Appropriateness of referrals for single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) in a developing community: a comparison between 2005 and 2009 versions of ACCF/ASNC appropriateness criteria

Prevalence of Hypertension in Cardiovascular Disease in Iran: Systematic Review and Meta-Analysis

BACKGROUND

Hypertension is a major cause of noncommunicable diseases such as cardiovascular disease. Therefore, this study aimed to estimate the prevalence of hypertension in cardiovascular patients in Iran by meta-analysis.

METHODS

The search was carried out using authentic Persian and English keywords in national and international databases including IranMedex, Scientific Information Database (SID), Magiran, IranDoc, Medlib, ScienceDirect, PubMed , Scopus, Cochrane, Embase, Web of Science, and Google Scholar search engine without any time limitation until 2017. Heterogeneity of studies was assessed using I2 statistic . Data were analyzed using STATA 11.1.

RESULTS

In 66 reviewed studies with a sample of 111,406 participants, the prevalence of hypertension was 44% in Iranian patients with cardiovascular disease 67%(95%CI: 38%-49%) in women and 42% in men. The prevalence of systolic hypertension in cardiac patients was 25%, diastolic 20%, diabetes 27%, and overexposure 43%. The prevalence of hypertension was 44% in patients with coronary artery disease, 50% in myocardial infarction, 33% in aortic aneurysm, and 44% in cardiac failure.

CONCLUSIONS

Hypertension has a higher prevalence in women with cardiovascular disease than men, and it increases with age. Among patients with cardiovascular disease, myocardial infarction patients have the highest levels of hypertension. The prevalence of systolic hypertension in cardiac patients is higher than diastolic hypertension.

The impact of combined cardiopulmonary exercise testing and SPECT myocardial perfusion imaging on downstream evaluation and management

OBJECTIVE

The diagnostic yield of combined cardiopulmonary exercise testing (CPET) and myocardial perfusion imaging (MPI) in patients referred for stress testing has received limited study.

METHODS

We evaluated consecutive patients who underwent combined CPET-MPI at a single tertiary referral center between 2011 and 2015. An abnormal CPET was defined as any of the following: reduced oxygen consumption, cardiac output impairment, or pulmonary impairment. Normal MPI was defined as the absence of resting or stress perfusion defect. The primary study outcome was change in clinical decision-making after CPET-MPI including management of pulmonary disease, management of deconditioning, heart failure management, and referral for cardiac catheterization. Outcomes of patients with normal and abnormal MPI were presented based on the specific CPET abnormality.

RESULTS

415 patients were included in the study. Of the 269 patients that had normal MPI, 206 (77%) had abnormal CPET. Patients with abnormal CPET and normal MPI, compared with patients that had normal CPET and normal MPI, were more frequently diagnosed with pulmonary disease (11.7% vs 3.2%, P = .04) and deconditioning (33.5% vs 17.4%, P = .01). Of the 146 patients that had abnormal MPI, 128 (88%) had abnormal CPET. Patients with abnormal CPET and abnormal MPI, compared with patients that had normal CPET and abnormal MPI, did not statistically differ with regard to the study outcome.

CONCLUSION

An abnormal CPET, if the MPI was normal, prompted further evaluation and led to management of pulmonary disease and deconditioning.

Significance of inferior wall ischemia in non-dominant right coronary artery anatomy

AIM

To investigate the relationship of inferior wall ischemia on myocardial perfusion imaging in patients with non-dominant right coronary artery anatomy.

METHODS

This was a retrospective observational analysis of consecutive patients who presented to the emergency department with primary complaint of chest pain. Only patients who underwent single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) were included. Patients who showed a reversible defect on SPECT MPI and had coronary angiography during the same hospitalization was analyzed. Patients with prior history of coronary artery disease (CAD) including history of percutaneous coronary intervention and coronary artery bypass graft surgerys were excluded. True positive and false positive results were identified on the basis of hemodynamically significant CAD on coronary angiography, in the same territory as identified on SPECT MPI. Coronary artery dominance was determined on coronary angiography. Patients were divided into group 1 and group 2. Group 1 included patients with non-dominant right coronary artery (RCA) (left dominant and codominant). Group 2 included patients with dominant RCA anatomy. Demographics, baseline characteristics and positive predictive value (PPV) were analyzed for the two groups.

RESULTS

The mean age of the study cohort was 57.6 years. Sixty-one point seven percent of the patients were males. The prevalence of self-reported diabetes mellitus, hypertension and dyslipidemia was 36%, 71.9% and 53.9% respectively. A comparison of baseline characteristics between the two groups showed that patients with a non-dominant RCA were more likely to be men. For inferior wall ischemia on SPECT MPI, patients in study group 2 had a significantly higher PPV, 32/42 (76.1%), compared to patients in group 1, in which only 3 out of the 29 patients (10.3%) had true positive results (P value < 0.001 Z test). The difference remained statistically significant even when only patients with left dominant coronary system (without co-dominant) were compared to patients with right dominant system (32/40, 76.1% in right dominant group, 3/19, 15.8% in left dominant group, P value < 0.001 Z test). There was no significant difference in mean hospital stay, re-hospitalization, and in-hospital mortality between the two groups.

CONCLUSION

The positive predictive value of SPECT MPI for inferior wall ischemia is affected by coronary artery dominance. More studies are needed to explain this phenomenon.

Budget impact of applying appropriateness criteria for myocardial perfusion scintigraphy: The perspective of a developing country

Myocardial perfusion imaging is widely used for the risk stratification of coronary artery disease. In view of its cost, besides radiation issues, judicious evaluation of the appropriateness of its indications is essential to prevent an unnecessary economic burden on the health system. We evaluated, at a tertiary-care, public Brazilian hospital, the appropriateness of myocardial perfusion scintigraphy indications, and estimated the budget impact of applying appropriateness criteria. An observational, cross-sectional study of 190 patients with suspected or known coronary artery disease referred for myocardial perfusion imaging was conducted. The appropriateness of myocardial perfusion imaging indications was evaluated with the Appropriate Use Criteria for Cardiac Radionuclide Imaging published in 2009. Budget impact analysis was performed with a deterministic model. The prevalence of appropriate requests was 78%; of inappropriate indications, 12%; and of uncertain indications, 10%. Budget impact analysis showed that the use of appropriateness criteria, applied to the population referred to myocardial perfusion scintigraphy within 1 year, could generate savings of $ 64,252.04 dollars. The 12% inappropriate requests for myocardial perfusion scintigraphy at a tertiary-care hospital suggest that a reappraisal of MPI indications is needed. Budget impact analysis estimated resource savings of 18.6% with the establishment of appropriateness criteria for MPI.

Appropriate Use of Cardiac Stress Testing with Imaging: A Systematic Review and Meta-Analysis

BACKGROUND

Appropriate use criteria (AUC) for cardiac stress tests address concerns about utilization growth and patient safety. We systematically reviewed studies of appropriateness, including within physician specialties; evaluated trends over time and in response to AUC updates; and characterized leading indications for inappropriate/rarely appropriate testing.

METHODS

We searched PubMed (2005-2015) for English-language articles reporting stress echocardiography or myocardial perfusion imaging (MPI) appropriateness. Data were pooled using random-effects meta-analysis and meta-regression.

RESULTS

Thirty-four publications of 41,578 patients were included, primarily from academic centers. Stress echocardiography appropriate testing rates were 53.0% (95% CI, 45.3%-60.7%) and 50.9% (42.6%-59.2%) and inappropriate/rarely appropriate rates were 19.1% (11.4%-26.8%) and 28.4% (23.9%-32.8%) using 2008 and 2011 AUC, respectively. Stress MPI appropriate testing rates were 71.1% (64.5%-77.7%) and 72.0% (67.6%-76.3%) and inappropriate/rarely appropriate rates were 10.7% (7.2%-14.2%) and 15.7% (12.4%-19.1%) using 2005 and 2009 AUC, respectively. There was no significant temporal trend toward rising rates of appropriateness for stress echocardiography or MPI. Unclassified stress echocardiograms fell by 79% (p = 0.04) with updated AUC. There were no differences between cardiac specialists and internists.

CONCLUSIONS

Rates of appropriate use tend to be lower for stress echocardiography compared to MPI, and updated AUC reduced unclassified stress echocardiograms. There is no conclusive evidence that AUC improved appropriate use over time. Further research is needed to determine if integration of appropriateness guidelines in academic and community settings is an effective approach to optimizing inappropriate/rarely appropriate use of stress testing and its associated costs and patient harms.

Outcomes after inappropriate nuclear myocardial perfusion imaging: A meta-analysis

BACKGROUND

The relationship between inappropriate MPI and cardiovascular outcomes is poorly understood. We sought to systematically review the literature on appropriate use criteria (AUC) for MPI, including temporal trend of inappropriate testing and resulting cardiovascular outcomes.

METHODS

We searched the MEDLINE database for studies related to AUC and MPI. The co-primary outcomes were abnormal test results and the presence of cardiac ischemia. Random effects odds ratios (OR) were constructed using DerSimonian-Laird method.

RESULTS

A total of 22 studies with 23,443 patients were included. The prevalence of inappropriate testing was 14.8% [95% confidence interval (CI) 11.6%-18.7%]. Inappropriate MPI studies were less likely to be abnormal (OR 0.41 95% CI 0.35-0.49, P < .0001) and to demonstrate ischemia (OR 0.40, 95% CI 0.24-0.67, P < .0001) compared to appropriate testing. No difference in the rate of inappropriate tests was detected based on the midpoint of the enrollment year (P = .54). The pattern of ordering inappropriate studies was not different between cardiology and non-cardiology providers (OR 0.74, 95% CI 0.51-1.06, P = .10).

CONCLUSION

Inappropriate MPI studies are less likely to yield abnormal results or demonstrate myocardial ischemia. The rate of inappropriate MPI has not decreased over time.

Appropriateness and diagnostic yield of cardiac magnetic resonance imaging from a tertiary referral center in the Middle East

PURPOSE

Cardiac magnetic resonance imaging (CMRI) is a novel non-invasive modality with many potential indications, and was recently introduced in Lebanon. We sought to assess the appropriateness and diagnostic yield of CMR studies performed at a tertiary referral center from the Middle East since the inception of the program.

METHODS

All patients who underwent CMR studies between January 1(st) 2013 and June 18(th) 2014 were enrolled in this study. CMR reports were retrospectively reviewed. The study indication, clinical history, and findings were extracted and analyzed. The appropriateness of the study was judged according to the 2010 updated Asian Society of Cardiac Imaging guidelines.

RESULTS

There were a total of 142 patients [mean age 42.1 (SD: 18) years, 24.6% females] that underwent CMR study. Two-thirds of studies were performed on an outpatient basis, and outside referrals constituted 16.2% of the entire cohort. The cardiologists referred 122 cases (86%) with main contribution from electrophysiology and imaging specialists. Of the 142 cases, 12 (8.4%) were not indicated and added little value. Of the remaining 130 appropriate studies (appropriateness level A8-A9), one-third had an incorrect diagnosis prior to CMR, and 8% had relevant findings that were missed on other studies but captured by CMR. Furthermore, CMR confirmed the diagnosis in 28% of the cases, provided relevant information on scar burden, shunt quantification, and ruled out infiltrative disease in the remaining patients. Also, CMR demonstrated the presence of scar in 45 of patients, among whom 20 (44%) had significant scar volume quantification (>5% of left ventricular myocardium). Finally, 9% of patients had a relevant extra-cardiac finding that needed further investigation.

CONCLUSIONS

Despite the recent launch of the CMR program at our institution, the majority of studies were appropriately indicated, provided relevant data and were clinically useful. Inappropriate or uncertain studies did not provide relevant data, and should be further minimized to avoid unnecessary costs and downstream testing. Large prospective CMR database with clinical follow-up is needed to provide more insight about cardiovascular disease and outcomes in our population.

Temporal changes in appropriateness of cardiac imaging

BACKGROUND

Appropriate use criteria (AUC) for cardiac imaging have been available for almost 10 years. The extent to which there has been a reported improvement in appropriate use is undefined.

OBJECTIVES

This study systematically reviewed published evidence to identify whether the promulgation of AUC has led to an improvement in the proportion of appropriate cardiac imaging requests.

METHODS

Electronic databases were systematically searched for English-language papers related to AUC and cardiovascular imaging. We found 59 reports involving 103,567 tests that were published from 2000 to 2012. The rate of appropriate testing over time was analyzed in a meta-regression.

RESULTS

New AUC were associated with apparent improvements in appropriateness for transthoracic echocardiography (TTE) (80% [95% confidence interval (CI): 0.75 to 0.84] vs. 85% [95% CI: 0.81 to 0.89]), transesophageal echocardiography (TEE) (89% [95% CI: 0.81 to 0.94] vs. 95% [95% CI: 0.93 to 0.96]) and computed tomography angiography (CTA) (37% [95% CI: 0.21 to 0.55] vs. 55% [95% CI: 0.44 to 0.65]) but not stress echocardiography (53% [95% CI: 0.45 to 0.61] vs. 52% [95% CI: 0.42 to 0.61]) or single-photon emission computed tomography (72% [95% CI: 0.66 to 0.77] vs. 68% [95% CI: 0.60 to 0.74]). Although there were no correlations between the proportion of appropriate TTEs and published year (p = 0.36) for 2007 AUC, there was a positive correlation between proportion of appropriateness and the year of publication (p = 0.01) for 2011 AUC. There was a significant decrease in the proportion of appropriateness over time using the 2007 TEE AUC (p = 0.03) and 2006 CT AUC (p = 0.02). There were no meaningful associations between appropriateness and publication year for stress echocardiography, CTA, or single-photon emission computed tomography.

CONCLUSIONS

Rates of reported appropriate use in imaging show improvements for TTE and CTA but not for stress imaging and TEE. The observed reductions in imaging studies are not matched by reported rates of appropriate use.

Applicability of the Appropriate use Criteria for Myocardial Perfusion Scintigraphy

Background

Appropriateness Criteria for nuclear imaging exams were created by American College of Cardiology (ACC) e American Society of Nuclear Cardiology (ASNC) to allow the rational use of tests. Little is known whether these criteria have been followed in clinical practice.

Objective

To evaluate whether the medical applications of myocardial perfusion scintigraphy (MPS) in a private nuclear medicine service of a tertiary cardiology hospital were suitable to the criteria of indications proposed by the American medical societies in 2005 and 2009 and compare the level of indication of both.

Methods

We included records of 383 patients that underwent MPS, November 2008 up to February 2009. Demographic characteristics, patient's origin, coronary risk factors, time of medical graduation and appropriateness criteria of medical applications were studied. The criteria were evaluated by two independent physicians and, in doubtful cases, defined by a medical expert in MPS.

Results

Mean age was 65 ± 12 years. Of the 367 records reviewed, 236 (64.3%) studies were performed in men and 75 (20.4%) were internee. To ACC 2005, 255 (69.5%) were considered appropriate indication and 13 (3.5%) inappropriate. With ACC 2009, 249 (67.8%) were considered appropriate indications and 13 (5.2%) inappropriate.

Conclusions

We observed a high rate of adequacy of medical indications for MPS. Compared to the 2005 version, 2009 did not change the results.

Applicability of the appropriate use criteria for SPECT myocardial perfusion imaging in Italy: preliminary results

PURPOSE

Clinical applicability of the appropriate use criteria for SPECT myocardial perfusion imaging has not yet been evaluated in Italy. We investigated the applicability of the Appropriate Use Criteria (AUC) in Italy.

METHODS

The indications for testing were prospectively recorded in three different nuclear cardiology laboratories: a general hospital, an academic hospital, and a tertiary centre. Indications were categorized as appropriate, uncertain or inappropriate according to the 2009 AUC; the specialty of the ordering physician was also noted. SPECT results were classified as: normal, probably normal, uncertain, probably abnormal, abnormal. The presence and severity of ischaemia were also noted.

RESULTS

Over a 9-month period, 2,134 patients (age 67 ± 10 years, 68 % men) were evaluated (62 % exercise stress test). On average, there were 700 (84 %) appropriate, 73 (7 %) inappropriate and 93 (9 %) uncertain tests. The rates for the appropriateness of indications were comparable in men and women (84 % and 83 %, not significant). As expected, the rate of nonnormal studies was higher (58 %) for appropriate than for inappropriate (33 %) indications. Appropriateness was lower in the tertiary centre (74 %), and uncertain (16 %) and inappropriate (10 %) indications were more common; this was related to the higher rate of outpatients scheduled by nonhospital cardiologists (37 %). The most common indications associated with inappropriate testing were: chest pain, low likelihood of coronary artery disease, interpretable ECG and able to exercise (29 %), and asymptomatic <2 years after percutaneous coronary intervention (24 %).

CONCLUSION

In this preliminary evaluation of the AUC in Italy, the majority of studies were classified as appropriate, but a consistent proportion of scheduled SPECT studies, particularly by nonhospital cardiologists, were still categorized as uncertain or inappropriate. Educational approaches should be implemented to reduce the rate of less appropriate examinations. However, a substantial proportion (33 %) of inappropriate studies were classified as nonnormal, with 26 % of these patients having ischaemia.

Utilization patterns of single-photon emission cardiac tomography myocardial perfusion imaging studies in a rural tertiary care setting

BACKGROUND

Appropriate use criteria (AUC) for single-photon emission computed tomographic myocardial perfusion imaging (SPECT MPI) were revised in 2009 to include 15 new clinical scenarios. We assessed multivariable predictors and overall appropriateness of MPI studies performed in a rural tertiary care setting.

HYPOTHESIS

We hypothesized that appropriate utilization rates of SPECT MPI imaging in a rural tertiary care center are similar for cardiology and non cardiology providers.

METHODS

We reviewed all SPECT MPI studies performed for over a 6-month period at our center. Using 67 scenarios in AUC, we categorized these studies as appropriate, inappropriate, uncertain, or unclassifiable.

RESULTS

Of 328 MPI studies, 287 (88%) studies were classified as appropriate, 18 (5.5%) as inappropriate, 23 (7%) as uncertain, and none as unclassifiable. Preoperative testing accounted for 44% of the inappropriate studies; 61% of uncertain tests were ordered for cardiovascular risk assessment in patients with prior normal coronary angiography or normal stress tests. The ordering provider specialty did not show any relation with appropriateness of the test (P = 0.46). Patients with inappropriate and uncertain studies were younger than patients with appropriate studies (P = 0.007).

CONCLUSIONS

We found that a majority of MPI studies are performed for appropriate indications regardless of ordering provider specialty. Few common scenarios accounted for the majority of the inappropriate or uncertain studies.

A multicenter evaluation of the appropriate use of single-photon emission tomography myocardial perfusion imaging in Greece

BACKGROUND

This study evaluates the appropriate use of myocardial perfusion imaging (MPI) and determines patterns and variables associated with inappropriate testing.

METHODS

Over a 10-month period data were collected prospectively from consecutive patients referred for MPI in four academic departments and an appropriate use grade was assigned (appropriate, uncertain, inappropriate, and unclassifiable scans) according to established criteria.

RESULTS

Among 3,032 referrals appropriate MPI had 72.8% of patients and 19.2% of studies were inappropriate, the remaining being uncertain (7.2%) or unclassifiable (0.8%). In multivariate analysis the asymptomatic status (odds ratio 10.7, P < .001), good functional capacity (odds ratio 1.9, P < .001), an interpretable resting electrocardiogram (odds ratio 1.8, P = .004), an age <65 years (odds ratio 1.5, P = .001) and the absence of diabetes (odds ratio 1.7, P < .001) or dyslipidemia (odds ratio 1.3, P = .014) were independent predictors of inappropriate scintigraphy. The most common indication for inappropriate testing was the assessment of asymptomatic patients <2 years after percutaneous coronary intervention (PCI) (38.9%).

CONCLUSIONS

The appropriate use of MPI is relatively high, but a considerable proportion of inappropriate scans is noted which is associated with markers of lower risk. The most common source of inappropriate testing is the assessment of asymptomatic patients <2 years after PCI.