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Alam L, Omar AMS, Patel KK. Improved Performance of PET Myocardial Perfusion Imaging Compared to SPECT in the Evaluation of Suspected CAD. Curr Cardiol Rep 2023; 25:281-293. [PMID: 36826689 DOI: 10.1007/s11886-023-01851-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/13/2023] [Indexed: 02/25/2023]
Abstract
PURPOSE OF REVIEW Myocardial perfusion imaging (MPI) with single photon emission computed tomography (SPECT) has played a central role in the non-invasive evaluation of patients with obstructive coronary artery disease (CAD) for decades. In this review, we discuss the key differences and advantages of positron emission tomography (PET) MPI over SPECT MPI as it relates to the diagnosis, prognosis, as well as clinical decision-making in patients with suspected CAD. RECENT FINDINGS Stress-induced perfusion abnormalities on SPECT help estimate presence, extent, and location of ischemia and flow-limiting obstructive CAD, help with risk stratification, and serve as a gatekeeper to identify patients who will benefit from downstream revascularization versus medical management. Some of the major limitations of SPECT include soft-tissue attenuation artifacts, underestimation of ischemia due to reliance on relative perfusion assessment, and longer protocols with higher radiation dose when performed with traditional equipment. PET MPI addresses most of these limitations and offers better quality images, higher diagnostic accuracy along with shorter protocols and lower radiation dose to the patient. A special advantage of PET scanning lies in the ability to quantify absolute myocardial blood flow and assess true extent of epicardial involvement along with identifying non-obstructive phenotypes of CAD such as diffuse atherosclerosis and microvascular dysfunction. In addition, stress acquisition at/near peak stress with PET allows us to measure left ventricular ejection fraction reserve and myocardial blood flow reserve, which help with identifying patients at a higher risk of future cardiac events and optimally select candidates for revascularization. The several technical advantages of PET MPI position as a superior method to diagnose obstructive and non-obstructive phenotypes of ischemic heart disease affecting the entirety of the coronary circulation offer incremental value for risk stratification and guide post-test management strategy for patients with suspected CAD.
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Affiliation(s)
- Loba Alam
- Department of Cardiology, Mount Sinai Morningside, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alaa Mabrouk Salem Omar
- Department of Cardiology, Mount Sinai Morningside, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Krishna K Patel
- Department of Cardiology, Mount Sinai Morningside, New York, NY, USA.
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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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: 54] [Impact Index Per Article: 27.0] [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.
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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.
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2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 78:2218-2261. [PMID: 34756652 DOI: 10.1016/j.jacc.2021.07.052] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM This executive summary of the 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 studies, 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. These guidelines present 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.
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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: 141] [Impact Index Per Article: 47.0] [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.
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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: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 144:e368-e454. [PMID: 34709928 DOI: 10.1161/cir.0000000000001030] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM This executive summary of the 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 studies, 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. These guidelines present 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.
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Martineau P, Slomka P, Goertzen A, Leslie WD. CRAX: A simple cardiovascular risk assessment tool to predict risk of acute myocardial infarction or death. J Nucl Cardiol 2020; 27:2365-2374. [PMID: 30535920 PMCID: PMC6565497 DOI: 10.1007/s12350-018-01556-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 11/21/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Determining the risk of cardiovascular events is essential to optimize patient management. METHODS AND RESULTS 5842 individuals underwent SPECT myocardial perfusion imaging (MPI) with 4.4 ± 1.2 years of follow-up. Models (the CRAX tool) were derived to predict the cumulative risk of death and acute myocardial infarction (AMI) at 1, 3, and 5 years using clinical and MPI variables. Predictors of AMI and death included age, number of hospitalizations in the 3 years preceding MPI, and left ventricular ejection fraction (LVEF). Additional predictors of death were the use of pharmacological stress, and global stress total perfusion deficit (sTPD), while transient ischemic dilation (TID), and ischemic total perfusion deficit (iTPD) change were predictive of AMI. CRAX predictions were significantly (P < .001) more accurate than clinical variables or MPI results alone, resulting in a significant net reclassification improvement (NRI, 7.5% for AMI, 14.5% death) compared to clinical variables alone. Accuracy for predicting major adverse cardiac events (MACE, comprising all-cause death, AMI, unstable angina, late revascularization) was comparable to that of AMI or death. CONCLUSIONS CRAX is a risk assessment tool that predicts the risk of AMI, death, or MACE, and improves prediction compared to clinical variables or MPI results alone.
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Affiliation(s)
- Patrick Martineau
- Department of Nuclear Medicine, University of Manitoba, 820 Sherbrook Street GC321, Winnipeg, MB, R3A 1R9, Canada
- Gordon Center for Medical Imaging, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Piotr Slomka
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Andrew Goertzen
- Department of Nuclear Medicine, University of Manitoba, 820 Sherbrook Street GC321, Winnipeg, MB, R3A 1R9, Canada
| | - William D Leslie
- Department of Nuclear Medicine, University of Manitoba, 820 Sherbrook Street GC321, Winnipeg, MB, R3A 1R9, Canada.
- Department of Internal Medicine, University of Manitoba, C5121-409 Tache Ave, Winnipeg, MB, R2H 2A6, Canada.
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Abidov A, Chehab O. Cardiovascular risk assessment models: Have we found the perfect solution yet? J Nucl Cardiol 2020; 27:2375-2385. [PMID: 30793251 DOI: 10.1007/s12350-019-01642-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 01/28/2019] [Indexed: 12/27/2022]
Affiliation(s)
- Aiden Abidov
- Division of Cardiology/Department of Internal Medicine, Wayne State University, Detroit, MI, USA.
- Cardiology Section/Department of Internal Medicine, John D. Dingell VA Medical Center, 4646 John R., Detroit, MI, 48201, USA.
| | - Omar Chehab
- Division of Cardiology/Department of Internal Medicine, Wayne State University, Detroit, MI, USA
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Ganyukov V, Kochergin N, Shilov A, Tarasov R, Skupien J, Szot W, Kokov A, Popov V, Kozyrin K, Barbarash O, Barbarash L, Musialek P. Randomized Clinical Trial of Surgical vs. Percutaneous vs. Hybrid Revascularization in Multivessel Coronary Artery Disease: Residual Myocardial Ischemia and Clinical Outcomes at One Year-Hybrid coronary REvascularization Versus Stenting or Surgery (HREVS). J Interv Cardiol 2020; 2020:5458064. [PMID: 31969796 PMCID: PMC6961598 DOI: 10.1155/2020/5458064] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 09/09/2019] [Indexed: 11/17/2022] Open
Abstract
AIM Optimal revascularization strategy in multivessel (MV) coronary artery disease (CAD) eligible for percutaneous management (PCI) and surgery remains unresolved. We evaluated, in a randomized clinical trial, residual myocardial ischemia (RI) and clinical outcomes of MV-CAD revascularization using coronary artery bypass grafting (CABG), hybrid coronary revascularization (HCR), or MV-PCI. METHODS Consecutive MV-CAD patients (n = 155) were randomized (1 : 1 : 1) to conventional CABG (LIMA-LAD plus venous grafts) or HCR (MIDCAB LIMA-LAD followed by PCI for remaining vessels) or MV-PCI (everolimus-eluting CoCr stents) under Heart Team agreement on equal technical and clinical feasibility of each strategy. SPECT at 12 months (primary endpoint of RI that the trial was powered for; a measure of revascularization midterm efficacy and an independent predictor of long-term prognosis) preceded routine angiographic control. RESULTS Data are given, respectively, for the CABG, HCR, and MV-PCI arms. Incomplete revascularization rate was 8.0% vs. 7.7% vs. 5.7% (p=0.71). Hospital stay was 13.8 vs. 13.5 vs. 4.5 days (p < 0.001), and sick-leave duration was 23 vs. 16 vs. 8 weeks (p < 0.001). At 12 months, RI was 5 (2, 9)% vs. 5 (3, 7)% vs. 6 (3, 10)% (median; Q1, Q3) with noninferiority p values of 0.0006 (HCR vs. CABG) and 0.016 (MV-PCI vs. CABG). Rates of angiographic graft stenosis/occlusion or in-segment restenosis were 20.4% vs. 8.2% vs. 5.9% (p=0.05). Clinical target vessel/graft failure occurred in 12.0% vs. 11.5% vs. 11.3% (p=0.62). Major adverse cardiac and cerebral event (MACCE) rate was similar (12% vs. 13.4% vs. 13.2%; p=0.83). CONCLUSION In this first randomized controlled study comparing CABG, HCR, and MV-PCI, residual myocardial ischemia and MACCE were similar at 12 months. There was no midterm indication of any added value of HCR. Hospital stay and sick-leave duration were shortest with MV-PCI. While longer-term follow-up is warranted, these findings may impact patient and physician choices and healthcare resources utilization. This trial is registered with NCT01699048.
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Affiliation(s)
- Vladimir Ganyukov
- Federal State Budgetary Institution “Research Institute for Complex Issues of Cardiovascular Diseases”, Kemerovo, Russia
| | - Nikita Kochergin
- Federal State Budgetary Institution “Research Institute for Complex Issues of Cardiovascular Diseases”, Kemerovo, Russia
| | - Aleksandr Shilov
- Federal State Budgetary Institution “Research Institute for Complex Issues of Cardiovascular Diseases”, Kemerovo, Russia
| | - Roman Tarasov
- Federal State Budgetary Institution “Research Institute for Complex Issues of Cardiovascular Diseases”, Kemerovo, Russia
| | - Jan Skupien
- Jagiellonian University School of Medicine, Krakow, Poland
| | - Wojciech Szot
- Jagiellonian University School of Medicine, Krakow, Poland
- Dept. of Nuclear Medicine, John Paul II Hospital, Krakow, Poland
| | - Aleksandr Kokov
- Federal State Budgetary Institution “Research Institute for Complex Issues of Cardiovascular Diseases”, Kemerovo, Russia
| | - Vadim Popov
- Federal State Budgetary Institution A. V. Vishnevsky Institute of Surgery, Moscow, Russia
| | - Kirill Kozyrin
- Federal State Budgetary Institution “Research Institute for Complex Issues of Cardiovascular Diseases”, Kemerovo, Russia
| | - Olga Barbarash
- Federal State Budgetary Institution “Research Institute for Complex Issues of Cardiovascular Diseases”, Kemerovo, Russia
| | - Leonid Barbarash
- Federal State Budgetary Institution “Research Institute for Complex Issues of Cardiovascular Diseases”, Kemerovo, Russia
| | - Piotr Musialek
- Jagiellonian University School of Medicine, Krakow, Poland
- Jagiellonian University Dept. of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland
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Heber D, Hacker M. [Ischemic burden vs. coronary artery morphology : What is crucial for the indication of revascularization?]. Herz 2016; 41:376-83. [PMID: 27333984 DOI: 10.1007/s00059-016-4450-4] [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: 10/21/2022]
Abstract
Ischemic heart disease still represents the leading cause of death in the western world despite a decrease of mortality in the last decade. For the diagnostics of coronary artery morphology, invasive coronary angiography represents the gold standard. Nevertheless, in recent years the importance of functional diagnostics of the coronary arteries has increased and various imaging procedures for the measurement of fractional flow reserve (FFR) during coronary angiography were established and recommended for ischemia testing in the actual guidelines on myocardial revascularization.Imaging modalities for diagnostics of the functional relevance of coronary artery disease include stress echocardiography, magnetic resonance imaging (MRI), single photon emission computed tomography (SPECT), and positron emission tomography (PET). These procedures enable advanced risk stratification and therapy guiding in patients with suspected or known coronary artery disease. In future algorithms, hybrid imaging may facilitate the determination of anatomical and functional aspects after only one investigation.In the present article, the role of ischemia testing is compared with morphological methods for the diagnosis of coronary artery disease, individual risk stratification, and therapy guiding.
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Affiliation(s)
- D Heber
- Klinische Abteilung für Nuklearmedizin, Universitätsklinik für Radiologie und Nuklearmedizin, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - M Hacker
- Klinische Abteilung für Nuklearmedizin, Universitätsklinik für Radiologie und Nuklearmedizin, Währinger Gürtel 18-20, 1090, Wien, Österreich.
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Koh AS, Gao F, Chin CT, Keng FYJ, Tan RS, Chua TSJ. Differential risk reclassification improvement by exercise testing and myocardial perfusion imaging in patients with suspected and known coronary artery disease. J Nucl Cardiol 2016; 23:366-78. [PMID: 26358085 DOI: 10.1007/s12350-015-0253-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 07/25/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The objective of this study is to compare the incremental prognostic and net risk reclassification value of exercise testing alone vs exercise myocardial perfusion imaging (MPI) for estimating the risk of death in patients with suspected and known coronary artery disease (CAD). METHODS 6702 patients with suspected CAD and 2008 with known CAD had treadmill exercise MPI and were followed for 2.5 ± 0.9 years for the occurrence of all-cause death. The estimation of risk of death and net reclassification improvement (NRI) were examined in three models. Model 1: clinical variables; Model 2: model 1+Duke Treadmill Score; and Model 3: model 2+ MPI variables. Risk estimates were categorized as <1%, 1-3%, and >3% risk of death per year. RESULTS In patients with suspected CAD, the global Chi-square for predicting risk of death increased significantly for Model 2 compared to Model 1 (74.78 vs 63.86 to (P = .001). However, adding MPI variables in Model 3 did not further improve predictive value (Chi-square 79.38, P = .10). In patients with suspected CAD risk, reclassification improved significantly in Model 2 over Model 1 (NRI = 0.12, 95% CI 0.02 to 0.22, P = .019), but not in Model 3 (NRI = 0.0009, 95% CI -0.072 to 0.070; P = .98). In contrast, in patients with known CAD Model 2 did not yield significant improvements for predicting risk and risk reclassification compared to Model 1. However, global Chi-square of Model 3 was significantly higher than that of Model 2 (30.03 vs 6.56, P < .0001) with associated significant reclassification improvement (NRI = 0.26 95% CI 0.067 to 0.46. P = .0084). CONCLUSION Risk reclassification by diagnostic testing is importantly influenced by baseline characteristics of patient cohorts. In patients with suspected CAD, NRI is predominately achieved by exercise variables, whereas in patients with known CAD, greatest NRI is obtained by MPI variables.
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Affiliation(s)
- Angela S Koh
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore.
- Duke-NUS Graduate Medical School, Singapore, Singapore.
| | - Fei Gao
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore
- Duke-NUS Graduate Medical School, Singapore, Singapore
| | - C T Chin
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore
- Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Felix Y J Keng
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore
| | - Ru-San Tan
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore
- Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Terrance S J Chua
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore
- Duke-NUS Graduate Medical School, Singapore, Singapore
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12
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Eshtehardi P, Isiadinso I, Shaw LJ. The benefits of advanced risk reclassification. J Nucl Cardiol 2016; 23:384-6. [PMID: 26396024 DOI: 10.1007/s12350-015-0282-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 08/20/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Parham Eshtehardi
- Division of Cardiology, Emory Clinical Cardiovascular Research Institute (ECCRI), Emory University School of Medicine, 1462 Clifton Rd NE, Room 529, Atlanta, GA, 30324, USA
| | - Ijeoma Isiadinso
- Division of Cardiology, Emory Clinical Cardiovascular Research Institute (ECCRI), Emory University School of Medicine, 1462 Clifton Rd NE, Room 529, Atlanta, GA, 30324, USA
| | - Leslee J Shaw
- Division of Cardiology, Emory Clinical Cardiovascular Research Institute (ECCRI), Emory University School of Medicine, 1462 Clifton Rd NE, Room 529, Atlanta, GA, 30324, USA.
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13
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Lee DS, Husain M, Wang X, Austin PC, Iwanochko RM. Cardiovascular outcomes after pharmacologic stress myocardial perfusion imaging. Am Heart J 2016; 174:138-46. [PMID: 26995380 DOI: 10.1016/j.ahj.2016.01.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 01/16/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND While pharmacologic stress single photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) is used for noninvasive evaluation of patients who are unable to perform treadmill exercise, its impact on net reclassification improvement (NRI) of prognosis is unknown. METHODS We evaluated the prognostic value of pharmacologic stress MPI for prediction of cardiovascular death or non-fatal myocardial infarction (MI) within 1 year at a single-center, university-based laboratory. We examined continuous and categorical NRI of pharmacologic SPECT-MPI for prediction of outcomes beyond clinical factors alone. RESULTS Six thousand two hundred forty patients (median age 66 years [IQR 56-74], 3466 men) were studied and followed for 5963 person-years. SPECT-MPI variables associated with increased risk of cardiovascular death or non-fatal MI included summed stress score, stress ST-shift, and post-stress resting left ventricular ejection fraction ≤50%. Compared to a clinical model which included age, sex, cardiovascular disease, risk factors, and medications, model χ(2) (210.5 vs. 281.9, P < .001) and c-statistic (0.74 vs. 0.78, P < .001) were significantly increased by addition of SPECT-MPI predictors (summed stress score, stress ST-shift and stress resting left ventricular ejection fraction). SPECT-MPI predictors increased continuous NRI by 49.4% (P < .001), reclassifying 66.5% of patients as lower risk and 32.8% as higher risk of cardiovascular death or non-fatal MI. Addition of MPI predictors to clinical factors using risk categories, defined as <1%, 1% to 3%, and >3% annualized risk of cardiovascular death or non-fatal MI, yielded a 15.0% improvement in NRI (95% CI 7.6%-27.6%, P < .001). CONCLUSIONS Pharmacologic stress MPI substantially improved net reclassification of cardiovascular death or MI risk beyond that afforded by clinical factors.
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Affiliation(s)
- Douglas S Lee
- Robert J. Burns Nuclear Cardiology Laboratory, University of Toronto, Toronto, Canada; Joint Department of Medical Imaging and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Canada; Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, Canada.
| | - Mansoor Husain
- Robert J. Burns Nuclear Cardiology Laboratory, University of Toronto, Toronto, Canada; Joint Department of Medical Imaging and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Canada; Ted Rogers Centre for Heart Research, University of Toronto, Toronto, Canada
| | - Xuesong Wang
- Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, Canada
| | - Peter C Austin
- Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, Canada
| | - Robert M Iwanochko
- Robert J. Burns Nuclear Cardiology Laboratory, University of Toronto, Toronto, Canada; Joint Department of Medical Imaging and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Canada
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14
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Cremer P, Hachamovitch R, Tamarappoo B. Clinical decision making with myocardial perfusion imaging in patients with known or suspected coronary artery disease. Semin Nucl Med 2015; 44:320-9. [PMID: 24948154 DOI: 10.1053/j.semnuclmed.2014.04.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Myocardial perfusion imaging (MPI) to diagnose coronary artery disease (CAD) is best performed in patients with intermediate pretest likelihood of disease; unfortunately, pretest likelihood is often overestimated, resulting in the inappropriate use of perfusion imaging. A good functional capacity often predicts low risk, and MPI for diagnosing CAD should be reserved for individuals with poor exercise capacity, abnormal resting electrocardiography, or an intermediate or high probability of CAD. With respect to anatomy-based testing, coronary CT angiography has a good negative predictive value, but stenosis severity correlates poorly with ischemia. Therefore decision making with respect to revascularization may be limited when a purely noninvasive anatomical test is used. Regarding perfusion imaging, the diagnostic accuracies of SPECT, PET, and cardiac magnetic resonance are similar, though fewer studies are available with cardiac magnetic resonance. PET coronary flow reserve may offer a negative predictive value sufficiently high to exclude severe CAD such that patients with mild to moderate reversible perfusion defects can forego invasive angiography. In addition, combined anatomical and perfusion-based imaging may eventually offer a definitive evaluation for diagnosing CAD, even in higher risk patients. Any remarkable findings on single-photon emission computed tomography and PET MPI studies are valuable for prognostication. Furthermore, assessment of myocardial blood flow with PET is particularly powerful for prognostication as it reflects the end result of many processes that lead to atherosclerosis. Decision making with respect to revascularization is limited for cardiac MRI and PET MPI. In contrast, retrospective radionuclide studies have identified an ischemic threshold, but randomized trials are needed. In patients with at least moderately reduced left ventricular systolic function, viable myocardium as assessed by PET or MRI, appears to identify patients who benefit from revascularization, but well-executed randomized trials are lacking.
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Affiliation(s)
- Paul Cremer
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Rory Hachamovitch
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Balaji Tamarappoo
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH.
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Miller TD, Askew JW, Herrmann J. Assessing clinical impact of myocardial perfusion studies: ischemia or other prognostic indicators? Curr Cardiol Rep 2014; 16:465. [PMID: 24585107 DOI: 10.1007/s11886-014-0465-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
One of the major strengths of nuclear myocardial perfusion imaging (MPI) is the robust prognostic databases from observational studies demonstrating significantly different outcomes in patients with low-risk vs high-risk scans. The severity of the MPI defect can be semi-quantitated using the summed stress score (SSS) and summed difference score (SDS). SSS is more strongly associated with mortality, whereas SDS is the better predictor of subsequent coronary angiography and revascularization. The strength of MPI variables as prognostic indicators decreases when adjusted for prognostically important clinical and stress test variables. Nonetheless, most studies of general patient populations have demonstrated that MPI adds incremental prognostic value to clinical and stress test information. In contrast to these positive results from observational studies, the application of MPI ischemia as a treatment guide in several recent trials (DIAD, WOMEN, COURAGE, BARI 2D, STICH) has largely failed to identify patient subsets with improved outcome. This issue will continue to be investigated in the ongoing PROMISE and ISCHEMIA trials.
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Affiliation(s)
- Todd D Miller
- Division of Cardiovascular Diseases and the Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA,
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Mieres JH, Gulati M, Bairey Merz N, Berman DS, Gerber TC, Hayes SN, Kramer CM, Min JK, Newby LK, Nixon JVI, Srichai MB, Pellikka PA, Redberg RF, Wenger NK, Shaw LJ. Role of noninvasive testing in the clinical evaluation of women with suspected ischemic heart disease: a consensus statement from the American Heart Association. Circulation 2014; 130:350-79. [PMID: 25047587 DOI: 10.1161/cir.0000000000000061] [Citation(s) in RCA: 181] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Shah S, Bellam N, Leipsic J, Berman DS, Quyyumi A, Hausleiter J, Achenbach S, Al-Mallah M, Budoff MJ, Cademartiri F, Callister TQ, Chang HJ, Chow BJW, Cury RC, Delago AJ, Dunning AL, Feuchtner GM, Hadamitzky M, Karlsberg RP, Kaufmann PA, Lin FY, Chinnaiyan KM, Maffei E, Raff GL, Villines TC, Gomez MJ, Min JK, Shaw LJ. Prognostic significance of calcified plaque among symptomatic patients with nonobstructive coronary artery disease. J Nucl Cardiol 2014; 21:453-66. [PMID: 24683047 PMCID: PMC4374635 DOI: 10.1007/s12350-014-9865-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 01/20/2014] [Indexed: 01/07/2023]
Abstract
BACKGROUND Coronary artery calcium (CAC) is a well-established predictor of clinical outcomes for population screening. Limited evidence is available as to its predictive value in symptomatic patients without obstructive coronary artery disease (CAD). The aim of the current study was to assess the prognostic value of CAC scores among symptomatic patients with nonobstructive CAD. METHODS From the COronary Computed Tomographic Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter (CONFIRM) registry, 7,200 symptomatic patients with nonobstructive CAD (<50% coronary stenosis) on coronary-computed tomographic angiography were prospectively enrolled and followed for a median of 2.1 years. Patients were categorized as without (0% stenosis) or with (>0% but <50% coronary stenosis) a luminal stenosis. CAC scores were calculated using the Agatston method. Univariable and multivariable Cox proportional hazard models were employed to estimate all-cause mortality and/or myocardial infarction (MI). Four-year death and death or MI rates were 1.9% and 3.3%. RESULTS Of the 4,380 patients with no luminal stenosis, 86% had CAC scores of <10 while those with a luminal stenosis had more prevalent and extensive CAC with 31.9% having a CAC score of ≥100. Among patients with no luminal stenosis, CAC was not predictive of all-cause mortality (P = .44). However, among patients with a luminal stenosis, 4-year mortality rates ranged from 0.8% to 9.8% for CAC scores of 0 to ≥400 (P < .0001). The mortality hazard was 6.0 (P = .004) and 13.3 (P < .0001) for patients with a CAC score of 100-399 and ≥400. In patients with a luminal stenosis, CAC remained independently predictive in all-cause mortality (P < .0001) and death or MI (P < .0001) in multivariable models containing CAD risk factors and presenting symptoms. CONCLUSIONS CAC allows for the identification of those at an increased hazard for death or MI in symptomatic patients with nonobstructive disease. From the CONFIRM registry, the extent of CAC was an independent estimator of long-term prognosis among symptomatic patients with luminal stenosis and may further define risk and guide preventive strategies in patients with nonobstructive CAD.
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Affiliation(s)
- Sana Shah
- Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA
| | - Naveen Bellam
- Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA
| | - Jonathon Leipsic
- Department of Radiology, St Paul’s Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Daniel S. Berman
- Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA
| | - Arshed Quyyumi
- Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA
| | - Jörg Hausleiter
- Division of Cardiology, Technische Universität München, Munich, Germany
| | | | - Mouaz Al-Mallah
- Department of Medicine, King Abdulaziz Cardiac Center, Riyadh, Saudi Arabia
| | | | - Fillippo Cademartiri
- Cardiovascular Imaging Unit, Giovanni XXIII Hospital, Monastier di Treviso, Italy
| | | | - Hyuk-Jae Chang
- Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea
| | - Benjamin J. W. Chow
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Ricardo C. Cury
- Baptist Hospital of Miami and Baptist Cardiac and Vascular Institute, Miami, FL
| | | | - Allison L. Dunning
- Department of Public Health and Medicine, Weill Cornell Medical College and the New York Presbyterian Hospital, New York, NY
| | - Gudrun M. Feuchtner
- Department of Radiology II, Innsbruck Medical University, Innsbruck, Austria
| | | | | | | | - Fay Y. Lin
- Department of Public Health and Medicine, Weill Cornell Medical College and the New York Presbyterian Hospital, New York, NY
| | | | - Erica Maffei
- Department of Medicine, Walter Reed Medical Center, Washington, DC
| | | | - Todd C. Villines
- Department of Medicine, Walter Reed Medical Center, Washington, DC
| | - Millie J. Gomez
- Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA
| | - James K. Min
- Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA
| | - Leslee J. Shaw
- Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA
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Cremer P, Hachamovitch R. Assessing the prognostic implications of myocardial perfusion studies: identification of patients at risk vs patients who may benefit from intervention? Curr Cardiol Rep 2014; 16:472. [PMID: 24585113 DOI: 10.1007/s11886-014-0472-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Stress myocardial perfusion imaging (MPI) has a well-established role in improving risk stratification. Recent analyses, compared with older data, suggest that the yield of stress MPI has decreased. In part, this trend relates to testing patients with heterogeneous, but improved, risk factor modification. In this setting, positron emission tomography with myocardial flow reserve enhances risk stratification as it reflects the end result of atherosclerosis. Recent studies have also emphasized the clinical impact of incremental risk stratification by assessing net reclassification improvement (NRI). Previous retrospective studies have favored an ischemic threshold to select patients that benefit from revascularization, but this finding has not been corroborated in randomized trials. However, no large randomized trial has directly tested a strategy of revascularization for patients with at least a moderate amount of ischemia at risk. Unfortunately, even when faced with a significantly abnormal MPI result, subsequent action is too often absent.
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Affiliation(s)
- Paul Cremer
- Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Desk J1-5 9500 Euclid Avenue, Cleveland, OH, 44915, USA
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Miller TD, Askew JW. Net Reclassification Improvement and Integrated Discrimination Improvement. Circ Cardiovasc Imaging 2013; 6:496-8. [DOI: 10.1161/circimaging.113.000797] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Todd D. Miller
- From the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - J. Wells Askew
- From the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
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20
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Incremental prognostic value of stress myocardial perfusion imaging in asymptomatic diabetic patients. Atherosclerosis 2013; 227:307-12. [PMID: 23375683 DOI: 10.1016/j.atherosclerosis.2013.01.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Revised: 01/10/2013] [Accepted: 01/10/2013] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Stress myocardial perfusion single-photon emission computed tomography (MPS) variables are robust estimators of prognosis. No data are available on the comparative ability of stress MPS risk markers using varied iterative and risk classification approaches in asymptomatic diabetic patients. We compared analytical approaches to estimate the added value of MPS variables in estimating coronary artery disease (CAD) outcomes in asymptomatic diabetic patients. We also evaluated the temporal characteristics of cardiac risk according to MPS findings. METHODS A total of 436 consecutive asymptomatic diabetic patients who underwent stress-rest gated MPS were prospectively enrolled. Multivariable Cox proportional hazards model was employed to estimate cardiac death and nonfatal myocardial infarction (MI). Risk reclassification was calculated and parametric survival analysis was used to predict time to events. RESULTS At multivariable analysis, post-stress left ventricular ejection fraction (LVEF) and stress MPS ischemia were independent predictors of CAD death or MI (both p < 0.01). The net reclassification improvement by adding MPS results to a model including pre-test CAD likelihood was 0.25 (95% confidence interval 0.06-0.44; p < 0.01). Parametric survival analysis showed the highest probability of CAD death or MI and the major risk acceleration in time in patients with stress MPS ischemia and post-stress LVEF ≤45%. CONCLUSION In asymptomatic diabetic patients, analytical approaches that establish the reclassification of events may serve for estimation of improved outcomes for stress MPS. Post-stress LVEF and stress-induced ischemia by gated MPS influence the temporal characteristic of the patient's risk at long-term follow-up.
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Shaw LJ. Cost-effectiveness and future implications for cardiovascular imaging. Can J Cardiol 2013; 29:350-7. [PMID: 23332968 DOI: 10.1016/j.cjca.2012.10.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 10/19/2012] [Accepted: 10/19/2012] [Indexed: 10/27/2022] Open
Abstract
This review highlights the current economic climate for health care and the evidentiary standards that are increasingly applied to appropriate use of cardiovascular imaging. Additionally, the evidence on cost efficiency and effectiveness is explored in this review. Ongoing multicentre registries and clinical trials will further enrich this evidence base with regard to value-based imaging strategies that provide enhanced effectiveness and efficiency resulting in improved patient outcomes.
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Affiliation(s)
- Leslee J Shaw
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia 30324, USA.
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23
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Dorbala S, Di Carli MF, Beanlands RS, Merhige ME, Williams BA, Veledar E, Chow BJW, Min JK, Pencina MJ, Berman DS, Shaw LJ. Prognostic value of stress myocardial perfusion positron emission tomography: results from a multicenter observational registry. J Am Coll Cardiol 2013; 61:176-84. [PMID: 23219297 PMCID: PMC3549438 DOI: 10.1016/j.jacc.2012.09.043] [Citation(s) in RCA: 147] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 09/10/2012] [Accepted: 09/16/2012] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The primary objective of this multicenter registry was to study the prognostic value of positron emission tomography (PET) myocardial perfusion imaging (MPI) and the improved classification of risk in a large cohort of patients with suspected or known coronary artery disease (CAD). BACKGROUND Limited prognostic data are available for MPI with PET. METHODS A total of 7,061 patients from 4 centers underwent a clinically indicated rest/stress rubidium-82 PET MPI, with a median follow-up of 2.2 years. The primary outcome of this study was cardiac death (n = 169), and the secondary outcome was all-cause death (n = 570). Net reclassification improvement (NRI) and integrated discrimination analyses were performed. RESULTS Risk-adjusted hazard of cardiac death increased with each 10% myocardium abnormal with mildly, moderately, or severely abnormal stress PET (hazard ratio [HR]: 2.3 [95% CI: 1.4 to 3.8; p = 0.001], HR: 4.2 [95% CI: 2.3 to 7.5; p < 0.001], and HR: 4.9 [95% CI: 2.5 to 9.6; p < 0.0001], respectively [normal MPI: referent]). Addition of percent myocardium ischemic and percent myocardium scarred to clinical information (age, female sex, body mass index, history of hypertension, diabetes, dyslipidemia, smoking, angina, beta-blocker use, prior revascularization, and resting heart rate) improved the model performance (C-statistic 0.805 [95% CI: 0.772 to 0.838] to 0.839 [95% CI: 0.809 to 0.869]) and risk reclassification for cardiac death (NRI 0.116 [95% CI: 0.021 to 0.210]), with smaller improvements in risk assessment for all-cause death. CONCLUSIONS In patients with known or suspected CAD, the extent and severity of ischemia and scar on PET MPI provided powerful and incremental risk estimates of cardiac death and all-cause death compared with traditional coronary risk factors.
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Affiliation(s)
- Sharmila Dorbala
- Brigham and Women's Hospital, Department of Radiology and Division of Cardiology, Noninvasive Cardiovascular Imaging Section, Boston, Massachusetts 02115, USA.
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Petretta M, Cuocolo A. Prediction models for risk classification in cardiovascular disease. Eur J Nucl Med Mol Imaging 2012; 39:1959-69. [PMID: 23053326 DOI: 10.1007/s00259-012-2254-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Accepted: 09/12/2012] [Indexed: 10/27/2022]
Abstract
Risk stratification is an increasingly important tool for the management of patients with different diseases and also for decision making in subjects not yet with overt disease but who are at risk of disease in the short or long term or during their lifetime. Careful risk assessment in the individual patient, based on clinical, laboratory and imaging data, can be helpful for making decisions about treatment or other prevention strategies. As regards cardiovascular disease, many models have been suggested and are available for the prediction of diagnosis and prognosis and there are several algorithms for risk prediction. However, current risk screening methods are not perfect. This review evaluates relative strengths and limitations of traditional and more recent methods for assessing the performance of prediction models.
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Affiliation(s)
- Mario Petretta
- Department of Internal Medicine, Cardiovascular and Immunological Sciences, University Federico II, Naples, Italy
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25
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Shaw LJ, Hage FG, Berman DS, Hachamovitch R, Iskandrian A. Prognosis in the era of comparative effectiveness research: where is nuclear cardiology now and where should it be? J Nucl Cardiol 2012; 19:1026-43. [PMID: 22760523 DOI: 10.1007/s12350-012-9593-y] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Leslee J Shaw
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, 1462 Clifton Road NE, Room 529, Atlanta, GA 30324, USA.
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Evaluating imaging and computer-aided detection and diagnosis devices at the FDA. Acad Radiol 2012; 19:463-77. [PMID: 22306064 DOI: 10.1016/j.acra.2011.12.016] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Revised: 12/22/2011] [Accepted: 12/28/2011] [Indexed: 11/22/2022]
Abstract
This report summarizes the Joint FDA-MIPS Workshop on Methods for the Evaluation of Imaging and Computer-Assist Devices. The purpose of the workshop was to gather information on the current state of the science and facilitate consensus development on statistical methods and study designs for the evaluation of imaging devices to support US Food and Drug Administration submissions. Additionally, participants expected to identify gaps in knowledge and unmet needs that should be addressed in future research. This summary is intended to document the topics that were discussed at the meeting and disseminate the lessons that have been learned through past studies of imaging and computer-aided detection and diagnosis device performance.
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Shaw LJ, Min JK, Hachamovitch R, Hendel RC, Borges-Neto S, Berman DS. Nomograms for estimating coronary artery disease prognosis with gated stress myocardial perfusion SPECT. J Nucl Cardiol 2012; 19:43-52. [PMID: 22045394 DOI: 10.1007/s12350-011-9468-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Accepted: 10/12/2011] [Indexed: 10/15/2022]
Abstract
BACKGROUND Nomograms can be useful tools for estimating coronary artery disease (CAD) risk. We sought to devise risk-based nomograms for stress myocardial perfusion SPECT to include measures of % ischemic myocardium and left ventricular function. METHODS A total of 4,575 patients were consecutively and prospectively enrolled in the Myoview Prognosis Registry. Multivariable Cox proportional hazards model were employed to estimate CAD death or MI. Nomograms were devised from the results of the Cox models. RESULTS CAD death or MI rates worsened in a gradient manner by the % ischemic myocardium. Higher risk patients were those with a rest and/or post-stress LVEF ≤ 45%. A nomogram was developed to estimate 2-year CAD death or MI-free survival for exercising and pharmacologic stress patients by their post-stress LVEF and % ischemic myocardium MPS results. Patients undergoing pharmacologic stress with a rest and/or post-stress LVEF ≤ 45% with high risk ischemic findings had the lowest CAD death or MI event-free survival. For exercising patients with a preserved resting LVEF > 45%, 2-year CAD death or MI event-free survival ranged from 99.4% to 89% for 0% to ≥20% ischemic myocardium. Those at highest risk included patients undergoing pharmacologic stress with depressed LVEF. For pharmacologic stress patients with a resting LVEF ≤45%, 2-year CAD death or MI event-free survival ranged from 89% to 48% for 0% to ≥20% ischemic myocardium. For pharmacologic stress patients with a post-stress LVEF ≤ 45%, 2-year CAD death or MI event-free survival ranged from 88% to 46% for 0% to ≥20% ischemic myocardium. A validation cohort revealed moderate-strong correlation between observed and predicted survival (r = 0.71). Average discordance between observed and predicted survival was ≤2% but was greater for higher risk patients with lower predicted survival estimates. CONCLUSIONS Risk-based nomograms estimating important CAD outcomes may serve as a clinically useful tool to target therapeutic intervention for high risk patient subsets.
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Affiliation(s)
- Leslee J Shaw
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, 1462 Clifton Rd NE, Room 530, Atlanta, GA 30306, USA.
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Stress Myocardial Perfusion Imaging for Assessing Prognosis: An Update. JACC Cardiovasc Imaging 2011; 4:1305-19. [DOI: 10.1016/j.jcmg.2011.10.003] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Revised: 10/21/2011] [Accepted: 10/27/2011] [Indexed: 12/25/2022]
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29
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The Prognostic Value of Coronary CT Angiography. CURRENT CARDIOVASCULAR IMAGING REPORTS 2011. [DOI: 10.1007/s12410-011-9107-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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30
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Acampa W, Petretta M, Evangelista L, Daniele S, Xhoxhi E, De Rimini ML, Cittanti C, Marranzano F, Spadafora M, Baldari S, Mansi L, Cuocolo A. Myocardial perfusion imaging and risk classification for coronary heart disease in diabetic patients. The IDIS study: a prospective, multicentre trial. Eur J Nucl Med Mol Imaging 2011; 39:387-95. [PMID: 22109666 DOI: 10.1007/s00259-011-1983-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 10/21/2011] [Indexed: 10/15/2022]
Abstract
PURPOSE To determine whether stress-rest myocardial perfusion single-photon emission (MPS) computed tomography improves coronary heart disease (CHD) risk classification in diabetic patients. METHODS In 822 consecutive diabetic patients, risk estimates for a CHD event were categorized as 0% to <3%, 3% to <5%, and ≥5% per year using Cox proportional hazards models. Model 1 used traditional CHD risk factors and electrocardiography (ECG) stress test data and model 2 used these variables plus MPS imaging data. We calculated the net reclassification improvement (NRI) and compared the distribution of risk using model 2 vs. model 1. CHD death, myocardial infarction and unstable angina requiring coronary revascularization were the outcome measures. RESULTS During follow-up (58 ± 11 months), 148 events occurred. Model 2 improved risk prediction compared to model 1 (NRI 0.25, 95% confidence interval, CI, 0.15-0.34; p < 0.001). Overall, 301 patients were reclassified to a higher risk category, with an event rate of 28%, and 26 to a lower risk category, with an event rate of 15%. Among patients at 3% to <5% risk, 53% were reclassified at higher risk and 25% at lower risk (NRI 0.42, 95% CI 0.07-0.76; p < 0.05). The cost per NRI was $880.80 for MPS imaging as compared to an outpatient visit with an ECG stress test. CONCLUSION The addition of MPS imaging data to a prediction model based on traditional risk factors and ECG stress test data significantly improved CHD risk classification in patients with diabetes.
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Affiliation(s)
- Wanda Acampa
- Department of Biomorphological and Functional Sciences, University Federico II, Napoli, Italy
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Coronary CT angiography and comparative effectiveness research prognostic value of atherosclerotic disease burden in appropriately indicated clinical examinations. JACC Cardiovasc Imaging 2011; 4:492-5. [PMID: 21565736 DOI: 10.1016/j.jcmg.2011.02.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Accepted: 02/28/2011] [Indexed: 11/21/2022]
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Perspectives on Radiation Exposure. J Nucl Cardiol 2011. [DOI: 10.1007/s12350-011-9351-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Schoenhagen P, Uno K. Coronary Computed Tomography in the Evaluation of Symptomatic Patients With Suspected Coronary Artery Disease. Circ J 2011; 75:2320-2321. [DOI: 10.1253/circj.cj-11-0692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Affiliation(s)
- Paul Schoenhagen
- Cleveland Clinic, Imaging Institute & Heart and Vascular Institute
| | - Kiyoko Uno
- Cleveland Clinic, Imaging Institute & Heart and Vascular Institute
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