1
|
Kraen M, Akil S, Hedén B, Kjellström B, Berg J, Ostenfeld E, Arheden H, Carlsson M, Engblom H. Short- and long-term prognostic performance of exercise ECG and myocardial perfusion SPECT. Clin Physiol Funct Imaging 2024. [PMID: 39154282 DOI: 10.1111/cpf.12899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 05/08/2024] [Accepted: 07/22/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND Myocardial perfusion SPECT (MPS) and exercise electrocardiography (Ex-ECG) results are of prognostic importance for short-term follow up duration. However, the value of MPS or Ex-ECG findings for long-term risk assessment is less evident as underlying risk factors for ischemic heart disease (IHD) gain in importance. OBJECTIVES To assess the short- and long-term prognostic value of MPS and Ex-ECG in relation to known risk factors. METHODS AND MATERIALS An observational study of 908 patients (age 63 years, 49% male, 45% prior IHD) referred for MPS and Ex-ECG. Follow-up was divided into two periods (short-term: <5 years and long-term: >5 years). Cardiac events were defined as a composite of acute myocardial infarction, unstable angina, unplanned revascularization and cardiovascular death. RESULTS The composite endpoint occurred in 95 patients (short-term follow up) and in 94 patients (long-term follow up). In multivariable models stress testing had a strong predictive value for short-term follow up (HR for MPS = 2.9, CI = 1.9-4.5, p < 0.001 and HR for Ex-ECG = 2.1, CI 1.3-3.3, p = 0.002), but no predictive value for long-term follow up (HR for MPS = 0.9, CI = 0.5-1.5, p = 0.70 and HR for Ex-ECG = 1.0, CI = 0.6-1.6, p = 0.92). Male sex and prior IHD were significant predictors regardless of follow up duration. Age, diabetes and decreased exercise capacity were risk factors for long-term follow up. CONCLUSIONS The prognostic value of MPS and Ex-ECG results are strong for short-term follow up but diminish over time and do not contribute significantly in multivariable models after 5 years. Long-term prognosis is primarily governed by underlying risk factors and exercise capacity.
Collapse
Affiliation(s)
- M Kraen
- Department of Clinical Sciences Lund, Clinical Physiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - S Akil
- Department of Clinical Sciences Lund, Clinical Physiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - B Hedén
- Department of Clinical Sciences Lund, Clinical Physiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - B Kjellström
- Department of Clinical Sciences Lund, Clinical Physiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - J Berg
- Department of Clinical Sciences Lund, Clinical Physiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - E Ostenfeld
- Department of Clinical Sciences Lund, Clinical Physiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - H Arheden
- Department of Clinical Sciences Lund, Clinical Physiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - M Carlsson
- Department of Clinical Sciences Lund, Clinical Physiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - H Engblom
- Department of Clinical Sciences Lund, Clinical Physiology, Skåne University Hospital, Lund University, Lund, Sweden
| |
Collapse
|
2
|
Abadie B, Albert C, Bhat P, Harb S, Jacob M, Starling RC, Tang WHW, Jaber WA. Frequency of screening for cardiac allograft vasculopathy: warranty period of initial low risk positron emission tomography. Eur Heart J Cardiovasc Imaging 2024; 25:814-820. [PMID: 38214683 DOI: 10.1093/ehjci/jeae015] [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: 10/06/2023] [Revised: 01/05/2024] [Accepted: 01/09/2024] [Indexed: 01/13/2024] Open
Abstract
AIMS The short-term risk of moderate-severe cardiac allograft vasculopathy (CAV) after a low-risk positron emission tomography/computed tomography (PET/CT) is unknown, and therefore, there is no guidance on how frequently to perform screening. The aim of this study was to assess the rate of progression to moderate-severe CAV as part of an annual screening programme. METHODS AND RESULTS Patients with no history of CAV 2/3 and a low-risk result on initial screening PET/CT (CAV 0/1) were enrolled in the study. The primary outcome was the progression to CAV 2/3 as part of an annual screening programme (within 6-18 months of initial scan). PET CAV results were graded according to a published and externally validated diagnostic criterion for CAV. Over the study period, 231 patients underwent an initial PET/CT and had a subsequent evaluation for CAV. In this cohort, 4.3% of patients progressed to CAV 2/3 at a median of 374 days (interquartile range 363-433). Initial PET CAV grade was the most significant patient characteristic associated with the progression of CAV, with 17% of patients with PET CAV 1 progressing to CAV 2/3 compared with 1.6% with PET CAV 0 (odds ratio 12.4, 95% confidence interval 3.06-50.3). CONCLUSION The rate of progression to moderate-severe CAV at 1 year after the lowest-risk PET/CT is low, but approximately 1/6 patients with PET CAV 1 progress to CAV 2/3. Annual screening with PET/CT for select patients with PET CAV 0 may not be warranted. The optimal screening interval awaits confirmation of our findings in multi-centre registries.
Collapse
Affiliation(s)
- Bryan Abadie
- Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, J1-5 Main Campus, Cleveland, OH 44195, USA
| | - Chonyang Albert
- Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, J1-5 Main Campus, Cleveland, OH 44195, USA
| | - Pavan Bhat
- Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, J1-5 Main Campus, Cleveland, OH 44195, USA
| | - Serge Harb
- Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, J1-5 Main Campus, Cleveland, OH 44195, USA
| | - Miriam Jacob
- Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, J1-5 Main Campus, Cleveland, OH 44195, USA
| | - Randall C Starling
- Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, J1-5 Main Campus, Cleveland, OH 44195, USA
| | - W H Wilson Tang
- Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, J1-5 Main Campus, Cleveland, OH 44195, USA
| | - Wael A Jaber
- Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, J1-5 Main Campus, Cleveland, OH 44195, USA
| |
Collapse
|
3
|
Kamerman M, van Dijk JD, Timmer JR, Ottervanger JP, Knollema S, Jager PL, Mouden M. The incremental value of coronary artery calcium score in predicting long-term prognosis and defining the warranty period of normal adenosine stress-only myocardial perfusion imaging using CZT SPECT. J Nucl Cardiol 2023; 30:2692-2701. [PMID: 37592058 DOI: 10.1007/s12350-023-03349-6] [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: 04/13/2023] [Accepted: 07/12/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Normal stress-only (SO) myocardial perfusion imaging (MPI) using SPECT reduces imaging time and radiation dose with a good prognosis. However, the long-term prognostic value of combining coronary artery calcium score (CACS) with SO MPI to determine the warranty period remains unknown. Hence, we assessed the incremental prognostic value of CACS and its impact on the warranty period of normal SO MPI using SPECT. METHODS We retrospectively included 1375 symptomatic patients without a history of coronary artery disease (CAD) and a normal SO MPI using adenosine who underwent simultaneous CAC scoring. Annual major adverse cardiac events (MACE) rates were calculated for CACS categories: 0, 1-399, 400-999, and ≥1000. RESULTS The mean age was 60.0 ± 11.8 years (66.9% female) with a median follow-up of 10.3 [IQR 9.6-10.9] years. The warranty period for annual MACE rate for normal SO SPECT extended the total follow-up time in years. MACE rate categorized by CAC categories demonstrated an increase in MACE rates with increasing CACS; CACS 0 and CACS 1-399 were associated with a 10-year warranty period, CACS 400-999 had a warranty period of 4 years and no warranty period could be given for CACS≥1000 (5.9 % at 1 year). CONCLUSIONS CACS as an adjunct to normal pharmacological SO MPI provides additional prognostic information and aids in determining a warranty period.
Collapse
Affiliation(s)
- Mandy Kamerman
- Department of Cardiology, Isala Clinics, Zwolle, The Netherlands.
- Department of Nuclear Medicine, Isala Clinics, Zwolle, The Netherlands.
| | - Joris D van Dijk
- Department of Nuclear Medicine, Isala Clinics, Zwolle, The Netherlands
| | - Jorik R Timmer
- Department of Cardiology, Isala Clinics, Zwolle, The Netherlands
| | | | - Siert Knollema
- Department of Nuclear Medicine, Isala Clinics, Zwolle, The Netherlands
| | - Pieter L Jager
- Department of Nuclear Medicine, Isala Clinics, Zwolle, The Netherlands
| | - Mohamed Mouden
- Department of Cardiology, Isala Clinics, Zwolle, The Netherlands
| |
Collapse
|
4
|
Romero-Farina G, Aguadé-Bruix S, Ferreira González I. Vall d'Hebron Risk Score II for myocardial infarction and cardiac death. Open Heart 2023; 10:e002431. [PMID: 37935561 PMCID: PMC10632909 DOI: 10.1136/openhrt-2023-002431] [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: 07/24/2023] [Accepted: 10/11/2023] [Indexed: 11/09/2023] Open
Abstract
OBJECTIVES The aim of this study was to create a new Vall d'Hebron Risk Score-II (VH-RS-II) for non-fatal myocardial infarction (MI) and/or cardiac death (CD), excluding patients with coronary revascularisation (CR) during the follow-up. METHODS We analysed 5215 consecutive patients underwent gated single photon emission CT (SPECT); 2960 patients (age 64.2±11, male 58.1%) had no previous MI and/or CR, and 2255 patients (age 63.3±11, male 81.9%) had previous MI and/or CR. During a follow-up of 4.3±2.6 years, the cardiac event (MI and CD) was evaluated. This study was reviewed and approved by the ethics committee of our institution (number form trial register, PR(AG)168.2012). To obtain the predictor model, multivariate Cox regression analysis and multivariate logistic regression analysis were used. RS-VH-II was validated with 679 patients. RESULTS In patients without previous MI and/or CR, age (HR: 1.01; p<0.001), diabetes (HR: 2.1, p=0.001), metabolic equivalent (METs) (HR: 0.89, p=0.038), ST segment depression (HR: 1.4, p=0.011), ejection fraction (EF) (HR: 0.97, p<0.001) and summed stress score (HR: 1.2, p<0.001) were the independent predictors of CE (C-statistic: 0.8). In patients with previous MI and/or CR, age (HR: 1.06, p<0.001), male (HR: 1.9, p=0.047), smoker (HR: 1.5, p=0.047), METs (HR: 0.8, p<0.001), ST segment depression (HR: 1.4, p=0.002), EF (HR: 0.96; p<0.001) and summed difference score (HR: 1.03, p=0.06) were the independent predictors of CE (C-statistic:0.8). CONCLUSION The VH-RS-II obtained from different clinical exercise and gated SPECT variables allow the risk stratification for MI and CD in patients with or without previous MI and/or CR in due form.
Collapse
Affiliation(s)
- Guillermo Romero-Farina
- Nuclear Cardiology, Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red: Enfermedades Cardiovasculares (CIBER-CV), Hospital Universitari Vall d'Hebron, Madrid, Spain
- Grup d'Imatge Mèdica Molecular (GRIMM), Vall d'Hebron University Hospital, Barcelona, Spain
- Cardiology Department, Consorci Sanitari de l'Alt Penedès i Garraf (CSAPG), Barcelona, Spain
- Cardiology Department, Hospital Universitari Vall d'Hebron, Valld'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Santiago Aguadé-Bruix
- Nuclear Cardiology, Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red: Enfermedades Cardiovasculares (CIBER-CV), Hospital Universitari Vall d'Hebron, Madrid, Spain
- Grup d'Imatge Mèdica Molecular (GRIMM), Vall d'Hebron University Hospital, Barcelona, Spain
| | - Ignacio Ferreira González
- Cardiology Department, Hospital Universitari Vall d'Hebron, Valld'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red: Epidemiología y Salud Pública (CIBER-EP), Madrid, Spain
| |
Collapse
|
5
|
Pieszko K, Shanbhag AD, Singh A, Hauser MT, Miller RJH, Liang JX, Motwani M, Kwieciński J, Sharir T, Einstein AJ, Fish MB, Ruddy TD, Kaufmann PA, Sinusas AJ, Miller EJ, Bateman TM, Dorbala S, Di Carli M, Berman DS, Dey D, Slomka PJ. Time and event-specific deep learning for personalized risk assessment after cardiac perfusion imaging. NPJ Digit Med 2023; 6:78. [PMID: 37127660 PMCID: PMC10151323 DOI: 10.1038/s41746-023-00806-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 03/27/2023] [Indexed: 05/03/2023] Open
Abstract
Standard clinical interpretation of myocardial perfusion imaging (MPI) has proven prognostic value for predicting major adverse cardiovascular events (MACE). However, personalizing predictions to a specific event type and time interval is more challenging. We demonstrate an explainable deep learning model that predicts the time-specific risk separately for all-cause death, acute coronary syndrome (ACS), and revascularization directly from MPI and 15 clinical features. We train and test the model internally using 10-fold hold-out cross-validation (n = 20,418) and externally validate it in three separate sites (n = 13,988) with MACE follow-ups for a median of 3.1 years (interquartile range [IQR]: 1.6, 3.6). We evaluate the model using the cumulative dynamic area under receiver operating curve (cAUC). The best model performance in the external cohort is observed for short-term prediction - in the first six months after the scan, mean cAUC for ACS and all-cause death reaches 0.76 (95% confidence interval [CI]: 0.75, 0.77) and 0.78 (95% CI: 0.78, 0.79), respectively. The model outperforms conventional perfusion abnormality measures at all time points for the prediction of death in both internal and external validations, with improvement increasing gradually over time. Individualized patient explanations are visualized using waterfall plots, which highlight the contribution degree and direction for each feature. This approach allows the derivation of individual event probability as a function of time as well as patient- and event-specific risk explanations that may help draw attention to modifiable risk factors. Such a method could help present post-scan risk assessments to the patient and foster shared decision-making.
Collapse
Affiliation(s)
- Konrad Pieszko
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Interventional Cardiology and Cardiac Surgery, Collegium Medicum, University of Zielona Góra, Zielona Góra, Poland
| | - Aakash D Shanbhag
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ananya Singh
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - M Timothy Hauser
- Department of Nuclear Cardiology, Oklahoma Heart Hospital, Oklahoma City, OK, USA
| | - Robert J H Miller
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Cardiac Sciences, University of Calgary and Libin Cardiovascular Institute, Calgary, AB, Canada
| | - Joanna X Liang
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Manish Motwani
- Institute of Cardiovascular Science, University of Manchester, Manchester, UK
- Department of Cardiology, Manchester Heart Institute, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Jacek Kwieciński
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - Tali Sharir
- Department of Nuclear Cardiology, Assuta Medical Centers, Tel Aviv, Israel
| | - Andrew J Einstein
- Division of Cardiology, Department of Medicine and Department of Radiology, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, NY, USA
| | - Mathews B Fish
- Oregon Heart and Vascular Institute, Sacred Heart Medical Center, Springfield, OR, USA
| | - Terrence D Ruddy
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Albert J Sinusas
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Edward J Miller
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | | | - Sharmila Dorbala
- Department of Radiology, Division of Nuclear Medicine and Molecular Imaging, Brigham and Women's Hospital, Boston, MA, USA
| | - Marcelo Di Carli
- Department of Radiology, Division of Nuclear Medicine and Molecular Imaging, Brigham and Women's Hospital, Boston, MA, USA
| | - Daniel S Berman
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Damini Dey
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Piotr J Slomka
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| |
Collapse
|
6
|
Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Cardiovasc Comput Tomogr 2022; 16:54-122. [PMID: 34955448 DOI: 10.1016/j.jcct.2021.11.009] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
Collapse
|
7
|
Miller RJH, Han D, Rozanski A, Gransar H, Friedman JD, Hayes S, Thomson L, Tamarappoo B, Slomka PJ, Berman DS. CZT camera systems may provide better risk stratification for low-risk patients. J Nucl Cardiol 2021; 28:2927-2936. [PMID: 32500175 DOI: 10.1007/s12350-020-02128-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 03/10/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND The photon sensitivity and spatial resolution of single-photon emission-computed tomography (SPECT) has been significantly improved by solid-state camera systems using cadmium zinc telluride (CZT) detectors. While the diagnostic accuracy of these systems is well established, there is little evidence directly comparing the prognostic utility to conventional NaI cameras. METHODS AND RESULTS Retrospective analysis of patients undergoing SPECT between 2008 and 2012. Visual SPECT assessment was performed utilizing the 17-segment model to determine summed stress scores (SSS). We identified 12,830 consecutive patients, mean age 63.2 ± 13.7 and 56.1% male, 5072 of whom underwent CZT and 7758 NaI imaging. During a median follow-up duration of 7.0 years (IQR 5.5-8.2), a total of 2788 (21.7%) patients died. Compared to SSS 0, minimal perfusion abnormality (SSS 1-3) was associated with increased all-cause mortality with CZT camera (adjusted HR 1.32, P = .017) and NaI camera (adjusted HR 1.29, P = .001, interaction P = .803). Increasing stress abnormality was associated with a similar increase in risk with CZT or NaI imaging (interaction P > .500). In a propensity matched analysis, patients with normal perfusion stress perfusion assessed with a CZT was associated with decreased mortality compared to normal perfusion assessed by a NaI camera system (hazard ratio .88, 95% CI .78-.99, P = .040). CONCLUSIONS Increasing stress perfusion abnormality was associated with similar increase in all-cause mortality with CZT or NaI cameras. CZT and NaI camera systems provide similar risk stratification, however, normal myocardial perfusion may be associated with a more benign prognosis when assessed with a CZT camera system.
Collapse
Affiliation(s)
- Robert J H Miller
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Donghee Han
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alan Rozanski
- Division of Cardiology, Mount Sinai St. Luke's Hospital, Mount Sinai Heart, and the Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Heidi Gransar
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - John D Friedman
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sean Hayes
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Louise Thomson
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Balaji Tamarappoo
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Piotr J Slomka
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel S Berman
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
- , Room 1258, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA.
| |
Collapse
|
8
|
Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 78:e187-e285. [PMID: 34756653 DOI: 10.1016/j.jacc.2021.07.053] [Citation(s) in RCA: 319] [Impact Index Per Article: 106.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
Collapse
|
9
|
Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 144:e368-e454. [PMID: 34709879 DOI: 10.1161/cir.0000000000001029] [Citation(s) in RCA: 152] [Impact Index Per Article: 50.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
Collapse
|
10
|
Planning the Follow-Up of Patients with Stable Chronic Coronary Artery Disease. Diagnostics (Basel) 2021; 11:diagnostics11101762. [PMID: 34679460 PMCID: PMC8535144 DOI: 10.3390/diagnostics11101762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 09/21/2021] [Accepted: 09/22/2021] [Indexed: 11/17/2022] Open
Abstract
Cardiovascular disease remains the leading cause of death among Europeans, Americans, and around the world. In addition, the prevalence of coronary artery disease (CAD) is increasing, with the highest number of hospital visits, hospital readmissions for patients with decompensated heart failure, and a high economic cost. It is, therefore, a priority to try to plan the follow-up of patients with stable chronic CAD (scCAD) in relation to the published data, experience, and new technology that we have today. Planning the follow-up of patients with scCAD goes beyond the information provided by clinical management guidelines. It requires understanding the importance of a cross-sectional and longitudinal analysis in the clinical history of scCAD, because it has an impact on the cost of healthcare in relation to mortality, economic factors, and the burden of medical consultations. Using the data provided in this work facilitates and standardizes the clinical follow-up of patients with scCAD, and following the marked line makes the work for the clinical physician much easier, by including most clinical possibilities and actions to consider. The follow-up intervals vary according to the clinical situation of each patient and can be highly variable. In addition, the ability to properly study patients with imaging techniques, to stratify at different levels of risk, helps plan the intervals during follow-up. Given the complexity of coronary artery disease and the diversity of clinical cases, more studies are required in the future focused on improving the planning of follow-up for patients with scCAD. The perspective and future direction are related to the valuable utility of integrated imaging techniques in clinical follow-up.
Collapse
|
11
|
Cost-effectiveness of myocardial perfusion SPECT and stress test according to coronary revascularization therapy, cardiac events and total mortality: Register of 8496 patients. Rev Esp Med Nucl Imagen Mol 2020. [DOI: 10.1016/j.remnie.2020.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
12
|
Miller RJH, Hu LH, Gransar H, Betancur J, Eisenberg E, Otaki Y, Sharir T, Fish MB, Ruddy TD, Dorbala S, Carli MD, Einstein AJ, Kaufmann PA, Sinusas AJ, Miller EJ, Bateman T, Germano G, Tamarappoo BK, Dey D, Berman DS, Slomka PJ. Transient ischaemic dilation and post-stress wall motion abnormality increase risk in patients with less than moderate ischaemia: analysis of the REFINE SPECT registry. Eur Heart J Cardiovasc Imaging 2020; 21:567-575. [PMID: 31302679 PMCID: PMC7167750 DOI: 10.1093/ehjci/jez172] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 04/03/2019] [Accepted: 06/25/2019] [Indexed: 11/13/2022] Open
Abstract
AIMS Ischaemia on single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) is strongly associated with cardiovascular risk. Transient ischaemic dilation (TID) and post-stress wall motion abnormalities (WMA) are non-perfusion markers of ischaemia with incremental prognostic utility. Using a large, multicentre SPECT MPI registry, we assessed the degree to which these features increased the risk of major adverse cardiovascular events (MACE) in patients with less than moderate ischaemia. METHODS AND RESULTS Ischaemia was quantified with total perfusion deficit using semiautomated software and classified as: none (<1%), minimal (1 to <5%), mild (5 to <10%), moderate (10 to <15%), and severe (≥15%). Univariable and multivariable Cox proportional hazard analyses were used to assess associations between high-risk imaging features and MACE. We included 16 578 patients, mean age 64.2 and median follow-up 4.7 years. During follow-up, 1842 patients experienced at least one event. Patients with mild ischaemia and TID were more likely to experience MACE compared with patients without TID [adjusted hazard ratio (HR) 1.42, P = 0.023], with outcomes not significantly different from patients with moderate ischaemia without other high-risk features (unadjusted HR 1.15, P = 0.556). There were similar findings in patients with post-stress WMA. However, in multivariable analysis of patients with mild ischaemia, TID (adjusted HR 1.50, P = 0.037), but not WMA, was independently associated with increased MACE. CONCLUSION In patients with mild ischaemia, TID or post-stress WMA identify groups of patients with outcomes similar to patients with moderate ischaemia. Whether these combinations identify patients who may derive benefit from revascularization deserves further investigation.
Collapse
Affiliation(s)
- Robert J H Miller
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA
| | - Lien-Hsin Hu
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA
- Department of Nuclear Medicine, Taipei Veterans General Hospital, No. 201, Section 2, Shipai Road, Taipei, Taiwan
| | - Heidi Gransar
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA
| | - Julian Betancur
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA
| | - Evann Eisenberg
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA
| | - Yuka Otaki
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA
| | - Tali Sharir
- Department of Nuclear Cardiology, Assuta Medical Center, HaBarzel St 20, Tel Aviv, Israel
| | - Mathews B Fish
- Department of Nuclear Medicine, Oregon Heart and Vascular Institute, Sacred Heart Medical Center, 3333 Riverbend Dr, Springfield, OR 97477, USA
| | - Terrence D Ruddy
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON K1Y 4W7, Canada
| | - Sharmila Dorbala
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Marcelo Di Carli
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Andrew J Einstein
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, 622 W 168th St, New York, NY 10032, USA
- Department of Radiology and Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 622 W 168th St, New York, NY 10032, USA
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Albert J Sinusas
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University, 333 Cedar St, New Haven, CT 06510, USA
| | - Edward J Miller
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University, 333 Cedar St, New Haven, CT 06510, USA
| | - Timothy Bateman
- Cardiovascular Imaging Technologies LLC, 4320 Wornall Rd, Kansas City, MO 64111, USA
| | - Guido Germano
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA
| | - Balaji K Tamarappoo
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA
| | - Damini Dey
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA
| | - Daniel S Berman
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA
| | - Piotr J Slomka
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA
| |
Collapse
|
13
|
Cost-effectiveness of myocardial perfusion SPECT and stress test according to coronary revascularization therapy, cardiac events and total mortality: Register of 8,496 patients. Rev Esp Med Nucl Imagen Mol 2020; 39:212-219. [PMID: 32273238 DOI: 10.1016/j.remn.2020.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 01/09/2020] [Accepted: 01/19/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The aim was to analyze the cost-effectiveness ratio (CER) of stress electrocardiogram (ES) and stress myocardial perfusion imaging (SPECT-MPI) according to coronary revascularization (CR) therapy, cardiac events (CE) and total mortality (TM). MATERIAL AND METHODS A total of 8,496 consecutive patients who underwent SPECT-MPI were followed-up (mean 5.3±3.5years). Cost-effectiveness for coronary bypass (CABG) or percutaneous CR (PCR) (45.6%/54.4%) according to combined electrocardiographic ischemia and scintigraphic ischemia were evaluated. Effectiveness was evaluated as TM, CE, life-year saved observed (LYSO) and CE-LYSO; costs analyses were conducted from the perspective of the health care payer. A sensitivity analysis was performed considering current CABG/PCR ratios (12%/88%). RESULTS When electrocardiogram and SPECT approaches are combined, the cost-effectiveness values for CABG ranged between 112,589€ (electrocardiographic and scintigraphic ischemia) and 2,814,715€ (without ischemia)/event avoided, 38,664 and 2,221,559€/LYSO; for PCR ranged between 18,824€ (electrocardiographic and scintigraphic ischemia) and 46,377€ (without ischemia)/event avoided, 6,464 and 36,604€/LYSO. To CE: the cost-effectiveness values of the CABG and CPR in presence of electrocardiographic and scintigraphic ischemia were 269,904€/CE-avoided and 24,428€/CE-avoided, respectively; and the €/LYSO of the CABG and PCR were 152,488 and 13,801, respectively. The RCE was maintained for the current proportion of revascularized patients (12%/88%). CONCLUSIONS Combined ES and SPECT-MPI results, allows differentiation between patient groups, where the PCR and CABG are more cost-effective in different economic frameworks. The major CER in relation to CR, CE and TM occurs in patients with electrocardiographic and scintigraphic ischemia. PCR is more cost-effective than CABG.
Collapse
|
14
|
Nappi C, Acampa W, Nicolai E, Daniele S, Zampella E, Assante R, Gaudieri V, Mannarino T, Petretta M, Cuocolo A. Long-term prognostic value of low-dose normal stress-only myocardial perfusion imaging by wide beam reconstruction: A competing risk analysis. J Nucl Cardiol 2020; 27:547-557. [PMID: 30027504 DOI: 10.1007/s12350-018-1373-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 07/10/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND A normal stress myocardial perfusion single-photon emission computed tomography (MPS) is associated with a good clinical outcome. New iterative algorithms, such as wide beam reconstruction (WBR), which improve image interpretation with half-dose or half-time acquisition, have been proposed for cardiac MPS. The aim of this study was to assess the long-term predictive value of a low-dose normal stress-only MPS with WBR using conventional Anger camera in patients with known or suspected coronary artery disease (CAD). METHODS AND RESULTS A total of 2106 patients with known or suspected CAD and normal perfusion at half-dose stress-only MPS protocol were followed for a mean of 6.6 ± 2.7 years. MPS data were reconstructed with WBR iterative algorithm. End-point events were cardiac death or nonfatal myocardial infarction. Noncardiac death was considered the competing event. During follow-up, 149 cardiac events occurred with an annualized event rate of 1.2%. Independent predictors of cardiac events at Cox analysis were age, male gender, diabetes mellitus, previous myocardial infarction and the need for pharmacologic stress testing. At Fine-Gray analysis the cumulative incidence of cardiac events progressively increases with age and in the presence of diabetes for any combination of gender and stress type. Survival tree analysis confirmed that long-term prognosis considerably varies according of risk factors profile. CONCLUSIONS Low-dose normal stress-only WBR MPS has a reliable long-term prognostic value in patients with suspected or known CAD. This finding supports the introduction of such a method into clinical practice with a consistent dose optimization in the interest of patients and exposed staff.
Collapse
Affiliation(s)
- Carmela Nappi
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Wanda Acampa
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
- Institute of Biostructure and Bioimaging, National Council of Research, Naples, Italy
| | | | - Stefania Daniele
- Institute of Biostructure and Bioimaging, National Council of Research, Naples, Italy
| | - Emilia Zampella
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Roberta Assante
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Valeria Gaudieri
- Institute of Biostructure and Bioimaging, National Council of Research, Naples, Italy
| | - Teresa Mannarino
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Mario Petretta
- Department of Translational Medical Sciences, University Federico II, Naples, Italy
| | - Alberto Cuocolo
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy.
| |
Collapse
|
15
|
Small GR, Ruddy TD. Are there any guarantees with the warranty period for normal stress SPECT myocardial perfusion imaging? J Nucl Cardiol 2020; 27:542-546. [PMID: 29948898 DOI: 10.1007/s12350-018-1334-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 06/01/2018] [Indexed: 01/27/2023]
Affiliation(s)
- Gary R Small
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Terrence D Ruddy
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada.
| |
Collapse
|
16
|
Acampa W, Rozza F, Zampella E, Assante R, Mannarino T, Nappi C, Mainolfi C, Petretta M, Trimarco B, Cuocolo A. Warranty period of normal stress myocardial perfusion imaging in hypertensive patients: A parametric survival analysis. J Nucl Cardiol 2020; 27:534-541. [PMID: 29679222 DOI: 10.1007/s12350-018-1285-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 04/11/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND We evaluated the warranty period of a normal stress myocardial perfusion single-photon emission computed tomography (MPS) in hypertensive patients. METHODS AND RESULTS A total of 471 consecutive hypertensive patients with suspected coronary artery disease and normal perfusion at stress MPS were followed for a mean of 76 ± 21 months. Endpoint events were cardiac death or nonfatal myocardial infarction. With Cox analysis, age (hazard ratio 1.1, P < .005) and stress test type (hazard ratio 2.7, P < .005) were independent predictors of events. With parametric Weibull analysis, patients ≤60 years old undergoing exercise stress test remained at low risk for the entire length of follow-up, while the highest probability of events and the major risk acceleration were observed in those > 60 years old who underwent pharmacologic stress test. In patients undergoing exercise test, peak systolic blood pressure (BP; hazard ratio 1.1, P < .005) emerged as predictor of events, and only subjects with peak systolic BP < 160 mmHg remained at low risk for the entire length of follow-up. In contrast, for patients with peak systolic BP ≥180 mmHg, the time to achieve a cumulative cardiac risk level of 3% was 18 months. CONCLUSIONS In hypertensive patients, the warranty period of a normal stress MPS varies according to stress type and peak systolic BP. A normal stress MPS can be considered reassuring in subjects ≤60 years old who performed exercise stress test and a peak systolic BP < 160 mmHg.
Collapse
Affiliation(s)
- Wanda Acampa
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
- Institute of Biostructure and Bioimaging, National Council of Research, Naples, Italy
| | - Francesco Rozza
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Emilia Zampella
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Roberta Assante
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Teresa Mannarino
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Carmela Nappi
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Ciro Mainolfi
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Mario Petretta
- Department of Translational Medical Sciences, University Federico II, Naples, Italy
| | - Bruno Trimarco
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Alberto Cuocolo
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy.
| |
Collapse
|
17
|
Whitman M, Padayachee C, Tilley P, Sear C, Rosanoff S, El Shinawi H, Manolis C, Jenkins C, Challa P. Scientist-led Exercise Testing Is Safe With Diagnostic Interpretation Equivalent to a Cardiologist. Crit Pathw Cardiol 2020; 19:14-17. [PMID: 31490210 DOI: 10.1097/hpc.0000000000000193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND The implementation of nonphysician-led exercise stress testing (EST) has increased over the last 30 years, with endorsement by many cardiovascular societies around the world. The comparable safety of nonphysician-led EST to physician-led studies has been demonstrated, with some studies also showing agreement in diagnostic preliminary interpretations. OBJECTIVE The study aim was to firstly confirm the safety of nonphysician-led EST in a large cohort and secondly compare the interobserver agreement and diagnostic accuracy of cardiac scientist and junior medical officer (JMO)-led EST reports to cardiology consultant overreads. METHODS All ESTs performed between 1/7/2010 and 30/6/2013 were included in the study for JMO led tests (n = 1332). ESTs performed for the investigation of coronary artery disease between 1/7/2013 and 30/6/2016 were included for scientist-led testing (n = 1904). RESULTS There was one adverse event, an ST segment myocardial infarction during the recovery phase of a JMO-led EST. Interobserver agreement was superior between the cardiologist and the scientist compared with the cardiologist and the JMO (P < 0.0001). Sensitivity for JMO-led tests differed from the cardiologist overread (86.96% vs. 96.77%, P = 0.03). There were no other significant differences between the cardiologist overread and the JMO- or scientist-led interpretation. CONCLUSIONS Scientist-led EST is safe in intermediate risk patients and their preliminary reports are equally diagnostic as cardiologist overreads. While JMO-led ESTs are just as safe, the preliminary reports differ significantly from cardiologist overread particularly with respect to sensitivity.
Collapse
Affiliation(s)
- Mark Whitman
- From the Cardiac Investigations Unit, Logan Hospital, Meadowbrook, Australia
- Menzies Health Institute, Queensland, Australia
- School of Human Movement and Nutrition Sciences, University of Queensland, Brisbane, Australia
| | - Cliantha Padayachee
- From the Cardiac Investigations Unit, Logan Hospital, Meadowbrook, Australia
| | - Prue Tilley
- From the Cardiac Investigations Unit, Logan Hospital, Meadowbrook, Australia
| | - Casey Sear
- From the Cardiac Investigations Unit, Logan Hospital, Meadowbrook, Australia
| | - Shelley Rosanoff
- From the Cardiac Investigations Unit, Logan Hospital, Meadowbrook, Australia
| | - Hadeir El Shinawi
- From the Cardiac Investigations Unit, Logan Hospital, Meadowbrook, Australia
| | - Christiana Manolis
- From the Cardiac Investigations Unit, Logan Hospital, Meadowbrook, Australia
| | - Carly Jenkins
- From the Cardiac Investigations Unit, Logan Hospital, Meadowbrook, Australia
| | - Prasad Challa
- From the Cardiac Investigations Unit, Logan Hospital, Meadowbrook, Australia
| |
Collapse
|
18
|
Romero-Farina G, Candell-Riera J, Aguadé-Bruix S, García Dorado D. A novel clinical risk prediction model for myocardial infarction, coronary revascularization, and cardiac death according to clinical, exercise, and gated SPECT variables (VH-RS). Eur Heart J Cardiovasc Imaging 2020; 21:210-221. [PMID: 31049558 DOI: 10.1093/ehjci/jez078] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 04/02/2019] [Indexed: 01/11/2023] Open
Abstract
AIMS To create a risk score for cardiac events (CE) according to clinical, exercise, and gated SPECT variables. METHODS AND RESULTS We analysed 5707 consecutive patients; 3181 patients (age 64.2 ± 11 years, male 59.6%) with suspected coronary artery disease (CAD) [without previous myocardial infarction (MI) or coronary revascularization (CR)] and 2526 patients (age 63.3 ± 11 years, male 81.7%) with established CAD (with previous MI or CR). To create the Vall d'Hebron Risk Score (VH-RS), first we analyse the predictors of CE (non-fatal MI, CR, and/or cardiac death), then the probability of CE for every patient according to the predictive variables. According to risk we stratified patients into four risk levels: very low risk (VLR), low risk (LR), moderate risk (MR), and high risk (HRi) using Multiple Cox Regression analysis models. Finally, we validate the VH-RS in another prospective cohort of 734 patients. In patients with suspected CAD; age (P < 0.001); gender (P = 0.001); hyperlipidaemia (P < 0.001); nitrates (P = 0.04); ejection fraction (EF) (P = 0.001); summed stress score (P < 0.001); METs (P < 0.001); exercise angina (P = 0.006); and mm of ST segment depression (P = 0.004) were the independent predictors of CE (C-statistic: 0.8; P < 0.001). In patients with established CAD, EF (P < 0.001); summed difference score (P = 0.001); age (P < 0.001); smoker (P = 0.002); nitrates (P = 0.003); exercise angina (P = 0.001); METs (P < 0.001); and mm of ST segment depression (P = 0.011) were the independent predictors of CE (C-statistic: 0.7; P < 0.001). The risk score obtained from these variables allows the stratification of patients into four risk levels: VLR, LR, MR, and HRi. CONCLUSIONS The cardiac risk stratification by mean of clinical, exercise, and gated SPECT variables is an objective aid to assessing an individual's cardiac risk.
Collapse
Affiliation(s)
- Guillermo Romero-Farina
- Cardiology Department, Hospital Universitari Vall d'Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Paseo Vall d'Hebron 119-129, Barcelona 08035, Spain.,Department of Nuclear Medicine, Hospital Universitari Vall d'Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Paseo Vall d'Hebron 119-129, Barcelona 08035, Spain
| | - Jaume Candell-Riera
- Cardiology Department, Hospital Universitari Vall d'Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Paseo Vall d'Hebron 119-129, Barcelona 08035, Spain
| | - Santiago Aguadé-Bruix
- Department of Nuclear Medicine, Hospital Universitari Vall d'Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Paseo Vall d'Hebron 119-129, Barcelona 08035, Spain
| | - David García Dorado
- Cardiology Department, Hospital Universitari Vall d'Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Paseo Vall d'Hebron 119-129, Barcelona 08035, Spain
| |
Collapse
|
19
|
Cho SG, Kim J, Song HC. Debates over NICE Guideline Update: What Are the Roles of Nuclear Cardiology in the Initial Evaluation of Stable Chest Pain? Nucl Med Mol Imaging 2019; 53:301-312. [PMID: 31723359 PMCID: PMC6821897 DOI: 10.1007/s13139-019-00607-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/12/2019] [Accepted: 08/19/2019] [Indexed: 12/12/2022] Open
Abstract
Recent clinical trials have demonstrated the values of cardiac computed tomography (CT) in the initial evaluation of stable chest pain which led to drastic changes in the National Institute for Health and Care Excellence (NICE) guidelines in 2016. According to the updated NICE guidelines, cardiac CT should be performed as the initial cardiac testing in stable chest pain regardless of pre-test probability (PTP) of coronary artery disease (CAD). As a result, cardiac CT is now considered as a validated gatekeeper for assessing stable chest pain, which precedes all the functional studies including nuclear myocardial perfusion imaging (MPI). Nuclear MPI, in contrast, has been assigned as one of the second-line studies, which is inevitably dependent on the results of cardiac CT. However, nuclear MPI has genuine values in the diagnosis, treatment decision, and prognostic stratification of stable chest pain, which cannot be replaced by cardiac CT. In this review, the updated NICE guidelines and related cardiac CT trials will be critically reviewed from the view of nuclear physicians and the exceptional values of nuclear MPI will be described along with the future perspectives.
Collapse
Affiliation(s)
- Sang-Geon Cho
- Department of Nuclear Medicine, Chonnam National University Hospital, 42, Jebong-ro, Dong-gu, Gwangju, 61469 South Korea
| | - Jahae Kim
- Department of Nuclear Medicine, Chonnam National University Hospital, 42, Jebong-ro, Dong-gu, Gwangju, 61469 South Korea
| | - Ho-Chun Song
- Department of Nuclear Medicine, Chonnam National University Hospital, 42, Jebong-ro, Dong-gu, Gwangju, 61469 South Korea
| |
Collapse
|
20
|
Whitman M, Jenkins C, Sabapathy S, Adams L. Comparison of heart rate reserve, age predicted maximum heart rate and rate pressure product as predictors of future cardiovascular events following a negative dobutamine stress echocardiogram. Acta Cardiol 2019; 75:659-666. [PMID: 31442096 DOI: 10.1080/00015385.2019.1653566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Dobutamine stress echocardiography (DSE) is a commonly used diagnostic stress test for the assessment of various cardiac pathologies on patients unable to perform exercise. Unlike exercise, there is no reliable subjective termination end-point such as fatigue to rely on. Consequently, DSE's are often concluded at a predetermined age predicted maximal heart rate (APMHR) such as 85%. The aim of this study was to assess if APMHR, heart rate reserve (HRR) and the maximum rate pressure product (MRPP) are valid measures of future cardiovascular (CV) events in otherwise negative DSEs. Methods: Following exclusions, receiver operating curve (ROC) analyses were performed on 652 patients using CV events during the follow-up period (4.2 ± 1.8 years) as the outcome variable. Results: ROC analyses failed to produce a statistically valid model for MRPP (p = .227, area under curve (AUC)=0.55) with a sensitivity and specificity of 21.1% and 91.9%, respectively at the optimal cut point (14948 MRPP). To the contrary, APMHR produced a sensitivity and specificity of 74.7% and 60.9%, respectively (p < .0001, AUC = 0.715). HRR however, with a sensitivity and specificity of 67.4% and 68.2% (p < .0001, AUC = 0.718) was the only predictor of CV events following Cox analysis (p < .0001). Conclusions: This study demonstrates MRPP as a poor measure of CV event prediction during DSE. While an APMHR of 89.3% demonstrated a statistically valid model, HRR was the only predictor of CV events in otherwise negative DSEs.
Collapse
Affiliation(s)
- Mark Whitman
- Cardiac Investigations Unit, Logan Hospital, Meadowbrook, Australia
- Menzies Health Institute, Gold Coast, Australia
- Department of Human Movement and Nutrition Sciences, University of Queensland, Brisbane, Australia
| | - Carly Jenkins
- Cardiac Investigations Unit, Logan Hospital, Meadowbrook, Australia
| | - Surendran Sabapathy
- Menzies Health Institute, Gold Coast, Australia
- Allied Health Sciences, Griffith University, Gold Coast, Australia
| | - Lewis Adams
- Menzies Health Institute, Gold Coast, Australia
- Allied Health Sciences, Griffith University, Gold Coast, Australia
| |
Collapse
|
21
|
Finck T, Hardenberg J, Will A, Hendrich E, Haller B, Martinoff S, Hausleiter J, Hadamitzky M. 10-Year Follow-Up After Coronary Computed Tomography Angiography in Patients With Suspected Coronary Artery Disease. JACC Cardiovasc Imaging 2019; 12:1330-1338. [DOI: 10.1016/j.jcmg.2018.07.020] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/10/2018] [Accepted: 07/23/2018] [Indexed: 11/25/2022]
|
22
|
Petretta M, Acampa W, Assante R, Zampella E, Nappi C, Petretta A, Cuocolo A. My warranty has expired: I need to be retested. J Nucl Cardiol 2019; 26:998-1006. [PMID: 29327253 DOI: 10.1007/s12350-017-1154-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 11/30/2017] [Indexed: 02/03/2023]
Abstract
The concept of warranty period, the duration of time during which the patient's risk remains low, is appealing. However, some points remain to be resolved before its translation in the clinical arena. Methodological issues should be standardized in order to compare the results of studies in different patient populations. Also, the definition of a "normal" study should always take into consideration the history of prior revascularization, the achieved level of exercise, and the stressor used. The promise of warranty can be questioned by the patient's baseline demographic and clinical characteristics and may also be influenced by life-style modification in the course of the follow-up. The "warranty period" concept should shift from data reflecting the time to a cardiac event to the development of ischemia, given an opportunity for intervention before a cardiac event occurs. In this context, clarify the role of serial imaging can be extremely useful, in particular to evaluate if and when retesting a patient after a normal scan.
Collapse
Affiliation(s)
- Mario Petretta
- Department of Translational Medical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Wanda Acampa
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
- Institute of Biostructure and Bioimaging, National Council of Research, Naples, Italy
| | - Roberta Assante
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Emilia Zampella
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Carmela Nappi
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Andrea Petretta
- Department of Arrhythmology, Maria Cecilia Hospital, GVM Care and Research, Cotignola, Italy
| | - Alberto Cuocolo
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy.
| |
Collapse
|
23
|
Whitman M, Sabapathy S, Jenkins C, Adams L. Is downstream cardiac testing required in patients with reduced functional capacity and otherwise negative exercise stress test? A single center observational study. Cardiol J 2018; 26:753-760. [PMID: 30234905 DOI: 10.5603/cj.a2018.0099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 07/05/2018] [Accepted: 07/07/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Exercise stress testing (EST) in patients with poor functional capacity measured by time on treadmill is typically deemed inconclusive and usually leads to further downstream testing. The aim of this study was firstly to evaluate the maximum rate pressure product (MRPP) during initial EST to assessthe need for follow-up testing; and secondly to investigate if MRPP is better than age predicted maximum heart rate (APMHR) for diagnostic outcome based on follow up cardiovascular (CV) events in patients with inconclusive EST due to poor functional capacity. METHODS From a total of 2761 tests performed, 236 tests were considered inconclusive due to poor functional capacity which were available for analysis. From receiver operating characteristic (ROC) analysis, a cut-off value for MRPP of 25000 was chosen using CV events as the outcome measure (sensitivity 97%, specificity 45%). Cases were then categorised into those with an MRPP > 25000 and < 25000. RESULTS Regardless of treadmill time, any patient attaining an MRPP > 25000 had no abnormal downstream testing or CV events at 2 years follow-up. On ROC analysis MRPP outperformed APMHR for sensitivity and specificity (area under curve 0.76 vs. 0.59, respectively). CONCLUSIONS The results suggest that regardless of functional capacity, individuals whose EST is terminated at maximal fatigue, with no electrocardiogram evidence or symptoms of myocardial ischemia and yields an MRPP > 25000, do not require further downstream testing. Furthermore, this group of patients, while not immune to future CV events, have significantly better outcomes than those not attaining a MRPP > 25000.
Collapse
Affiliation(s)
- Mark Whitman
- Griffith University, Gold Coast, 4215 Southport, Australia. .,QLD Health, Logan Hospital, 4131 Meadowbrook, Australia.
| | | | - Carly Jenkins
- QLD Health, Logan Hospital, 4131 Meadowbrook, Australia
| | - Lewis Adams
- Griffith University, Gold Coast, 4215 Southport, Australia
| |
Collapse
|
24
|
Myocardial Perfusion in Rheumatoid Arthritis Patients: Associations with Traditional Risk Factors and Novel Biomarkers. BIOMED RESEARCH INTERNATIONAL 2017; 2017:6509754. [PMID: 28553649 PMCID: PMC5434312 DOI: 10.1155/2017/6509754] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 04/02/2017] [Indexed: 12/16/2022]
Abstract
Introduction. Cardiovascular (CV) diseases are a major cause of death in rheumatoid arthritis (RA) patients. Novel biomarkers [B-type natriuretic peptide (BNP); osteoprotegerin (OPG)/receptor activator of nuclear factor-kappa B ligand (RANKL) ratio; and dickkopf-1 (DKK-1)] have been used in CV risk assessment. We analysed, in established RA patients, the presence of silent myocardial ischemia and its association with clinical variables, BNP, and bone and atheroma biomarkers. Methods. From a single-center tertiary referral hospital, RA patients asymptomatic for CV disease were submitted to myocardial perfusion scintigraphy (MPS) under adenosine stress and biomarkers measurements. Logistic regression was used to estimate crude odds ratios (OR) and 95% confidence intervals (CI). Results. In 189 patients, perfusion defects were frequent (25%) and associated with BNP ≥ 100 pg/mL (OR = 5.68; 95% CI: 2.038–15.830), fourth log OPG/RANKL ratio quartile (OR = 2.88; 95% CI: 1.091–7.622), and DKK-1 ≥ 133 pmol/L (OR = 2.69; 95% CI: 1.058–6.840). Similar associations were confirmed in those with C-reactive protein > or ≤ 3 mg/L. No relationship was found with the majority of traditional CV factors nor with disease variables. Conclusions. Our results corroborated the hypothesis that MPS could reveal subclinical CV dysfunction, supported the utility of BNP measurements as a screening tool, and put in perspective the potential usefulness of complementary approaches in CV risk assessment in RA patients.
Collapse
|
25
|
Standbridge K, Reyes E. The role of pharmacological stress testing in women. J Nucl Cardiol 2016; 23:997-1007. [PMID: 27515346 DOI: 10.1007/s12350-016-0602-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 05/16/2016] [Accepted: 05/16/2016] [Indexed: 11/24/2022]
Abstract
Pharmacological stress is an alternative method to dynamic exercise that combined with noninvasive imaging allows the detection of flow-limiting coronary artery disease (CAD). It represents the stress procedure of choice in patients who cannot exercise appropriately. In women, pharmacological stress combined with myocardial perfusion scintigraphy (MPS) has demonstrated to be highly accurate for the detection of obstructive CAD and a valuable tool that helps separate patients at low cardiac risk from those with an adverse prognosis. Pharmacological stress with positron emission tomographic (PET) imaging is increasingly used in the investigation of suspected obstructive CAD; available evidence shows that the diagnostic profile and prognostic value of stress PET imaging is similar to that of stress MPS in women.
Collapse
Affiliation(s)
- Katherine Standbridge
- Nuclear Medicine Department, Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London, SW3 6NP, United Kingdom
| | - Eliana Reyes
- Nuclear Medicine Department, Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London, SW3 6NP, United Kingdom.
| |
Collapse
|
26
|
López-Fernández T, Saura D, Rodríguez-Palomares JF, Aguadé-Bruix S, Pérez de Isla L, Barba-Cosials J. Selección de temas de actualidad en imagen cardiaca 2015. Rev Esp Cardiol 2016. [DOI: 10.1016/j.recesp.2015.10.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
|
27
|
López-Fernández T, Saura D, Rodríguez-Palomares JF, Aguadé-Bruix S, Pérez de Isla L, Barba-Cosials J. Cardiac Imaging 2015: A Selection of Topical Issues. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2016; 69:286-93. [PMID: 26752219 DOI: 10.1016/j.rec.2015.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 10/03/2015] [Indexed: 01/22/2023]
Affiliation(s)
| | - Daniel Saura
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - José F Rodríguez-Palomares
- Servicio de Cardiología, Hospital Universitari Vall d'Hebron, Institut de Recerca-VHIR, Universitat Autónoma de Barcelona, Barcelona, Spain
| | | | | | - Joaquín Barba-Cosials
- Departamento de Cardiología, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
| |
Collapse
|
28
|
Zellweger MJ. Looking at the whole picture. J Nucl Cardiol 2015; 22:901-2. [PMID: 25762034 DOI: 10.1007/s12350-015-0085-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 01/26/2015] [Indexed: 12/12/2022]
Affiliation(s)
- Michael J Zellweger
- Cardiology Department, University Hospital, Petersgraben 4, 4031, Basel, Switzerland.
| |
Collapse
|
29
|
|
30
|
Rodríguez-Palomares JF, Aguadé-Bruix S. Nuclear cardiology: role in the world of multimodality cardiac imaging. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2015; 68:460-464. [PMID: 25944190 DOI: 10.1016/j.rec.2015.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 03/04/2015] [Indexed: 06/04/2023]
Affiliation(s)
- José F Rodríguez-Palomares
- Servei de Cardiologia, Hospital Vall d'Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain.
| | | |
Collapse
|
31
|
Shaw LJ. Does a test impact on a patient's life many years from now? J Nucl Cardiol 2015; 22:55-6. [PMID: 25138426 DOI: 10.1007/s12350-014-9974-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 08/04/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Leslee J Shaw
- Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, 1462 Clifton Road NE, Room 529, Atlanta, GA, USA,
| |
Collapse
|