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Rozanski A, Miller RJH, Han D, Gransar H, Hayes SW, Friedman JD, Thomson LEJ, Berman DS. Comparative predictors of mortality among patients referred for stress single-photon emission computed tomography versus positron emission tomography myocardial perfusion imaging. J Nucl Cardiol 2024; 32:101811. [PMID: 38244976 DOI: 10.1016/j.nuclcard.2024.101811] [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] [Indexed: 01/22/2024]
Abstract
BACKGROUND There is currently little information regarding the usage and comparative predictors of mortality among patients referred for single-photon emission computed tomography (SPECT) versus positron emission tomography (PET) myocardial perfusion imaging (MPI) within multimodality imaging laboratories. METHODS We compared the clinical characteristics and mortality outcomes among 15,718 patients referred for SPECT-MPI and 6202 patients referred for PET-MPI between 2008 and 2017. RESULTS Approximately two-thirds of MPI studies were performed using SPECT-MPI. The PET-MPI group was substantially older and included more patients with known coronary artery disease (CAD), hypertension, diabetes, and myocardial ischemia. The annualized mortality rate was also higher in the PET-MPI group, and this difference persisted after propensity matching 3615 SPECT-MPI and 3615 PET-MPI patients to have similar clinical profiles. Among the SPECT-MPI patients, the most potent predictor of mortality was exercise ability and performance, including consideration of patients' mode of stress testing and exercise duration. Among the PET-MPI patients, myocardial flow reserve (MFR) was the most potent predictor of mortality. CONCLUSIONS In our real-world setting, PET-MPI was more commonly employed among older patients with more cardiac risk factors than SPECT-MPI patients. The most potent predictors of mortality in our SPECT and PET-MPI groups were variables exclusive to each test: exercise ability/capacity for SPECT-MPI patients and MFR for PET-MPI patients.
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Affiliation(s)
- Alan Rozanski
- Division of Cardiology and Department of Medicine, Mount Sinai Morningside Hospital, Mount Sinai Heart and the Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Robert J H Miller
- Division of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Canada
| | - Donghee Han
- The Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Heidi Gransar
- The Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sean W Hayes
- The Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - John D Friedman
- The Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Louise E J Thomson
- The Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel S Berman
- The Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Ferko N, Priest S, Almuallem L, Walczyk Mooradally A, Wang D, Oliva Ramirez A, Szabo E, Cabra A. Economic and healthcare resource utilization assessments of PET imaging in Coronary Artery Disease diagnosis: a systematic review and discussion of opportunities for future economic evaluations. J Med Econ 2024; 27:715-729. [PMID: 38650543 DOI: 10.1080/13696998.2024.2345507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/17/2024] [Indexed: 04/25/2024]
Abstract
AIMS This systematic literature review (SLR) consolidated economic and healthcare resource utilization (HCRU) evidence for positron emission tomography (PET) and single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) to inform future economic evaluations. MATERIALS AND METHODS An electronic search was conducted in MEDLINE, Embase, and Cochrane databases from 2012-2022. Economic and HCRU studies in adults who underwent PET- or SPECT-MPI for coronary artery disease (CAD) diagnosis were eligible. A qualitative methodological assessment of existing economic evaluations, HCRU, and downstream cardiac outcomes was completed. Exploratory meta-analyses of clinical outcomes were performed. RESULTS The search yielded 13,439 results, with 71 records included. Economic evaluations and comparative clinical trials were limited in number and outcome types (HCRU, downstream cardiac outcomes, and diagnostic performance) assessed. No studies included all outcome types and only one economic evaluation linked diagnostic performance to HCRU. The meta-analyses of comparative studies demonstrated significantly higher rates of early- and late-invasive coronary angiography and revascularization for PET- compared to SPECT-MPI; however, the rate of repeat testing was lower with PET-MPI. The rate of acute myocardial infarction was lower, albeit non-significant with PET- vs. SPECT-MPI. LIMITATIONS AND CONCLUSIONS This SLR identified economic and HCRU evaluations following PET- and SPECT-MPI for CAD diagnosis and determined that existing studies do not capture all pertinent outcome parameters or link diagnostic performance to downstream HCRU and cardiac outcomes, thus, resulting in simplified assessments of CAD burden. A limitation of this work relates to heterogeneity in study designs, patient populations, and follow-up times of existing studies. Resultingly, it was challenging to pool data in meta-analyses. Overall, this work provides a foundation for the development of comprehensive economic models for PET- and SPECT-MPI in CAD diagnosis, which should link diagnostic outcomes to HCRU and downstream cardiac events to capture the full CAD scope.
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Affiliation(s)
| | | | | | | | - Di Wang
- EVERSANA, Burlington, Canada
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Rozanski A, Han D, Miller RJH, Gransar H, Slomka P, Hayes SW, Friedman JD, Thomson LEJ, Berman DS. Comparison of coronary artery calcium scores among patients referred for cardiac imaging tests. Prog Cardiovasc Dis 2023; 81:24-32. [PMID: 37858662 DOI: 10.1016/j.pcad.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 10/15/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND While coronary artery calcium (CAC) can now be evaluated by multiple imaging modalities, there is presently scant study regarding how CAC scores may vary among populations of varying clinical risk. METHODS We evaluated the distribution of CAC scores among three patient groups: 18,941 referred for CAC scanning, 5101 referred for diagnostic coronary CT angiography (CCTA), and 3307 referred for diagnostic positron emission tomography (PET) myocardial perfusion imaging (MPI). We assessed the relationship between CAC score and myocardial ischemia, obstructive coronary artery disease (CAD), and all-cause mortality across imaging modalities. RESULTS Within each age group, the frequency of CAC abnormalities were relatively similar across testing modalities, despite an annualized mortality rate which varied from 0.5%/year among CAC patients to 3.8%/year among PET-MPI patients (p < 0.001). Among CCTA and PET-MPI patients, a zero CAC score was common, occurring in ~70% of patients <50 years, ~40% of patients 50-59 years, and ~ 25% of patients 60-69 years. Among CCTA patients, zero CAC was associated with a normal coronary angiogram with high frequency, ranging from 92.2% among patients <50 years to 87.9% among patients ≥70 years. Among PET-MPI patients, zero CAC was associated with a very low frequency of inducible ischemia across all age groups, ranging from 1.5% among patients <50 years to 0.9% among patients ≥70 years. CONCLUSIONS In our study, relatively similar CAC scores were noted among patients varying markedly in mortality risk. Clinically, zero CAC scores predicted both a low likelihood of obstructive CAD and inducible myocardial ischemia in all age groups and were observed with high frequency across diagnostic testing modalities.
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Affiliation(s)
- Alan Rozanski
- Division of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, the Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
| | - Donghee Han
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Robert J H Miller
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America; Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Heidi Gransar
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Piotr Slomka
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Sean W Hayes
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - John D Friedman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Louise E J Thomson
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Daniel S Berman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
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Tottleben J, Torres A, Doukky R. Impact of change of ischemic burden on the outcomes of ESRD patients awaiting kidney transplantation. J Nucl Cardiol 2023; 30:1897-1903. [PMID: 37170063 DOI: 10.1007/s12350-023-03287-3] [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: 11/30/2022] [Accepted: 04/07/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND In asymptomatic patients with end-stage renal disease (ESRD) wait-listed for kidney transplantation (KT), it is unclear whether a change in ischemic burden on serial surveillance SPECT myocardial perfusion imaging (MPI) impacts outcome. METHODS AND RESULTS In a retrospective cohort of 700 asymptomatic KT candidates with ≥ 2 sequential SPECT-MPI studies, we defined a significant change in ischemic burden between MPIs as ΔSDS of ≥ 2 points. Patients were followed for mean 19 ± 12 months after MPI2 for cardiac death or myocardial infarction. Between MPIs, 29 (4%) subjects received coronary revascularization which was associated with a greater incidence of reduction in ischemic burden on MPI2 (31% vs. 17%, P = 0.049). Among 514 patients with no ischemia on MPI1 (SDS ≤ 1), 15% had new ischemia on MPI2 which was associated with increased MACE (adjusted HR 1.75; CI 1.02-3.01; P = 0.041). Among 186 patients with ischemia on MPI1 (SDS ≥ 2), 66% had improvement of ischemic burden on MPI2 which was associated with significantly lower MACE (adjusted HR 0.46; CI 0.25-0.82; P = 0.009). There was no significant interaction between coronary revascularization and improvement in ischemic burden impacting outcome (interaction P = 0.845). CONCLUSION Among KT candidates who underwent serial MPI for CAD surveillance, new ischemia was associated with increased MACE risk. Improvement in ischemic burden was associated with lower MACE risk irrespective of coronary revascularization status.
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Affiliation(s)
- Jonathan Tottleben
- Division of Cardiology, Cook County Health, 1901 W. Harrison Street, Chicago, IL, 60612, USA
| | - Andrea Torres
- Division of Cardiology, Cook County Health, 1901 W. Harrison Street, Chicago, IL, 60612, USA
| | - Rami Doukky
- Division of Cardiology, Cook County Health, 1901 W. Harrison Street, Chicago, IL, 60612, USA.
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA.
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Doukky R, Henzlova M. Is dyspnea the new angina? The ever-changing profile of patients referred for CAD evaluation. J Nucl Cardiol 2023; 30:1321-1323. [PMID: 37428399 DOI: 10.1007/s12350-023-03327-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: 06/09/2023] [Accepted: 06/10/2023] [Indexed: 07/11/2023]
Affiliation(s)
- Rami Doukky
- Division of Cardiology, Cook County Health, 1901 W. Harrison St., Chicago, IL, 60612, USA.
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA.
| | - Milena Henzlova
- Division of Cardiology, Mount Sinai Health System, New York, NY, USA
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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.
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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
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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.
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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
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8
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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.
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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.
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Tottleben J, Howland J, Rofael M, Co MLF, Torres A, Doukky R. The prognostic and diagnostic implications of surveillance serial myocardial perfusion imaging in asymptomatic renal transplant candidates. J Nucl Cardiol 2023; 30:152-163. [PMID: 35705845 DOI: 10.1007/s12350-022-03017-1] [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: 10/30/2021] [Accepted: 05/12/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The utility of serial SPECT myocardial perfusion imaging (MPI) for CAD surveillance in asymptomatic ESRD patients awaiting kidney transplantation (KT) is uncertain. METHODS AND RESULTS We retrospectively investigated 700 asymptomatic KT candidates with ≥ 2 pre-transplant SPECT-MPIs (mean interval, 20 ± 13 months). Worsening MPI was defined as total perfusion deficit increase (ΔTPD) > 5%. High clinical risk was defined as ≥ 3 AHA/ACC KT risk factors. The primary outcome was major adverse cardiac events (MACE) of cardiac death or myocardial infarction. The initial MPI was normal in 462 (66%) subjects. On repeat MPI, ΔTPD > 5% was observed in 82 (12%) subjects, and the incidence increased with increasing time gap between MPIs (P = .006). During a mean follow-up of 16 ± 8 months, there were 119 (17%) MACEs. In the entire cohort, ΔTPD > 5% was not significantly associated with MACE (HR = 1.38; P = .210). ΔTPD > 5% was associated with increased MACE rate among patients with normal initial MPI (HR = 2.30; P = .005), but not among those with abnormal initial MPI (P = .260). There was a significant interaction between ΔTPD > 5% and initial MPI normalcy status in predicting MACE (interaction P = .018), such that the predictive value of ΔTPD is dependent on the initial MPI normalcy. Among subjects with normal initial MPI, ΔTPD > 5% was significantly associated with MACE only if the sum of KT risk factors was ≥ 3 (HR = 2.26; P = .016). Among 123 patients who underwent coronary angiography, ΔTPD > 5% was associated with a higher prevalence of obstructive CAD when the initial MPI was normal and the sum of KT risk factors was ≥ 3. CONCLUSION Among patients with ESRD waitlisted for KT, new/worsening MPI abnormalities are expected. On serial surveillance, ΔTPD > 5% is associated with MACE and obstructive CAD among those with a normal initial MPI and ≥ 3 AHA/ACC KT risk factors.
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Affiliation(s)
- Jonathan Tottleben
- Division of Cardiology, Cook County Health, 1901 W. Harrison Street, Chicago, IL, 60612, USA
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Julia Howland
- School of Public Health, University of Illinois at Chicago, Chicago, IL, USA
| | - Michael Rofael
- Division of Cardiology, Cook County Health, 1901 W. Harrison Street, Chicago, IL, 60612, USA
| | | | - Andrea Torres
- Division of Cardiology, Cook County Health, 1901 W. Harrison Street, Chicago, IL, 60612, USA
| | - Rami Doukky
- Division of Cardiology, Cook County Health, 1901 W. Harrison Street, Chicago, IL, 60612, USA.
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA.
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Rozanski A, Miller RJH, Han D, Gransar H, Slomka P, Dey D, Hayes SB, Friedman J, Thomson LB, Berman DS. The prevalence and predictors of inducible myocardial ischemia among patients referred for radionuclide stress testing. J Nucl Cardiol 2022; 29:2839-2849. [PMID: 34608604 DOI: 10.1007/s12350-021-02797-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/30/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND The frequency of inducible myocardial ischemia has declined in contemporary stress test cohorts, suggesting a need to re-evaluate its optimal use. To-date, however, a comprehensive analysis of the most potent predictors of myocardial ischemia among cardiac stress test patients has not been conducted. METHODS We assessed 27,615 patients referred for stress-rest SPECT myocardial perfusion imaging between January 1, 2004 and December 31, 2017. Chi-square analysis was used to ascertain the most potent predictors of ischemia. RESULTS Among our cohort, CAD status (presence/absence of known CAD), rest left ventricular ejection fraction (LVEF), and typical angina were the most potent predictors of ischemia. The frequency of ischemia was only 6.6% among patients with an LVEF > 55% but 38.1% for patients with LVEF < 45% (P < 0.001). The frequency of myocardial ischemia was fourfold higher among patients with known CAD vs no known CAD (28.0% vs 6.5%, P < 0.001) and approximately threefold higher among patients with typical angina vs patients with atypical symptoms (P < 0.001). CONCLUSIONS The frequency of myocardial ischemia varies markedly according to the common clinical parameters and is particularly high among patients with known CAD, low LVEF, and typical angina. These observations may be used to develop more cost-effective strategies for referring patients for cardiac stress testing.
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Affiliation(s)
- Alan Rozanski
- Division of Cardiology and Department of Medicine, Mount Sinai Morningside Hospital, Mount Sinai Heart and the Icahn School of Medicine at Mount Sinai, 1111 Amsterdam Avenue, New York, NY, 10025, USA.
| | - Robert J H Miller
- Division of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada
| | - Donghee Han
- 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
| | - Piotr Slomka
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Damini Dey
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sean B Hayes
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - John Friedman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Louise B 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
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11
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Kassab K, Doukky R. Cardiac imaging for the assessment of patients being evaluated for liver transplantation. J Nucl Cardiol 2022; 29:1078-1090. [PMID: 33825142 DOI: 10.1007/s12350-021-02591-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 02/23/2021] [Indexed: 02/06/2023]
Abstract
Cardiac risk assessment prior to liver transplantation has become widely accepted. With the emergence of nonalcoholic steatohepatitis among the leading causes of end-stage liver disease and the steady rise of the age of liver transplant recipients, the burden of cardiovascular diseases has markedly increased in this population. Selecting appropriate liver transplant candidates is crucial due to the increasing demand for scarce donor organs. The use of noninvasive cardiac imaging for pre-operative assessment of the cardiovascular status of liver transplant recipients has been on the rise, yet the optimal assessment strategy remains an area of active debate. In this review, we examine the relevant literature pertaining to the diagnostic and prognostic applications of noninvasive cardiac imaging in this population. We also propose a simple literature-based evaluation algorithm for CAD surveillance in liver transplant candidates.
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Affiliation(s)
- Kameel Kassab
- Division of Cardiology, Cook County Health, Chicago, IL, USA
| | - Rami Doukky
- Division of Cardiology, Cook County Health, Chicago, IL, USA.
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA.
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12
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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
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13
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Kassab K, Doukky R. Cardiac imaging for the assessment of patients being evaluated for kidney transplantation. J Nucl Cardiol 2022; 29:543-557. [PMID: 33666870 DOI: 10.1007/s12350-021-02561-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 01/27/2021] [Indexed: 12/20/2022]
Abstract
Cardiac risk assessment before kidney transplantation has become widely accepted. However, the optimal patient selection and screening tool for cardiac assessment remain controversial. Clinicians face several challenges in this process, including the ever-growing pre-transplant population, aging transplant candidates, increasing prevalence of coronary artery disease, and scarcity of donor organs. Optimizing the cardiovascular risk profile in kidney transplant candidates is necessary to better appropriate limited donor organs and improve patient outcomes. Increasing waiting times from the initial evaluation for transplant candidacy to the actual transplant raises questions regarding re-testing and re-stratification of risk. In this review, we summarize and discuss the current literature on cardiac evaluation prior to kidney transplantation. We also propose simple evidence-based evaluation algorithms for initial and follow-up CAD surveillance in patients being wait-listed for kidney transplantation.
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Affiliation(s)
- Kameel Kassab
- Division of Cardiology, Cook County Health, 1901 W. Harrison St., Suite 3620, Chicago, IL, 60612, USA
| | - Rami Doukky
- Division of Cardiology, Cook County Health, 1901 W. Harrison St., Suite 3620, Chicago, IL, 60612, USA.
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA.
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14
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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.
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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.
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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
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16
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Khan MS, Arif AW, Doukky R. The prognostic implications of ST-segment and T-wave abnormalities in patients undergoing regadenoson stress SPECT myocardial perfusion imaging. J Nucl Cardiol 2022; 29:810-821. [PMID: 33034037 DOI: 10.1007/s12350-020-02382-z] [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: 07/04/2020] [Accepted: 09/11/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND The prognostic implications of ST-segment and T-wave (ST/T) abnormalities in patients undergoing stress SPECT-myocardial perfusion imaging (MPI) are not well defined. METHODS AND RESULTS This was a single-center, retrospective cohort study of consecutive patients who underwent regadenoson stress SPECT-MPI. Patients with baseline electrocardiogram (ECG) abnormalities that impede ST/T analysis or those with known coronary artery disease were excluded. Patients were categorized as having primary ST abnormalities, secondary ST/T abnormalities due to ventricular hypertrophy or right bundle branch block, T-wave abnormalities, or normal ECG. The primary outcome was major adverse cardiovascular events (MACE) defined as the composite of cardiac death or myocardial infarction. Among 6,059 subjects, 1912 (32%) had baseline ST/T abnormalities. During a mean follow-up of 2.3 ± 1.9 years, the incidence of MACE was significantly higher among patients with secondary ST/T abnormalities compared to those with normal ECG (HR 2.05; 95% confidence interval [CI], 1.04-4.05; P = 0.039). No significant difference in MACE was observed among patients with primary ST abnormalities (HR 1.64; CI 0.87-3.06; P = 0.124) or T-wave abnormalities (HR 1.15; CI 0.62-2.16; P = 0.658) compared with patients who had normal ECG. Among patients with secondary ST/T changes, abnormal MPI was not associated with a significant increase in MACE rates compared to normal MPI (HR 1.18; CI 0.31-4.58; P = 0.808). However, abnormal MPI was associated with higher MACE rates among patients with primary ST abnormalities (HR 4.50; CI 1.44-14.10; P = 0.005) and T-wave abnormalities (HR 3.74; CI 1.20-11.68; P = 0.015). Similarly, myocardial ischemia on regadenoson stress SPECT-MPI was not associated with a significant increase in MACE rates in patients with secondary ST/T abnormalities (HR 1.45; CI 0.38-5.61; P = 0.588), while it was associated with a higher incidence of MACE in patients with primary ST abnormalities (HR 3.012; CI 0.95-9.53; P = 0.049) and T-wave abnormalities (HR 5.06; CI 1.60-15.96; P = 0.002). CONCLUSION While patients with secondary ST/T abnormalities had significantly higher MACE risk, abnormal MPI or presence of myocardial ischemia on regadenoson SPECT-MPI in this group does not add prognostic information. Patients with primary ST abnormalities and T-wave abnormalities do not seem to have a significantly higher MACE risk compared to those with normal ECG; however, abnormal MPI or presence of myocardial ischemia, in these groups, correlates with higher MACE rates.
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Affiliation(s)
| | | | - Rami Doukky
- Department of Medicine, Cook County Health, Chicago, IL, USA.
- Division of Cardiology, Cook County Health, 1901 W. Harrison St., Chicago, IL, 60612, USA.
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA.
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Rozanski A, Gransar H, Hayes SW, Friedman JD, Thomson LEJ, Lavie CJ, Berman DS. Synergistic Assessment of Mortality Risk According to Body Mass Index and Exercise Ability and Capacity in Patients Referred for Radionuclide Stress Testing. Mayo Clin Proc 2021; 96:3001-3011. [PMID: 34311969 DOI: 10.1016/j.mayocp.2021.05.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 05/11/2021] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To determine the interrelationship between body mass index (BMI), mode of stress testing (exercise or pharmacological), exercise capacity, and all-cause mortality in patients referred for stress-rest single photon emission computed tomography myocardial perfusion imaging. PATIENTS AND METHODS We evaluated all-cause mortality in 21,638 patients undergoing stress-rest single photon emission computed tomography myocardial perfusion imaging between January 2, 1991, and December 31, 2012. Patients were divided into exercise and pharmacologically tested groups and 9 BMI categories. The median follow-up was 12.8 years (range, 5.0-26.8 years). RESULTS In exercise patients, mortality was increased with both low and high BMI vs patients with a normal referent BMI of 22.5 to 24.9 kg/m2. In pharmacologically tested patients, only low BMI, but not high BMI, was associated with increased mortality vs normal BMI. When exercise and pharmacologically tested groups were compared directly, pharmacologically tested patients manifested a marked increase in mortality risk vs exercise patients within each BMI category, ranging from an approximately 4-fold increase in mortality in those with normal or high BMI to a 12.3-fold increase in those with low BMI values. Similar findings were observed in a cohort of 4804 exercise and 4804 pharmacologically tested patients matched to have similar age and coronary artery disease risk factor profiles. In exercise patients, further risk stratification was achieved when considering both BMI and metabolic equivalent tasks of achieved exercise. CONCLUSION The combined assessment of BMI and exercise ability and capacity provides synergistic and marked risk stratification of future mortality risk in patients referred for radionuclide stress testing, providing considerable insights into the "obesity paradox" that is observed in populations referred for stress testing.
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Affiliation(s)
- Alan Rozanski
- Department of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Imaging and Department of Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Heidi Gransar
- Department of Imaging and Department of Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Sean W Hayes
- Department of Imaging and Department of Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - John D Friedman
- Department of Imaging and Department of Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Louise E J Thomson
- Department of Imaging and Department of Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Carl J Lavie
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School-the UQ School of Medicine, New Orleans, LA
| | - Daniel S Berman
- Department of Imaging and Department of Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
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18
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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.
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Kattoor AJ, Kolkailah AA, Iskander F, Iskander M, Diep L, Khan R, Doukky R. The prognostic value of regadenoson SPECT myocardial perfusion imaging: The largest cohort to date. J Nucl Cardiol 2021; 28:2799-2807. [PMID: 32383079 DOI: 10.1007/s12350-020-02135-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 04/06/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND Data on the prognostic value of regadenoson SPECT myocardial perfusion imaging (MPI) is limited and based on small cohorts. METHODS AND RESULTS We conducted a single-center, retrospective cohort study of 10,275 consecutive patients who underwent regadenoson SPECT-MPI. Among the study subjects, 28.7% had abnormal MPI and 25.5% had myocardial ischemia. Patients were followed for a mean of 2.4 ± 2.2 years for major adverse cardiac events (MACE), defined as cardiac death or myocardial infarction. There was a significant stepwise increase in MACE with an increasing burden of perfusion abnormality (P < .001) and myocardial ischemia (P < .001). Abnormal MPI (adjusted HR 1.52; 95% CI 1.21 to 1.91) and myocardial ischemia (adjusted HR 1.53; 95% CI 1.25 to 1.89) were associated with MACE, independent of and incremental to clinical covariates and left ventricular ejection fraction (LVEF). Moreover, post-stress LVEF, LVEF reserve, and left ventricular end-diastolic volume added significant prognostic information. Transient ischemic dilation ≥ 1.31 did not provide incremental prognostic value (adjusted HR 1.02; P = .906). CONCLUSION In the largest cohort to date, we demonstrated that the presence and severity of perfusion abnormality and myocardial ischemia on regadenoson stress SPECT-MPI are associated with an independent increase in MACE.
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Affiliation(s)
- Ajoe John Kattoor
- Division of Cardiology, Cook County Health, 1901 W. Harrison St., Chicago, IL, 60612, USA
| | | | - Fady Iskander
- Division of Cardiology, Cook County Health, 1901 W. Harrison St., Chicago, IL, 60612, USA
| | - Mina Iskander
- Division of Cardiology, Cook County Health, 1901 W. Harrison St., Chicago, IL, 60612, USA
| | - Lisa Diep
- Health Research and Solutions Unit, Cook County Health, Chicago, IL, USA
| | - Rozi Khan
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
- Department of Medicine, Medstar Union Memorial Hospital, Baltimore, MD, USA
| | - Rami Doukky
- Division of Cardiology, Cook County Health, 1901 W. Harrison St., Chicago, IL, 60612, USA.
- Department of Medicine, Cook County Health, Chicago, IL, USA.
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA.
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20
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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.
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21
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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.
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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
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22
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Malhotra S, Doukky R. Differential Impact of Appropriate Use Criteria on the Association between Age and an Abnormal Stress Myocardial Perfusion SPECT. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2019; 4:63-69. [PMID: 31069038 DOI: 10.15212/cvia.2019.0005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background The diagnostic and prognostic value of appropriate use criteria (AUC) for coronary artery disease (CAD) is well established. Whether the diagnostic yield of AUC for predicting CAD is preserved among the elderly is not known. Methods We analyzed a multi-site prospective cohort of 1511 consecutive patients (mean age 59 ±13 years, 57% males) who underwent outpatient, community-based SPECT myocardial perfusion imaging (MPI). Appropriateness of the studies was determined based on the 2013 multimodality AUC for detection and risk assessment of stable ischemic heart disease. An abnormal SPECT MPI was defined by either a summed stress score ≥ 4 or a summed difference score ≥ 2. Results Abnormal SPECT MPI was present in 190 patients (12.5%), while ischemia on MPI alone was present in 122 (8%). In multivariate logistic regression analysis, age ≥ 60 years, male gender, hypertension, diabetes mellitus, and known CAD were independent predictors of an abnormal SPET MPI, while appropriate indication of testing was not. Age ≥ 60 years was also an independent predictor of inducible myocardial ischemia, while appropriate indication for testing was not. Among elderly (≥ 60 year), regardless of appropriateness of testing, there was no difference in the prevalence of an abnormal SPECT (19% vs. 14%, p=0.14) or prevalence of SPECT ischemia (11% vs. 11%, p=1.00). Among younger patients however, appropriate testing predicted a greater prevalence of an abnormal SPECT (12% vs. 7%, p=0.013). Conclusion In this multi-site cohort, testing based on AUC did not discriminate the risk of an abnormal SPECT MPI among the elderly. Caution is advised when relying on AUC for referring elderly patients for SPECT MPI.
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Affiliation(s)
- Saurabh Malhotra
- Division of Cardiology, Cook County Health, Chicago, IL.,Division of Cardiology, Rush University, Chicago, IL
| | - Rami Doukky
- Division of Cardiology, Cook County Health, Chicago, IL.,Division of Cardiology, Rush University, Chicago, IL
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23
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Gomez J, Doukky R. Artificial Intelligence in Nuclear Cardiology. J Nucl Med 2019; 60:1042-1043. [DOI: 10.2967/jnumed.118.222356] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 03/18/2019] [Indexed: 02/02/2023] Open
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Carpeggiani C, Landi P, Michelassi C, Andreassi MG, Sicari R, Picano E. Stress Echocardiography Positivity Predicts Cancer Death. J Am Heart Assoc 2017; 6:e007104. [PMID: 29233827 PMCID: PMC5779024 DOI: 10.1161/jaha.117.007104] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 10/17/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Stress echocardiography (SE) predicts cardiac death, but an increasing share of cardiac patients eventually die of cancer. The aim of the study was to assess whether SE positivity predicts cancer death. METHODS AND RESULTS In a retrospective analysis of prospectively acquired single-center, observational data, we evaluated 4673 consecutive patients who underwent SE from 1983 to 2009. All patients were cancer-free at index SE and were followed up for a median of 131 months (interquartile range 134). We separately analyzed predetermined end points: cardiovascular, cancer, and noncardiovascular, noncancer death, with and without competing risk. SE was positive in 1757 and negative in 2916 patients; 869 cardiovascular, 418 cancer, and 625 noncardiovascular, noncancer deaths were registered. The 25-year mortality was higher in SE-positive than in SE-negative patients, considering cardiovascular (40% versus 31%; P<0.001) and cancer mortality (26% versus 17%; P<0.01). SE positivity was a strong predictor of cancer (cause-specific hazard ratio 1.19; 95% confidence interval, 1.16-1.73; P=0.05) and cardiovascular mortality (1.18; 95% confidence interval, 1.03-1.35; P=0.02). Fine-Gray analysis to account for competing risk gave similar results. Cancer risk diverged after 15 years, whereas differences were already significant at 5 years for cardiovascular risk. CONCLUSIONS SE results predict cardiovascular and cancer mortality. SE may act as a proxy of the shared risk factor milieu for cancer or cardiovascular death.
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Affiliation(s)
| | | | | | | | - Rosa Sicari
- CNR Institute of Clinical Physiology, Pisa, Italy
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25
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Hage FG, AlJaroudi WA. Review of cardiovascular imaging in the journal of nuclear cardiology in 2016: Part 2 of 2-myocardial perfusion imaging. J Nucl Cardiol 2017; 24:1190-1199. [PMID: 28386817 DOI: 10.1007/s12350-017-0875-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 03/22/2017] [Indexed: 12/20/2022]
Abstract
In 2016, the Journal of Nuclear Cardiology published many high-quality articles. Similar to previous years, we will summarize here a selection of the articles that were published in the Journal in 2016 to provide a concise review of the main advancements that have recently occurred in the field. In the first article of this two-part series we focused on publications dealing with positron emission tomography, computed tomography, and magnetic resonance. This review will place emphasis on myocardial perfusion imaging using single-photon emission-computed tomography summarizing advances in the field including in diagnosis, prognosis, and appropriate use.
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Affiliation(s)
- Fadi G Hage
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
- Section of Cardiology, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA.
| | - Wael A AlJaroudi
- Division of Cardiovascular Medicine, Cardiovascular Imaging, Clemenceau Medical Center, P.O. Box 11-2555, Beirut, Lebanon
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26
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Abstract
In contrast to invasive techniques, the goal of non-invasive cardiac imaging is to identify or exclude heart disease in response to a patient's clinical history of cardiac localizing symptoms. Imaging also aims to establish the risk of an individual developing future heart disease with a view to preventing major cardiovascular events such as myocardial infarction. As well as a role in risk stratification, non-invasive cardiac imaging also helps with decision making for future medical and procedural interventions. This review outlines the non-invasive imaging modalities available to physicians to identify and risk stratify cardiovascular disease. It discusses the strengths of each imaging technique, in which circumstances it is most useful and its diagnostic accuracy.
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Affiliation(s)
- Mark J Davies
- Cardiology Registrar, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, and Department of Cardiology, Wycombe Hospital, Buckinghamshire NHS Trust, High Wycombe, Buckinghamshire HP11 2TT
| | - James D Newton
- Consultant Cardiologist, Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford
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27
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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.
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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
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Abstract
PURPOSE OF REVIEW Patients with end-stage renal disease (ESRD) have an increased risk of cardiovascular morbidity and mortality. Cardiac risk assessment, though challenging, is critical in these high-risk patients, particularly in the pre-transplant population. In this review, we discuss the burden of coronary artery disease in the ESRD population and review the literature on the diagnostic and prognostic performance, clinical value, and future directions of single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) in ESRD patients. RECENT FINDINGS Stress myocardial perfusion imaging provides incremental prognostic value to clinical data. The AHA/ACCF consensus statement on the cardiac assessment of kidney transplant candidates provides some guidance on the selection of asymptomatic patients for further non-invasive risk stratification. Additionally, the novel selective A2A receptor agonist vasodilator stress agent, regadenoson, is safe and effective in ESRD and has recently been approved by the Food and Drug Administration for use in this population. Ancillary stress MPI findings, namely heart rate response to vasodilator stress, can provide incremental risk stratification. SUMMARY While myocardial perfusion imaging is widely used as a risk assessment tool, its utilization and clinical implications in the ESRD population are controversial. Though stress SPECT-MPI has imperfect diagnostic accuracy in this specific patient population, it is still a valuable non-invasive modality in cardiovascular risk assessment.
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Doukky R, Fughhi I, Campagnoli T, Wassouf M, Ali A. The prognostic value of regadenoson SPECT myocardial perfusion imaging in patients with end-stage renal disease. J Nucl Cardiol 2017; 24:112-118. [PMID: 26582040 DOI: 10.1007/s12350-015-0303-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Revised: 10/01/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND The prognostic value of regadenoson SPECT myocardial perfusion imaging (MPI) has not been specifically studied in patients with end-stage renal disease (ESRD). METHODS AND RESULTS We prospectively followed ESRD patients enrolled in the ASSUAGE and ASSUAGE-CKD trials in which they received regadenoson-stress 99mTc-tetrofosmin SPECT-MPI. Images were semiquantitatively analyzed by an investigator blinded to clinical and outcome data. Patients were followed for cardiac death, myocardial infarction (MI), and coronary revascularization (CR). Revascularizations occurring >90 days post-MPI were considered "late" events. Survival analysis was performed using Cox regression models, adjusting for age, gender, diabetes, dyslipidemia, smoking, and known coronary artery disease. We analyzed 303 patients (mean age 54 years; 64% men), who were followed for 35 ± 10 months. Adjusting for clinical covariates, abnormal regadenoson-stress MPI (SSS ≥ 4) was associated with increased risk of the composite of cardiac death or MI (23.9% vs 14.4%; HR 1.88; CI 1.04-3.41; P = .037) and the composite of cardiac death, MI, or late CR (27.3% vs 16.7%; HR 1.80; CI 1.03-3.14; P = .039). Adjusting for clinical covariates, regadenoson-induced myocardial ischemia (SDS ≥ 2) was associated with increased rate of the composite endpoint of cardiac death, MI, or CR (33.3% vs 16.9%; HR 1.97; CI 1.19-3.27; P = .008). CONCLUSION Regadenoson-stress SPECT-MPI provides a significant prognostic value in patients with ESRD. ESRD patients with normal SPECT-MPI have relatively high adverse event rates.
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Affiliation(s)
- 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.
| | - Ibtihaj Fughhi
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Tania Campagnoli
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Marwan Wassouf
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Amjad Ali
- Department of Radiology and Nuclear Medicine, Rush University Medical Center, Chicago, IL, USA
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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.
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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.
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Balfour PC, Gonzalez JA, Kramer CM. Non-invasive assessment of low- and intermediate-risk patients with chest pain. Trends Cardiovasc Med 2016; 27:182-189. [PMID: 27717538 DOI: 10.1016/j.tcm.2016.08.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 07/28/2016] [Accepted: 08/16/2016] [Indexed: 01/26/2023]
Abstract
Coronary artery disease (CAD) remains a significant global public health burden despite advancements in prevention and therapeutic strategies. Common non-invasive imaging modalities, anatomic and functional, are available for the assessment of patients with stable chest pain. Exercise electrocardiography is a long-standing method for evaluation for CAD and remains the initial test for the majority of patients who can exercise adequately with a baseline interpretable electrocardiogram. The addition of cardiac imaging to exercise testing provides incremental benefit for accurate diagnosis for CAD and is particularly useful in patients who are unable to exercise adequately and/or have uninterpretable electrocardiograms. Radionuclide myocardial perfusion imaging and echocardiography with exercise or pharmacological stress provide high sensitivity and specificity in the detection and further risk stratification of patients with CAD. Recently, coronary computed tomography angiography has demonstrated its growing role to rule out significant CAD given its high negative predictive value. Although less available, stress cardiac magnetic resonance provides a comprehensive assessment of cardiac structure and function and provides a high diagnostic accuracy in the detection of CAD. The utilization of non-invasive testing is complex due to various advantages and limitations, particularly in the assessment of low- and intermediate-risk patients with chest pain, where no single study is suitable for all patients. This review will describe currently available non-invasive modalities, along with current evidence-based guidelines and appropriate use criteria in the assessment of low- and intermediate-risk patients with suspected, stable CAD.
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Affiliation(s)
- Pelbreton C Balfour
- Department of Medicine (Cardiology), Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA
| | - Jorge A Gonzalez
- Department of Medicine (Cardiology), Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA
| | - Christopher M Kramer
- Department of Medicine (Cardiology), Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA; Department of Radiology, University of Virginia Health System, Charlottesville, VA.
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Doukky R, Hayes K, Frogge N. Appropriate use criteria for SPECT myocardial perfusion imaging: Are they appropriate for women? J Nucl Cardiol 2016; 23:695-705. [PMID: 26304956 DOI: 10.1007/s12350-015-0233-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 06/26/2015] [Indexed: 01/30/2023]
Abstract
BACKGROUND Several studies have reported that women are more likely to receive inappropriate SPECT myocardial perfusion imaging (MPI), suggesting gender disparity in AUC determination. We investigated the impact of gender on the diagnostic and prognostic utility of AUC. METHODS AND RESULTS We analyzed a multi-site prospective cohort of 1511 consecutive patients (43.5% women) who underwent outpatient, community-based SPECT-MPI. Subjects were stratified into gender groups and appropriateness subgroups, and followed for 27 ± 10 months for cardiac death, myocardial infarction, and coronary revascularization. Women were more likely to receive inappropriate MPI (60.7% vs 33.8%, P < .001). Irrespective of appropriateness, women were less likely to have an abnormal MPI (6.1% vs 14.9%, P < .001), even after adjusting for clinical covariates [odds ratio = 0.40 (95% confidence interval = 0.26-0.60), P < .001]. Irrespective of appropriateness, women were at lower risk for MACE (composite of cardiac death, myocardial infarction, or coronary revascularization) after adjusting for clinical and imaging covariates [hazard ratio = 0.49 (95% confidence interval = 0.28-0.86), P = .01]. There was no interaction between gender and appropriateness group as a determinant of abnormal MPI or MACE (interaction P values ≥ .26), indicating that female gender was associated with similar relative risk of an abnormal MPI and MACE irrespective of appropriateness group. Abnormal MPI was similarly predictive of increased hazard of MACE in both genders, regardless of appropriateness (interaction P values ≥ .46). CONCLUSION In this multi-site cohort, there was no demonstrable gender-based differential impact of AUC on the diagnostic or prognostic utility of SPECT-MPI. The study validates the methods used in determining risk in the AUC algorithm and endorses the widespread application of AUC in men and women.
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Affiliation(s)
- Rami Doukky
- Division of Cardiology, John H. Stroger, Jr. Hospital of Cook County, 1901 W. Harrison St, Suite 3620, Chicago, 60612, IL, USA.
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA.
| | - Kathleen Hayes
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Nathan Frogge
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
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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.
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Doukky R. The prognostic value of regadenoson stress: Has the case been made? J Nucl Cardiol 2015; 22:608-10. [PMID: 25995185 DOI: 10.1007/s12350-015-0179-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 05/11/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Rami Doukky
- Division of Cardiology, John H. Stroger, Jr. Hospital of Cook County, 1901 W. Harrison St., Suite # 3620, Chicago, IL, 60612, USA,
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