, Martin JC, Guillamon L, Bernà L, Martínez-Rubio A. Differences in Clinical Characteristics, Results and Management of Patients Referred for Pharmacologic Cardiac Stress SPECT Depending on the Protocol Used. Eur Cardiol 2017; 12:102. [PMID: 30416572 PMCID: PMC6213215 DOI: 10.15420/ecr.2017:23:11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | - Lluís Bernà
- Hospital Universitari Parc Taulí - Nuclear Medicine
| | | |
Collapse
|
28
|
Reyes E, Hage FG. The blood pressure response to vasodilator stress does not provide independent prognostic information. J Nucl Cardiol 2017; 24:1976-1978. [PMID: 27572924 DOI: 10.1007/s12350-016-0651-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 08/10/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Eliana Reyes
- Royal Brompton and Harefield Hospitals, London, UK
| | - Fadi G Hage
- Division of Cardiovascular Disease, Department of Medicine, The University of Alabama at Birmingham, Lyons Harrison Research Building 306, 1900 University BLVD, Birmingham, AL, 35294, USA.
- Section of Cardiology, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA.
| |
Collapse
|
29
|
Prognostic Usefulness of Cardiac Stress Test Modalities in Patients With Type 2 Diabetes Mellitus Who Underwent Myocardial Perfusion Scintigraphy (from the Basel Asymptomatic High-Risk Diabetics' Outcome Trial). Am J Cardiol 2017; 120:1098-1103. [PMID: 28807404 DOI: 10.1016/j.amjcard.2017.06.048] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 06/10/2017] [Accepted: 06/28/2017] [Indexed: 12/21/2022]
Abstract
Our study aimed to assess predictors of the stress test technique used and to evaluate the impact of exercise level achieved on risk stratification in patients with asymptomatic type 2 diabetes without a previous coronary artery disease. Little is known whether co-morbidities of these patients predict the stress technique and whether physical performance provides risk stratification: 400 patients underwent clinical evaluation and myocardial perfusion scintigraphy (MPS) using physical or pharmacological stress. Physical patients were divided into 2 groups: achieving <6 and ≥6 METs, respectively. The mean follow-up time was 2 years. Major cardiac events (MACEs) included myocardial infarction and/or cardiac death. Independent predictors of pharmacological stress were a body mass index of >30 kg/m2 (hazard ratio 1.076, 95% confidence interval 1.027 to 1.127, p = 0.002) and a peripheral arterial disease (hazard ratio 2.888, 95% confidence interval 1.446 to 5.769, p = 0.003). Pharmacological patients had more MACE than physical patients (3.2% vs 1.0%, p = 0.03). Patients achieving <6 METs had a similar MACE rate as pharmacological patients (3.0% vs 3.2%, p = not significant) and more MACE than patients achieving ≥6 METs (3.0% vs 0.4%, p = 0.01). In patients achieving <6 METs and in pharmacological patients, MPS added an incremental prognostic value to pretest information (p values for global chi-square 0.012 and 0.04, respectively). In high-risk asymptomatic diabetic patients, co-morbidities were predictive of the stress technique used. Pharmacological patients had more MACE, similar to those unable to achieve 6 METs. MPS provided an incremental prognostic value in pharmacological patients and in patients with <6METs. In contrast, patients who were able to achieve ≥6 METs were at low risk and do not need further risk stratification.
Collapse
|
30
|
Koh AS, Lye WK, Chia SY, Salunat-Flores J, Sim LL, Keng FY, Tan RS, Chua TS. Long-Term Prognostic Value of Appropriate Myocardial Perfusion Imaging. Am J Cardiol 2017; 119:1957-1962. [PMID: 28456317 DOI: 10.1016/j.amjcard.2017.03.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 03/10/2017] [Accepted: 03/10/2017] [Indexed: 10/19/2022]
Abstract
Appropriate use criteria (AUC) for single-photon emission computed tomography myocardial perfusion images (SPECT-MPIs) were developed to address the growth of cardiac imaging studies. Long-term prognostic value of AUC in SPECT-MPI has not been tested in existing cohorts. We sought to determine the long-term prognostic value of MPI classified as appropriate. AUC was evaluated in a prospectively designed cohort of patients who underwent clinically indicated MPI. MPI studies were classified based on 2009 AUC for SPECT-MPI. Data regarding downstream coronary angiography (cath), revascularization and all-cause mortality, cardiac death, and nonfatal myocardial infarction (MI) were collected from national registries. Among n = 1,129 MPI scans that received an appropriate grading, 148 all-cause deaths, 109 MIs, 58 cardiac deaths, 152 caths, 113 revascularization procedures occurred over a mean follow-up period of 5.4 ± 1.2 years (0.9% cardiac death rate per year, 1.8% MI rate per year). Most of the scans were low-risk normal MPI scans (summed stress score ≤3; 74.1%). An abnormal scan was associated with higher rates of MI (19.5% vs 6.2%, hazard ratio 1.72, p = 0.017) and cardiac death (13.4% vs 2.3%, hazard ratio 2.12, p = 0.016). In conclusion, MPI scans classified as appropriate have long-term prognostic value, despite a high proportion of low-risk scans. This provides support for clinicians to consider the use of appropriate grading in addition to MPI scan results in patient management.
Collapse
|
31
|
Argulian E, Po JRF, Uretsky S, Kommaraju KK, Patel S, Agarwal V, Cohen R, Rozanski A. Comparison of the current reasons for undergoing pharmacologic stress during echocardiographic and radionuclide stress testing. J Nucl Cardiol 2017; 24:546-554. [PMID: 26911366 DOI: 10.1007/s12350-016-0398-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 11/28/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Symptom-limited exercise is the preferred method of cardiac stress testing, but pharmacologic testing has been increasing over time. The exact reasons for pharmacologic stress testing have not been rigorously categorized. Thus, we systematically explored the reasons for pharmacologic stress testing in patients referred for cardiac stress imaging. METHODS We studied consecutive patients referred for stress imaging [stress echocardiography or radionuclide myocardial perfusion imaging (MPI)] at Mount Sinai St Luke's hospital between August 2013 and April 2014. Baseline information was obtained using a standardized questionnaire and a trained physician triaged the patient for symptom-limited exercise stress testing or pharmacologic stress testing. RESULTS In total, 551(48%) of our entire stress cohort underwent cardiac imaging following initial exercise testing and 589 (52%) underwent imaging with initial pharmacologic stress testing. Deconditioning and inability to walk (primarily due to musculoskeletal conditions) constituted the top two reasons for performing pharmacologic stress, followed by frailty, left bundle branch block (for MPI), resting wall motion abnormality (for echocardiography), and failed exercise attempts. The reasons for performing pharmacologic stress testing were similar in the MPI and echocardiography patients, despite a much higher level of disease acuity in the MPI group. CONCLUSIONS We have applied a systematic approach for categorizing the reasons for pharmacologic stress. These reasons are heterogeneous, but similar across MPI and echo stress laboratories.
Collapse
Affiliation(s)
- Edgar Argulian
- Division of Cardiology, Mount Sinai St. Luke's Hospital, 1111 Amersterdam Avenue, New York, NY, USA.
- The Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | | | - Seth Uretsky
- Division of Cardiology, Mount Sinai St. Luke's Hospital, 1111 Amersterdam Avenue, New York, NY, USA
- The Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Morristown Medical Center, Morristown, NJ, USA
| | - Kiran K Kommaraju
- Division of Cardiology, Mount Sinai St. Luke's Hospital, 1111 Amersterdam Avenue, New York, NY, USA
- The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Suketukumar Patel
- Division of Cardiology, Mount Sinai St. Luke's Hospital, 1111 Amersterdam Avenue, New York, NY, USA
- The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Vikram Agarwal
- Division of Cardiology, Mount Sinai St. Luke's Hospital, 1111 Amersterdam Avenue, New York, NY, USA
- The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Randy Cohen
- Division of Cardiology, Mount Sinai St. Luke's Hospital, 1111 Amersterdam Avenue, New York, NY, USA
- The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alan Rozanski
- Division of Cardiology, Mount Sinai St. Luke's Hospital, 1111 Amersterdam Avenue, New York, NY, USA
- The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
32
|
Mental Stress, Exercise, and Other Determinants of Elevation in High-Sensitivity Troponin Levels: A Call for Standardization of Laboratory Protocols. JACC Cardiovasc Imaging 2017; 11:612-615. [PMID: 28330668 DOI: 10.1016/j.jcmg.2017.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 01/19/2017] [Indexed: 11/20/2022]
|
33
|
|
34
|
Standbridge K, Reyes E. The role of pharmacological stress testing in women. J Nucl Cardiol 2016; 23:997-1007. [PMID: 27515346 DOI: 10.1007/s12350-016-0602-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 05/16/2016] [Accepted: 05/16/2016] [Indexed: 11/24/2022]
Abstract
Pharmacological stress is an alternative method to dynamic exercise that combined with noninvasive imaging allows the detection of flow-limiting coronary artery disease (CAD). It represents the stress procedure of choice in patients who cannot exercise appropriately. In women, pharmacological stress combined with myocardial perfusion scintigraphy (MPS) has demonstrated to be highly accurate for the detection of obstructive CAD and a valuable tool that helps separate patients at low cardiac risk from those with an adverse prognosis. Pharmacological stress with positron emission tomographic (PET) imaging is increasingly used in the investigation of suspected obstructive CAD; available evidence shows that the diagnostic profile and prognostic value of stress PET imaging is similar to that of stress MPS in women.
Collapse
Affiliation(s)
- Katherine Standbridge
- Nuclear Medicine Department, Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London, SW3 6NP, United Kingdom
| | - Eliana Reyes
- Nuclear Medicine Department, Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London, SW3 6NP, United Kingdom.
| |
Collapse
|
35
|
Heydari B, Juan YH, Liu H, Abbasi S, Shah R, Blankstein R, Steigner M, Jerosch-Herold M, Kwong RY. Stress Perfusion Cardiac Magnetic Resonance Imaging Effectively Risk Stratifies Diabetic Patients With Suspected Myocardial Ischemia. Circ Cardiovasc Imaging 2016; 9:e004136. [PMID: 27059504 DOI: 10.1161/circimaging.115.004136] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 02/08/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND Diabetics remain at high risk of cardiovascular disease and mortality despite advancements in medical therapy. Noninvasive cardiac risk profiling is often more difficult in diabetics owing to the prevalence of silent ischemia with unrecognized myocardial infarction, reduced exercise capacity, nondiagnostic electrocardiographic changes, and balanced ischemia from diffuse epicardial coronary atherosclerosis and microvascular dysfunction. METHODS AND RESULTS A consecutive cohort of 173 patients with diabetes mellitus (mean age, 61.7±11.9 years; 37% women) with suspected myocardial ischemia underwent stress perfusion cardiac magnetic resonance imaging. Patients were evaluated for adverse cardiac events after cardiac magnetic resonance imaging with mean follow-up time of 2.9±2.5 years. Mean hemoglobin A1c for the population was 7.9±1.8%. Primary end point was a composite of cardiac death and nonfatal myocardial infarction. Diabetics with no inducible ischemia (n=94) experienced an annualized event rate of 1.4% compared with 8.2% (P=0.0003) in those with inducible ischemia (n=79). Diabetics without late gadolinium enhancement or inducible ischemia had a low annual cardiac event rate (0.5% per year). The presence of inducible ischemia was the strongest unadjusted predictor (hazard ratio, 4.86; P<0.01) for cardiac death and nonfatal myocardial infarction. This association remained robust in adjusted stepwise multivariable Cox regression analysis (hazard ratio, 4.28; P=0.02). In addition, categorical net reclassification index using 5-year risk cutoffs of 5% and 10% resulted in reclassification of 43.4% of the diabetic cohort with net reclassification index of 0.38 (95% confidence interval, 0.20-0.56; P<0.0001). CONCLUSIONS Stress perfusion cardiac magnetic resonance imaging provided independent prognostic utility and effectively reclassified risk in patients with diabetes mellitus referred for ischemic assessment. Further evaluation is required to determine whether a noninvasive imaging strategy with cardiac magnetic resonance imaging can favorably affect downstream outcomes and improve cost-effectiveness of care in diabetics.
Collapse
Affiliation(s)
- Bobak Heydari
- From the Noninvasive Cardiovascular Imaging Program, Division of Cardiovascular Medicine, and Radiology, Departments of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.H., Y.-H.J., H.L., S.A., R.S., R.B., M.S., M.J.-H., R.Y.K.); Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou and Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan (Y.-H.J.)
| | - Yu-Hsiang Juan
- From the Noninvasive Cardiovascular Imaging Program, Division of Cardiovascular Medicine, and Radiology, Departments of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.H., Y.-H.J., H.L., S.A., R.S., R.B., M.S., M.J.-H., R.Y.K.); Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou and Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan (Y.-H.J.)
| | - Hui Liu
- From the Noninvasive Cardiovascular Imaging Program, Division of Cardiovascular Medicine, and Radiology, Departments of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.H., Y.-H.J., H.L., S.A., R.S., R.B., M.S., M.J.-H., R.Y.K.); Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou and Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan (Y.-H.J.)
| | - Siddique Abbasi
- From the Noninvasive Cardiovascular Imaging Program, Division of Cardiovascular Medicine, and Radiology, Departments of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.H., Y.-H.J., H.L., S.A., R.S., R.B., M.S., M.J.-H., R.Y.K.); Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou and Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan (Y.-H.J.)
| | - Ravi Shah
- From the Noninvasive Cardiovascular Imaging Program, Division of Cardiovascular Medicine, and Radiology, Departments of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.H., Y.-H.J., H.L., S.A., R.S., R.B., M.S., M.J.-H., R.Y.K.); Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou and Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan (Y.-H.J.)
| | - Ron Blankstein
- From the Noninvasive Cardiovascular Imaging Program, Division of Cardiovascular Medicine, and Radiology, Departments of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.H., Y.-H.J., H.L., S.A., R.S., R.B., M.S., M.J.-H., R.Y.K.); Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou and Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan (Y.-H.J.)
| | - Michael Steigner
- From the Noninvasive Cardiovascular Imaging Program, Division of Cardiovascular Medicine, and Radiology, Departments of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.H., Y.-H.J., H.L., S.A., R.S., R.B., M.S., M.J.-H., R.Y.K.); Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou and Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan (Y.-H.J.)
| | - Michael Jerosch-Herold
- From the Noninvasive Cardiovascular Imaging Program, Division of Cardiovascular Medicine, and Radiology, Departments of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.H., Y.-H.J., H.L., S.A., R.S., R.B., M.S., M.J.-H., R.Y.K.); Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou and Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan (Y.-H.J.)
| | - Raymond Y Kwong
- From the Noninvasive Cardiovascular Imaging Program, Division of Cardiovascular Medicine, and Radiology, Departments of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.H., Y.-H.J., H.L., S.A., R.S., R.B., M.S., M.J.-H., R.Y.K.); Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou and Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan (Y.-H.J.).
| |
Collapse
|
36
|
Bajaj NS, Singh S, Farag A, El-Hajj S, Heo J, Iskandrian AE, Hage FG. The prognostic value of non-perfusion variables obtained during vasodilator stress myocardial perfusion imaging. J Nucl Cardiol 2016; 23:390-413. [PMID: 26940574 DOI: 10.1007/s12350-016-0441-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 01/21/2016] [Indexed: 11/25/2022]
Abstract
Myocardial perfusion imaging (MPI) is an established diagnostic test that provides useful prognostic data in patients with known or suspected coronary artery disease. In more than half of the patients referred for stress testing, vasodilator stress is used in lieu of exercise. Unlike exercise, vasodilator stress does not provide information on exercise and functional capacity, heart rate recovery, and chronotropy, and ECG changes are less frequent. These non-perfusion data provide important prognostic and patient management information. Further, event rates in patients undergoing vasodilator MPI are higher than in those undergoing exercise MPI and even in those with normal images probably due to higher pretest risk. However, there are a number of non-perfusion variables that are obtained during vasodilator stress testing, which have prognostic relevance but their use has not been well emphasized. The purpose of this review is to summarize the prognostic values of these non-perfusion data obtained during vasodilator MPI.
Collapse
Affiliation(s)
- Navkaranbir S Bajaj
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Lyons Harrison Research Building 306, 701 19th Street South, Birmingham, AL, 35294-0007, USA
| | - Siddharth Singh
- Division of Cardiovascular Disease, Cedars Sinai Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Ayman Farag
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Lyons Harrison Research Building 306, 701 19th Street South, Birmingham, AL, 35294-0007, USA
| | - Stephanie El-Hajj
- Division of Cardiovascular Disease, Medical University of South Carolina, Charleston, SC, USA
| | - Jack Heo
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Lyons Harrison Research Building 306, 701 19th Street South, Birmingham, AL, 35294-0007, USA
| | - Ami E Iskandrian
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Lyons Harrison Research Building 306, 701 19th Street South, Birmingham, AL, 35294-0007, USA
| | - Fadi G Hage
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Lyons Harrison Research Building 306, 701 19th Street South, Birmingham, AL, 35294-0007, USA.
- Section of Cardiology, Birmingham Veteran's Administration Medical Center, Birmingham, AL, USA.
| |
Collapse
|
37
|
Uretsky S. Beyond ischemia evaluation: The potential for assessing and addressing physical inactivity in the cardiac stress laboratory. J Nucl Cardiol 2016; 23:212-4. [PMID: 25814219 DOI: 10.1007/s12350-015-0103-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Seth Uretsky
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center, 100 Madison Ave, Morristown, NJ, 07960, USA.
| |
Collapse
|
38
|
Poulin MF, Alexander S, Doukky R. Prognostic implications of stress modality on mortality risk and cause of death in patients undergoing office-based SPECT myocardial perfusion imaging. J Nucl Cardiol 2016; 23:202-11. [PMID: 25788401 DOI: 10.1007/s12350-014-0064-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 12/27/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND Patients requiring vasodilator single-photon emission computed-tomography myocardial perfusion imaging (SPECT-MPI) have a higher mortality risk than those selected for exercise or vasodilator with low-level exercise SPECT-MPI. However, it is unknown whether the increased mortality is driven by cardiac deaths alone or cardiac and non-cardiac deaths. METHODS In a prospective cohort of 1,511 consecutive patients referred for SPECT-MPI, patients were classified according to stress test modality: exercise, adenosine with low-level exercise (AdenoEx), and adenosine. Subjects were followed for events of all-cause mortality and cause of death. Survival analyses using multivariate Cox regression and propensity score matching methods were performed. RESULTS During a follow-up of 4.9 ± 0.9 years, a total of 68 (4.5%) deaths occurred: 50 non-cardiac and 18 cardiac. The adenosine group had the highest annual mortality (all-cause 3.65%, non-cardiac 2.36%, cardiac 1.29%), while exercise stress had the lowest mortality (all-cause 0.42%, non-cardiac 0.37%, cardiac 0.05%) and AdenoEx had an intermediate mortality (all-cause 1.3%, non-cardiac 0.91%, cardiac 0.39%); all P values <0.001. The majority of non-cardiac deaths were attributed to cancer. Using exercise stress as a reference standard, multivariable Cox regression analyses demonstrated that adenosine stress was independently predictive of all-cause mortality [HR 3.23 (CI 1.77-5.88); P < 0.001], non-cardiac death [HR 2.67 (CI 1.34-5.31); P = 0.005], and cardiac death [HR 6.30 (CI 1.55-25.56); P = 0.010] after adjusting for univariate predictors of mortality. These findings were consistent in the subgroups of patients with normal and abnormal MPI. AdenoEx was predictive of all-cause, non-cardiac, and cardiac deaths in univariate analysis, but it was not predictive by multivariate analysis. Propensity score matched cohort analysis showed that the adenosine stress group had the highest all-cause (P < 0.001), non-cardiac (P = 0.013), and cardiac deaths (P < 0.001), while the exercise stress group had the lowest mortality of any cause. CONCLUSIONS The inability to perform any level of exercise during a SPECT-MPI stress is associated with high mortality risk, which is derived from both cardiac and non-cardiac deaths.
Collapse
Affiliation(s)
| | - Sarah Alexander
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Rami Doukky
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA.
- Division of Cardiology, John H. Stroger, Jr. Hospital of Cook County, 1901 W. Harrison St., Suite # 3620, Chicago, IL, 60612, USA.
| |
Collapse
|
39
|
Hage FG, Ghimire G, Lester D, Mckay J, Bleich S, El-Hajj S, Iskandrian AE. The prognostic value of regadenoson myocardial perfusion imaging. J Nucl Cardiol 2015; 22:1214-21. [PMID: 25677160 PMCID: PMC4537401 DOI: 10.1007/s12350-014-0050-y] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 11/28/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Regadenoson (REGA), a selective adenosine A2A receptor agonist, is the most widely used stress agent for SPECT myocardial perfusion imaging (MPI) in the United States. The diagnostic accuracy of REGA MPI is comparable to Adenosine MPI, but its prognostic value is not well defined. METHODS We categorized 1,400 patients (700 consecutive normal and 700 consecutive abnormal REGA-MPIs) into 4 groups based on the perfusion defect size using automated quantitative analysis: Group 1: normal perfusion; Group 2: <10% of left ventricle; Group 3: 10%-20%; Group 4: >20%. The primary outcome was a composite of cardiac death, myocardial infarction (MI), and late coronary revascularization (CR >90 days after MPI). RESULTS Of the 1,400 patients (42% male, 37% diabetes, 21% heart failure, 26% end-stage renal disease), the primary outcome occurred in 23% (17% cardiac death, 4% MI, 6% late CR) during 46 ± 18 months of follow-up and 8% had early CR (within 90 days of MPI). Early CR occurred in 0.4%, 9%, 17%, and 17% and the primary outcome in 10%, 27%, 31%, and 43% in Groups 1-4, respectively (P < .001 for both). In an adjusted Cox proportional model, the hazard ratio for the primary outcome was 2.68 (1.77-4.06), 3.32 (2.28-4.83), and 4.05 (2.78-5.91) for Groups 2-4 compared to Group 1. CONCLUSION REGA MPI provides powerful prognostic information that has important implications in patient management and can guide clinical practice.
Collapse
Affiliation(s)
- Fadi G Hage
- Department of Medicine, University of Alabama at Birmingham, Lyons Harrison Research Building 314, 1900 University BLVD, Birmingham, AL, 35294, USA.
- Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA.
| | - Gopal Ghimire
- Department of Medicine, University of Alabama at Birmingham, Lyons Harrison Research Building 314, 1900 University BLVD, Birmingham, AL, 35294, USA
| | - Davis Lester
- School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Joshua Mckay
- Department of Medicine, University of Alabama at Birmingham, Lyons Harrison Research Building 314, 1900 University BLVD, Birmingham, AL, 35294, USA
| | - Steven Bleich
- Department of Medicine, University of Alabama at Birmingham, Lyons Harrison Research Building 314, 1900 University BLVD, Birmingham, AL, 35294, USA
| | - Stephanie El-Hajj
- Department of Medicine, Louisiana State University, Baton Rouge, LA, USA
| | - Ami E Iskandrian
- Department of Medicine, University of Alabama at Birmingham, Lyons Harrison Research Building 314, 1900 University BLVD, Birmingham, AL, 35294, USA
| |
Collapse
|
40
|
Abstract
Stress-rest myocardial perfusion imaging (MPI) is a potent method for assessing the presence and magnitude of inducible myocardial ischemia. Stress MPI currently faces increased scrutiny for its therapeutic effectiveness because of the emergence of other competing means for assessing clinical risk. New data have examined the usefulness stress-rest-MPI as a predictor for long-term clinical outcomes, in contrast to its traditional role for assessing short-term cardiovascular risk. These data indicates that temporal risk is highly influenced by both the magnitude of ischemia and various baseline clinical factors. An optimized assessment of stress MPI, which includes long-term risk prediction, might improve the potential future clinical effectiveness of this imaging modality.
Collapse
|
41
|
Cardiovascular mortality prediction in veterans with arm exercise vs pharmacologic myocardial perfusion imaging. Am Heart J 2015; 170:362-70. [PMID: 26299235 DOI: 10.1016/j.ahj.2015.05.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 05/05/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND No data exist comparing outcome prediction from arm exercise vs pharmacologic myocardial perfusion imaging (MPI) stress test variables in patients unable to perform treadmill exercise. METHODS In this retrospective study, 2,173 consecutive lower extremity disabled veterans aged 65.4 ± 11.0years (mean ± SD) underwent either pharmacologic MPI (1730 patients) or arm exercise stress tests (443 patients) with MPI (n = 253) or electrocardiography alone (n = 190) between 1997 and 2002. Cox multivariate regression models and reclassification analysis by integrated discrimination improvement (IDI) were used to characterize stress test and MPI predictors of cardiovascular mortality at ≥10-year follow-up after inclusion of significant demographic, clinical, and other variables. RESULTS Cardiovascular death occurred in 561 pharmacologic MPI and 102 arm exercise participants. Multivariate-adjusted cardiovascular mortality was predicted by arm exercise resting metabolic equivalents (hazard ratio [HR] 0.52, 95% CI 0.39-0.69, P < .001), 1-minute heart rate recovery (HR 0.61, 95% CI 0.44-0.86, P < .001), and pharmacologic and arm exercise delta (peak-rest) heart rate (both P < .001). Only an abnormal arm exercise MPI prognosticated cardiovascular death by multivariate Cox analysis (HR 1.98, 95% CI 1.04-3.77, P < .05). Arm exercise MPI defect number, type, and size provided IDI over covariates for prediction of cardiovascular mortality (IDI = 0.074-0.097). Only pharmacologic defect size prognosticated cardiovascular mortality (IDI = 0.022). CONCLUSIONS Arm exercise capacity, heart rate recovery, and pharmacologic and arm exercise heart rate responses are robust predictors of cardiovascular mortality. Arm exercise MPI results are equivalent and possibly superior to pharmacologic MPI for cardiovascular mortality prediction in patients unable to perform treadmill exercise.
Collapse
|
42
|
Romero-Farina G, Candell-Riera J, Ferreira-González I, Aguadé-Bruix S, Pizzi N, García-Dorado D. Normal Myocardial Perfusion Gated SPECT and Positive Stress Test: Different Prognoses in Women and Men. J Nucl Cardiol 2015; 22:453-65. [PMID: 25352529 DOI: 10.1007/s12350-014-0009-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 09/30/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND The aim of this study was to analyze different prognoses in women and men with normal myocardial perfusion gated SPECT, according to stress test results. METHODS Differences between women and men in terms of hard events (HE) (non-fatal acute myocardial infarction or cardiac death) and HE plus coronary revascularization (HE + CR) were analyzed in 2,414 consecutive patients (mean age 62.8 ± 13.5 years, 1,438 women) with a normal stress-rest gated SPECT, taking into account their stress test results. RESULTS Four hundred and seven patients (16.9%) (15.9% women and 17.5% men) had a positive stress test (ST-segment depression ≥1 mm and/or angina). During a follow-up of 5.1 ± 3.4 years, there were more significant HE (6.5% vs 2.3%; P = .005) and HE + CR (11.6% vs 4.8%, P = .001) in men with a positive stress test than in men with a negative stress test. These differences were not observed in women. In multivariate regression models, HE and HE + CR were also more frequent in men with a positive stress test (HR:3.3 [95% CI 1.1% to 9.5%]; HR:4.2 [95% CI 1.8% to 9.9%]; respectively) vs women with a positive stress test. CONCLUSIONS Although patients with normal gated SPECT studies have a favorable outcome, men with an abnormal stress test have a more adverse prognosis than women.
Collapse
Affiliation(s)
- Guillermo Romero-Farina
- Cardiology Department, Hospital Universitari Vall d'Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Paseo Vall d'Hebron 119-129, Barcelona, 08035, Spain,
| | | | | | | | | | | |
Collapse
|
43
|
Romero-Farina G, Candell-Riera J, Aguadé-Bruix S, Ferreira-González I, Cuberas-Borrós G, Pizzi N, García-Dorado D. Warranty periods for normal myocardial perfusion stress SPECT. J Nucl Cardiol 2015; 22:44-54. [PMID: 25116906 DOI: 10.1007/s12350-014-9957-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 06/27/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND To assess different warranty periods following a normal myocardial perfusion SPECT based on patients' clinical characteristics and the type of stress performed. METHODS AND RESULTS A study was done of 2,922 consecutive patients (62.9 ± 13 years; 53.4% women) with a normal stress-rest SPECT. The warranty period was defined as the period during which patients remained at a low risk (<1% events/year) of total mortality (TM), or hard events (HE) (cardiac death or non-fatal myocardial infarction). Of these patients, 2,051 were given an exercise myocardial perfusion imaging (Ex-MPI); 461 submaximal exercise plus dipyridamole (Ex+Dipy-MPI); and 410 dipyridamole (Dipy-MPI). During a mean follow-up of 5 ± 3.3 years, a significant reduction (P < .05) of the warranty period for TM (13.5, 9.6 and 8 months) and HE (34.8, 20.5 and 8.2 months) was observed, for Ex-MPI, Ex+Dipy-MPI and Dipy-MPI, respectively. Other warranty period determinants were the clinical variables of age, sex, diabetes and known coronary artery disease. An abnormal left ventricular ejection fraction on gated-SPECT also significantly shortened the warranty period for HE in patients undergoing Ex+Dipy-MPI (P = .001) or Dipy-MPI alone (P = .007). CONCLUSIONS The warranty period for a normal stress-rest SPECT is highly variable since it is primarily determined by the type of stress, the patient's clinical characteristics and LVEF.
Collapse
Affiliation(s)
- Guillermo Romero-Farina
- Cardiology Department, Hospital Universitari Vall d'Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Paseo Vall d'Hebron 119-129, 08035 Barcelona, Spain.
| | | | | | | | | | | | | |
Collapse
|
44
|
Nair SU, Ahlberg AW, Katten DM, Heller GV. Does risk for major adverse cardiac events in patients undergoing vasodilator stress with adjunctive exercise differ from patients undergoing either standard exercise or vasodilator stress with myocardial perfusion imaging? J Nucl Cardiol 2015; 22:22-35. [PMID: 25124828 DOI: 10.1007/s12350-014-9967-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Accepted: 07/15/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND In patients with functional limitations, the use of adjunctive exercise with vasodilator stress has advantages over vasodilator stress alone in single photon emission computed tomography myocardial perfusion imaging (MPI) for technical reasons and with regards to more effective cardiac risk stratification. Whether patients who undergo vasodilator with adjunctive exercise stress MPI possess clinical characteristics and cardiac risk that differs from those who undergo standard exercise or vasodilator stress MPI is unknown. METHODS Prospectively collected data on 19,367 consecutive patients referred for stress MPI to a tertiary care center (9,331 [48%] underwent exercise-only, 3,793 [20%] underwent vasodilator plus exercise, and 6,243 [32%] underwent vasodilator-only) were analyzed. Perfusion data were scored using the ASNC 17-segment with a summed stress score (SSS) < 4 = normal, 4-8 = mildly abnormal, and > 8 = moderate to severely abnormal. Patients were followed a mean of 1.96 ± 0.95 years. Demographics, clinical characteristics, and the occurrence of major adverse cardiac events (cardiac death or nonfatal myocardial infarction) were compared between the three stress modality groups. RESULTS Comparison of demographics and clinical characteristics revealed significant differences in gender, age, cardiac risk factors, and stress MPI between the three stress modality groups (P < .001). In follow-up, cardiac event-free survival of patients in the vasodilator plus exercise stress group was significantly higher than those in the vasodilator-only group but lower than those in the exercise-only group (P < .001). Annualized cardiac event rates of patients in the vasodilator plus exercise stress group were significantly lower than those in the vasodilator-only group for all three categories of the SSS (P < .001). After multivariable adjustment, with exercise-only as reference category, vasodilator plus exercise and vasodilator-only stress emerged as independent predictors (more likely occurrence) of cardiac death, while vasodilator-only stress emerged as an independent predictor (more likely occurrence) of cardiac death or nonfatal myocardial infarction. With vasodilator-only as the reference category, exercise-only and vasodilator plus exercise stress emerged as independent predictors (less likely occurrence) of cardiac death as well as of cardiac death or nonfatal myocardial infarction. CONCLUSIONS Patients undergoing vasodilator plus exercise stress MPI possess clinical characteristics and cardiac risk that differs significantly from those undergoing either standard exercise or vasodilator stress MPI and places them in a lower risk category compared to vasodilator stress alone.
Collapse
Affiliation(s)
- Sanjeev U Nair
- Division of Cardiology, Lehigh Valley Health Network/University of South Florida College of Medicine, 1250 S Cedar Crest Blvd, Suite 300, Allentown, PA, USA.
| | | | | | | |
Collapse
|
45
|
Trends in noninvasive testing for coronary artery disease: less exercise, less information. Am J Med 2015; 128:5-7. [PMID: 25195187 DOI: 10.1016/j.amjmed.2014.08.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 08/12/2014] [Accepted: 08/12/2014] [Indexed: 11/22/2022]
|
46
|
Murray GL. Angina Relief by Ranolazine Identifies False-Negative SPECT Myocardial Perfusion Scans in Patients with Coronary Disease Demonstrated by Coronary Angiography. Int J Angiol 2014; 23:165-70. [PMID: 25317027 DOI: 10.1055/s-0034-1382290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Normal myocardial perfusion imaging (MPI) reduces intermediate- or high-risk pretest probability patients to low- or intermediate-risk posttest probability, respectively, for coronary disease (CD). Since ranolazine (RAN) relieves only angina, anginal patients with normal MPI whose angina is relieved by RAN present a significant dilemma. The purpose of this retrospective chart review was to confirm the impression that coronary angiography (CA) is indicated in patients whose class 3 to 4 angina is relieved by RAN, but have normal myocardial single-photon emission computed tomography (SPECT) MPIs. Charts of patients with stable class 3 to 4 angina (typical and atypical) and normal MPIs (left ventricular ejection fraction [LVEF] ≥50% and segmental score = 0) were reviewed. CA was done on all the patients with complete angina relief taking RAN, as well as nonresponders whose anginal etiology could not be explained. Stenoses were considered flow-restrictive when more than 70% diameter stenosis is observed by quantitative CA, or, when 50 to 70%, fractional flow reserve (FFR) measured ≤0.80. RAN relieved angina in 36 of 54 (67%) patients. Of the known cases, 25 of these 36 (69%) had 43 stenoses ≥50% (mean = 66%): 15 (60%) had 1 vessel disease; 9 (36%) had multivessel disease; 18 (72%) had left anterior descending (LAD) disease; 1 (4%) had left main disease. Twenty one of 43 (49%) stenosis were > 70%; 22 (51%) stenoses were 50 to 70% and required FFR measurement. Twenty nine of 43 stenoses (67%) were considered flow-restrictive in 18 of these 25 (72%) patients. Eight RAN nonresponders with no explanation for angina had no CD at CA. RAN angina relief is invaluable in identifying falsely negative SPECT MPI, and 50% of these patients have flow-restrictive stenoses.
Collapse
Affiliation(s)
- Gary L Murray
- Director Medical Research, Heart and Vascular Institute, Germantown, Tennessee
| |
Collapse
|
47
|
Romero-Farina G, Candell-Riera J, Aguadé-Bruix S, Cuberas-Borrós G, Pizzi M, Santos A, de León G, García-Dorado D. Variables that influence the indication of a second myocardial perfusion gated-SPECT after a normal stress-rest gated SPECT. Rev Esp Med Nucl Imagen Mol 2014. [DOI: 10.1016/j.remnie.2014.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
48
|
Murgueitio R, Merlano S, Rodríguez EJ. Consideraciones sobre el valor pronóstico de los estudios de perfusión miocárdica. REVISTA COLOMBIANA DE CARDIOLOGÍA 2014. [DOI: 10.1016/s0120-5633(14)70259-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|
49
|
Uretsky S, Rozanski A. Long-term outcomes following a normal stress myocardial perfusion scan. J Nucl Cardiol 2013; 20:715-8. [PMID: 23975602 DOI: 10.1007/s12350-013-9769-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Seth Uretsky
- Division of Cardiology and Department of Medicine, St. Luke's and Roosevelt Hospitals, 1111 Amsterdam Ave, New York, NY, 10025, USA,
| | | |
Collapse
|
50
|
Rozanski A, Cohen R, Uretsky S. The coronary calcium treadmill test: a new approach to the initial workup of patients with suspected coronary artery disease. J Nucl Cardiol 2013; 20:719-30. [PMID: 23975601 DOI: 10.1007/s12350-013-9763-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Due to the growth of cardiac testing and increasing cost of cardiovascular healthcare, the development of more cost-effective strategies has now become a dominant issue regarding future utilization of cardiac imaging procedures. To that end, we review the potential of combining two relatively inexpensive tests, the coronary artery calcium (CAC) scan and exercise electrocardiography (ECG), as a first-line test for the workup of patients with suspected coronary artery disease (CAD). The CAC scan was initially introduced as a screening test for CAD, based on data indicating that it is a specific marker for atherosclerosis, predicts clinical risk in accordance with the magnitude of CAC, and provides incremental information for prognostic risk compared to more readily available clinical data. However, CAC scores also predict the likelihood of observing myocardial ischemia among patients undergoing exercise myocardial perfusion SPECT imaging. Exercise ECG predicts clinical events according to the ST-segment response and according to functional exercise capacity, with the latter parameter as a stronger predictor of clinical outcomes. Like CAC scores, exercise functional capacity can also be used to predict the likelihood of ischemia since ischemia diminishes proportionally with increasing exercise capacity. Recent work indicates that when patients are designated by Bayesian analyses into low, intermediate, and high likelihood categories for CAD based on clinical data and the response to exercise ECG, the frequency of inducible myocardial ischemia is very low among both low and intermediate CAD likelihood patients who have a CAC score <400. Future studies are needed to investigate what clinical factors might further modify the CAC-ischemia relationship. On the basis of current data, an initial testing strategy that employs the combined calcium treadmill test has the inherent ability to designate a substantial number of intermediate likelihood patients who would not require further testing due to relatively low CAC scores and reasonable functional capacity.
Collapse
Affiliation(s)
- Alan Rozanski
- Division of Cardiology and Department of Medicine, St. Lukes Roosevelt Hospital, 1111 Amsterdam Avenue, New York, NY, 10025, USA,
| | | | | |
Collapse
|