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Kelsey MD, Kelsey AM. Diagnosing Coronary Artery Disease in the Patient Presenting with Stable Ischemic Heart Disease: The Role of Anatomic versus Functional Testing. Med Clin North Am 2024; 108:427-439. [PMID: 38548455 DOI: 10.1016/j.mcna.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
There are unique advantages and disadvantages to functional versus anatomic testing in the work-up of patients who present with symptoms suggestive of obstructive coronary artery disease. Evaluation of these individuals starts with an assessment of pre-test probability, which guides subsequent testing decisions. The choice between anatomic and functional testing depends on this pre-test probability. In general, anatomic testing has particular utility among younger individuals and women; while functional testing can be helpful to rule-in ischemia and guide revascularization decisions. Ultimately, selection of the most appropriate test should be individualized to the patient and clinical scenario.
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Affiliation(s)
- Michelle D Kelsey
- Division of Cardiology, Department of Medicine, Duke University, 2301 Erwin Road, Durham, NC 27710, USA; Duke Clinical Research Institute, 300 West Morgan Street, Durham, NC 27701, USA.
| | - Anita M Kelsey
- Division of Cardiology, Department of Medicine, Duke University, 2301 Erwin Road, Durham, NC 27710, USA. https://twitter.com/AnitaKelseyMD
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2
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Pappas MA, Auerbach AD, Kattan MW, Blackstone EH, Rothberg MB, Sessler DI. Diagnostic and prognostic value of cardiac stress testing before major noncardiac surgery-A cohort study. J Clin Anesth 2023; 90:111193. [PMID: 37441833 PMCID: PMC10529226 DOI: 10.1016/j.jclinane.2023.111193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 06/16/2023] [Accepted: 06/25/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVE To assess the incremental contribution of preoperative stress test results toward a diagnosis of obstructive coronary artery disease (CAD), prediction of mortality, or prediction of perioperative myocardial infarction in patients considering noncardiac, nonophthalmologic surgery. DESIGN, SETTING, PARTICIPANTS A retrospective cohort study of visits to a preoperative risk assessment and optimization clinic in a large health system between 2008 and 2018. MEASUREMENTS To assess diagnostic information of preoperative stress testing, we used the Begg and Greenes method to calculate test characteristics adjusted for referral bias, with a gold standard of angiography. To assess prognostic information, we first created multiply-imputed logistic regression models to predict 90-day mortality and perioperative myocardial infarction (MI), starting with two tools commonly used to assess perioperative cardiac risk, Revised Cardiac Risk Index (RCRI) and Myocardial Infarction or Cardiac Arrest (MICA). We then added stress test results and compared the discrimination for models with and without stress test results. MAIN RESULTS Among 136,935 visits by patients without an existing diagnosis of CAD, the decision to obtain preoperative stress testing identified around 4.0% of likely new diagnoses. Stress testing increased the likelihood of CAD (likelihood ratio: 1.31), but for over 99% of patients, stress testing should not change a decision on whether to proceed to angiography. In 117,445 visits with subsequent noncardiac surgery, stress test results failed to improve predictions of either perioperative MI or 90-day mortality. Reweighting the models and adding hemoglobin improved the prediction of both outcomes. CONCLUSIONS Cardiac stress testing before noncardiac, nonophthalmologic surgery does not improve predictions of either perioperative mortality or myocardial infarction. Very few patients considering noncardiac, nonophthalmologic surgery have a pretest probability of CAD in a range where stress testing could usefully select patients for angiography. Better use of existing patient data could improve predictions of perioperative adverse events without additional patient testing.
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Affiliation(s)
- Matthew A Pappas
- Center for Value-based Care Research, Cleveland Clinic, Cleveland, OH, United States of America; Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH, United States of America; Outcomes Research Consortium, Cleveland, OH, United States of America.
| | - Andrew D Auerbach
- Department of Hospital Medicine, University of California, San Francisco, San Francisco, CA, United States of America
| | - Michael W Kattan
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Eugene H Blackstone
- Miller Family Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Michael B Rothberg
- Center for Value-based Care Research, Cleveland Clinic, Cleveland, OH, United States of America
| | - Daniel I Sessler
- Outcomes Research Consortium, Cleveland, OH, United States of America; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2023; 82:833-955. [PMID: 37480922 DOI: 10.1016/j.jacc.2023.04.003] [Citation(s) in RCA: 71] [Impact Index Per Article: 71.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2023; 148:e9-e119. [PMID: 37471501 DOI: 10.1161/cir.0000000000001168] [Citation(s) in RCA: 180] [Impact Index Per Article: 180.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Affiliation(s)
| | | | | | | | | | | | - Dave L Dixon
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | - William F Fearon
- Society for Cardiovascular Angiography and Interventions representative
| | | | | | | | - Dhaval Kolte
- AHA/ACC Joint Committee on Clinical Data Standards
| | | | | | | | - Daniel B Mark
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | | | | | | | - Mariann R Piano
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
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Rozanski A, Sakul S, Narula J, Uretsky S, Lavie CJ, Berman D. Assessment of lifestyle-related risk factors enhances the effectiveness of cardiac stress testing. Prog Cardiovasc Dis 2023; 77:95-106. [PMID: 36931544 DOI: 10.1016/j.pcad.2023.03.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 03/13/2023] [Indexed: 03/19/2023]
Abstract
Cardiac stress tests have been widely utilized since the 1960s for the diagnostic and prognostic assessment of patients with suspected coronary artery disease (CAD). Clinical risk is primarily based on assessing the presence and magnitude of inducible myocardial ischemia. However, the primary factors driving mortality risk have changed over recent decades. Factors such as typical angina and inducible ischemia have decreased, whereas the percentage of patients with diabetes, obesity and hypertension have increased. There has also been a marked temporal increase in the percentage of patients who require pharmacologic testing due to inability to perform treadmill exercise at the time of cardiac stress testing and this need has emerged as the most potent predictor of mortality risk in contemporary stress test populations. However, the long-term clinical risk posed by the inability to perform exercise and concomitant CAD risk factors are rarely reflected in the assessment of patients' prognostic risk in cardiac stress test reports. In this review, we suggest that the clinical utility of present-day cardiac stress testing can be improved by developing a more comprehensive assessment that integrates and reports all factors which modulate patients' long-term clinical risk following stress testing. This should include assessment of patients' CAD risk factors, physical activity habits and mobility risks, identification of the reasons why patients could not exercise at the time of cardiac stress testing. In addition, the assessment of four core non-aerobic functional parameters should be considered among patients who cannot exercise: assessment of gait speed, handgrip strength, lower extremity strength, and standing balance.
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Affiliation(s)
- Alan Rozanski
- Department of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
| | - Sakul Sakul
- Department of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Jagat Narula
- Department of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Seth Uretsky
- Morristown Medical Center, Morristown, NJ, United States of America
| | - Carl J Lavie
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School-the UQ School of Medicine, New Orleans, LA, United States of America
| | - Daniel Berman
- Departments of Imaging and Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
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Han D, Rozanski A, Gransar H, Tzolos E, Miller RJH, Sharir T, Einstein AJ, Fish MB, Ruddy TD, Kaufmann PA, Sinusas AJ, Miller EJ, Bateman TM, Dorbala S, Di Carli M, Liang JX, Hu LH, Dey D, Berman DS, Slomka PJ. Comparison of diabetes to other prognostic predictors among patients referred for cardiac stress testing: A contemporary analysis from the REFINE SPECT Registry. J Nucl Cardiol 2022; 29:3003-3014. [PMID: 34757571 PMCID: PMC9085969 DOI: 10.1007/s12350-021-02810-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 08/12/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Diabetes mellitus (DM) is increasingly prevalent among contemporary populations referred for cardiac stress testing, but its potency as a predictor for major adverse cardiovascular events (MACE) vs other clinical variables is not well delineated. METHODS AND RESULTS From 19,658 patients who underwent SPECT-MPI, we identified 3122 patients with DM without known coronary artery disease (CAD) (DM+/CAD-) and 3564 without DM with known CAD (DM-/CAD+). Propensity score matching was used to control for the differences in characteristics between DM+/CAD- and DM-/CAD+ groups. There was comparable MACE in the matched DM+/CAD- and DM-/CAD+ groups (HR 1.15, 95% CI 0.97-1.37). By Chi-square analysis, type of stress (exercise or pharmacologic), total perfusion deficit (TPD), and left ventricular function were the most potent predictors of MACE, followed by CAD and DM status. The combined consideration of mode of stress, TPD, and DM provided synergistic stratification, an 8.87-fold (HR 8.87, 95% CI 7.27-10.82) increase in MACE among pharmacologically stressed patients with DM and TPD > 10% (vs non-ischemic, exercised stressed patients without DM). CONCLUSIONS Propensity-matched patients with DM and no known CAD have similar MACE risk compared to patients with known CAD and no DM. DM is synergistic with mode of stress testing and TPD in predicting the risk of cardiac stress test patients.
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Affiliation(s)
- Donghee Han
- Departments of Medicine (Division of Artificial Intelligence), Imaging, and Biomedical Sciences, Cedars-Sinai, Los Angeles, CA, USA
| | - Alan Rozanski
- Division of Cardiology, Mount Sinai St. Luke's Hospital, New York, NY, USA
| | - Heidi Gransar
- Departments of Medicine (Division of Artificial Intelligence), Imaging, and Biomedical Sciences, Cedars-Sinai, Los Angeles, CA, USA
| | - Evangelos Tzolos
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Robert J H Miller
- Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Tali Sharir
- Department of Nuclear Cardiology, Assuta Medical Centers, Tel Aviv, Israel
- Ben Gurion University of the Negev, Beersheba, Israel
| | - Andrew J Einstein
- Division of Cardiology, Department of Medicine, and Department of Radiology, Columbia University Irving Medical Center and New York-Presbyterian Hospital, New York, NY, USA
| | - 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
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Marcelo Di Carli
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Joanna X Liang
- Departments of Medicine (Division of Artificial Intelligence), Imaging, and Biomedical Sciences, Cedars-Sinai, Los Angeles, CA, USA
| | - Lien-Hsin Hu
- Department of Nuclear Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Damini Dey
- Departments of Medicine (Division of Artificial Intelligence), Imaging, and Biomedical Sciences, Cedars-Sinai, Los Angeles, CA, USA
| | - Daniel S Berman
- Departments of Medicine (Division of Artificial Intelligence), Imaging, and Biomedical Sciences, Cedars-Sinai, Los Angeles, CA, USA
| | - Piotr J Slomka
- Departments of Medicine (Division of Artificial Intelligence), Imaging, and Biomedical Sciences, Cedars-Sinai, Los Angeles, CA, USA.
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7
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Perry C, Winchester DE. Diabetes is still a CAD risk equivalent, now what? J Nucl Cardiol 2022; 29:3015-3017. [PMID: 34773187 DOI: 10.1007/s12350-021-02859-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 10/28/2021] [Indexed: 01/18/2023]
Affiliation(s)
- Christopher Perry
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida College of Medicine, 1600 SW Archer Road, PO Box 100277, Gainesville, FL, 32610-0277, USA
| | - David E Winchester
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida College of Medicine, 1600 SW Archer Road, PO Box 100277, Gainesville, FL, 32610-0277, USA.
- Cardiology Section, Medical Service, Malcom Randall VA Medical Center, Gainesville, FL, USA.
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Thompson RC, Phillips LM, Dilsizian V, Gutierrez DP, Einstein AJ, Crews SF, Skali H, Jih FKY, Dondi M, Gimelli A, Bateman TM, Al-Mallah MH, Ghesani M, Dorbala S, Calnon DA. Update on guidance and best practices for nuclear cardiology laboratories during the coronavirus disease 2019 (COVID-19) pandemic: Emphasis on transition to chronic endemic state. An information statement from ASNC, IAEA, and SNMMI. J Nucl Cardiol 2022; 29:2013-2018. [PMID: 35499661 PMCID: PMC9059683 DOI: 10.1007/s12350-022-02984-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 04/18/2022] [Indexed: 02/06/2023]
Affiliation(s)
- Randall C Thompson
- Department of Cardiology, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO, USA.
- American Society of Nuclear Cardiology (ASNC), Fairfax, VA, USA.
| | - Lawrence M Phillips
- Division of Cardiology, NYU Langone Medical Center, New York, NY, USA
- American Society of Nuclear Cardiology (ASNC), Fairfax, VA, USA
| | - Vasken Dilsizian
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- Society of Nuclear Medicine and Molecular Imaging (SNMMI), Reston, VA, USA
| | - Diana Paez Gutierrez
- Nuclear Medicine and Diagnostic Imaging Section, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
- International Atomic Energy Agency (IAEA), Vienna, Austria
| | - Andrew J Einstein
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, and Department of Radiology, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, NY, USA
- American Society of Nuclear Cardiology (ASNC), Fairfax, VA, USA
| | - Suzanne F Crews
- Nuclear Cardiology, Northeast Georgia Health System, Gainesville, GA, USA
- American Society of Nuclear Cardiology (ASNC), Fairfax, VA, USA
| | - Hicham Skali
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Cardiovascular Division, Department of Medicine. Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- American Society of Nuclear Cardiology (ASNC), Fairfax, VA, USA
| | - Felix Keng Yung Jih
- National Heart Centre, Singapore, Singapore
- American Society of Nuclear Cardiology (ASNC), Fairfax, VA, USA
| | - Maurizio Dondi
- Nuclear Medicine and Diagnostic Imaging Section, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
- International Atomic Energy Agency (IAEA), Vienna, Austria
| | - Alessia Gimelli
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
- American Society of Nuclear Cardiology (ASNC), Fairfax, VA, USA
| | - Timothy M Bateman
- Department of Cardiology, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO, USA
- Society of Nuclear Medicine and Molecular Imaging (SNMMI), Reston, VA, USA
| | - Mouaz H Al-Mallah
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX, USA
- American Society of Nuclear Cardiology (ASNC), Fairfax, VA, USA
| | - Munir Ghesani
- Icahn School of Medicine, Mount Sinai Hospital, New York, NY, USA
- Society of Nuclear Medicine and Molecular Imaging (SNMMI), Reston, VA, USA
| | - Sharmila Dorbala
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Cardiovascular Division, Department of Medicine. Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- American Society of Nuclear Cardiology (ASNC), Fairfax, VA, USA
| | - Dennis A Calnon
- OhioHealth Heart and Vascular Physicians, Columbus, OH, USA
- American Society of Nuclear Cardiology (ASNC), Fairfax, VA, USA
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Zheng C, Sun BC, Wu YL, Ferencik M, Lee MS, Redberg RF, Kawatkar AA, Musigdilok VV, Sharp AL. Automated abstraction of myocardial perfusion imaging reports using natural language processing. J Nucl Cardiol 2022; 29:1178-1187. [PMID: 33155169 PMCID: PMC8096860 DOI: 10.1007/s12350-020-02401-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 09/29/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Findings and interpretations of myocardial perfusion imaging (MPI) studies are documented in free-text MPI reports. MPI results are essential for research, but manual review is prohibitively time consuming. This study aimed to develop and validate an automated method to abstract MPI reports. METHODS We developed a natural language processing (NLP) algorithm to abstract MPI reports. Randomly selected reports were double-blindly reviewed by two cardiologists to validate the NLP algorithm. Secondary analyses were performed to describe patient outcomes based on abstracted-MPI results on 16,957 MPI tests from adult patients evaluated for suspected ACS. RESULTS The NLP algorithm achieved high sensitivity (96.7%) and specificity (98.9%) on the MPI categorical results and had a similar degree of agreement compared to the physician reviewers. Patients with abnormal MPI results had higher rates of 30-day acute myocardial infarction or death compared to patients with normal results. We identified issues related to the quality of the reports that not only affect communication with referring physicians but also challenges for automated abstraction. CONCLUSION NLP is an accurate and efficient strategy to abstract results from the free-text MPI reports. Our findings will facilitate future research to understand the benefits of MPI studies but requires validation in other settings.
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Affiliation(s)
- Chengyi Zheng
- Research and Evaluation Department, Kaiser Permanente Southern California, 100 S Los Robles Ave, 2nd Floor, Pasadena, CA, 91101, USA.
| | - Benjamin C Sun
- Department of Emergency Medicine and Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA, USA
| | - Yi-Lin Wu
- Research and Evaluation Department, Kaiser Permanente Southern California, 100 S Los Robles Ave, 2nd Floor, Pasadena, CA, 91101, USA
| | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
| | - Ming-Sum Lee
- Division of Cardiology, Kaiser Permanente Southern California, Los Angeles Medical Center, Los Angeles, CA, USA
| | - Rita F Redberg
- Division of Cardiology, University of California, San Francisco, San Francisco, CA, USA
| | - Aniket A Kawatkar
- Research and Evaluation Department, Kaiser Permanente Southern California, 100 S Los Robles Ave, 2nd Floor, Pasadena, CA, 91101, USA
| | - Visanee V Musigdilok
- Research and Evaluation Department, Kaiser Permanente Southern California, 100 S Los Robles Ave, 2nd Floor, Pasadena, CA, 91101, USA
| | - Adam L Sharp
- Research and Evaluation Department, Kaiser Permanente Southern California, 100 S Los Robles Ave, 2nd Floor, Pasadena, CA, 91101, USA
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10
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Rozanski A, Berman DS, Iskandrian AE. The imperative to assess physical function among all patients undergoing stress myocardial perfusion imaging. J Nucl Cardiol 2022; 29:946-951. [PMID: 33073319 DOI: 10.1007/s12350-020-02378-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 09/04/2020] [Indexed: 12/31/2022]
Affiliation(s)
- Alan Rozanski
- Department of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, and The Icahn School of Medicine at Mount Sinai, 1111 Amsterdam Avenue, New York, NY, 10025, USA.
| | - Daniel S Berman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ami E Iskandrian
- Division of Cardiovascular Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, USA
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11
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Rozanski A, Gransar H, Hayes SW, Friedman JD, Thomson L, Berman DS. Mortality risk among patients undergoing exercise versus pharmacologic myocardial perfusion imaging: A propensity-based comparison. J Nucl Cardiol 2022; 29:840-852. [PMID: 33047282 DOI: 10.1007/s12350-020-02294-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 06/22/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND The increased risk associated with pharmacologic versus exercise testing is obscured by the higher prevalence of clinical risk factors among pharmacologic patients. Thus, we assessed comparative mortality in a large risk factor-matched group of exercise versus pharmacologic patients undergoing stress/rest SPECT myocardial perfusion imaging (MPI). METHODS 39,179 patients undergoing stress/rest SPECT-MPI were followed for 13.3 ± 5.0 years for all-cause mortality (ACM). We applied propensity-matching to create pharmacologic and exercise groups with similar risk profiles. RESULTS In comparison to exercise patients, pharmacologic patients had an increased risk-adjusted hazard ratio for ACM for each level of ischemia: increased by 3.8-fold (95%CI 3.5-4.1) among nonischemic patients, 2.5-fold (95%CI 2.0-3.2) among mildly ischemic patients, and 2.6-fold (95%CI 2.1-3.3) among moderate/severe ischemic patients. Similar findings were observed among a propensity-matched cohort of 10,113 exercise and 10,113 pharmacologic patients as well as in an additional cohort that also excluded patients with noncardiac co-morbidities. CONCLUSIONS Patients requiring pharmacologic stress testing manifest substantially heightened clinical risk at each level of myocardial ischemia and even when myocardial ischemia is absent. These findings suggest the need to study the pathophysiological drivers of increased risk in association with pharmacologic testing and to convey this risk in clinical reports.
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Affiliation(s)
- Alan Rozanski
- The Department of Cardiology, Mount Sinai Morningside Hospital and Mount Sinai Heart, 1111 Amsterdam Avenue, New York, 10025, USA.
- Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Heidi Gransar
- Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Sean W Hayes
- Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - John D Friedman
- Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Louise Thomson
- Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Daniel S Berman
- Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
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12
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Rodriguez Lozano P, Bourque JM. Beyond traditional cardiovascular risk factors: Could frailty and other morbidities explain the worse prognosis in patients undergoing pharmacologic stress? J Nucl Cardiol 2022; 29:853-856. [PMID: 33241477 PMCID: PMC8144235 DOI: 10.1007/s12350-020-02441-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 11/03/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Patricia Rodriguez Lozano
- Division of Cardiovascular Medicine and the Cardiac Imaging Center, University of Virginia Health System, 1215 Lee Street, PO Box 800158, Charlottesville, VA, 22908, USA
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA, USA
| | - Jamieson M Bourque
- Division of Cardiovascular Medicine and the Cardiac Imaging Center, University of Virginia Health System, 1215 Lee Street, PO Box 800158, Charlottesville, VA, 22908, USA.
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA, USA.
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13
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Talledo-Paredes LS, Guerrero-Ramírez DMT, Mendoza-Paulini A, Rodríguez-Urteaga Z, Angulo-Poblete D, Ríos-Ortega JC. [Prediction of significant coronary lesions by SPECT myocardial perfusion. Results from a national reference hospital in Lima-Peru]. ARCHIVOS PERUANOS DE CARDIOLOGIA Y CIRUGIA CARDIOVASCULAR 2022; 3:74-81. [PMID: 37283600 PMCID: PMC10241335 DOI: 10.47487/apcyccv.v3i2.222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 06/30/2022] [Indexed: 06/08/2023]
Abstract
Objective To determine the discriminative capacity of myocardial perfusion with single photon emission tomography (SPECT) to predict coronary obstructions by coronary angiography. To determine mortality and major cardiovascular events at follow-up. Materials and methods . Retrospective observational study with clinical follow-up in patients undergoing SPECT and then coronary angiography. We excluded patients with myocardial infarction and percutaneous and/or surgical revascularization in the previous 6 months. Results 105 cases were included in the study. The most commonly used SPECT protocol was pharmacological (70%). Patients with perfusion defect ≥10% of total ventricular mass (TVM) had significant coronary lesions (SCL) in 88% of cases (sensitivity 87.5% and specificity 83%). On the other hand, having ischemia ≥10% of the TVM was associated with 80% SCL (sensitivity: 72%, specificity: 65%). Clinical follow-up at 48 months evidenced that a perfusion defect ≥ 10% was predictive of major cardiovascular events (MACE) in both univariate (HR=5.3; 95%CI 1.2 - 22.2; p=0.022) and multivariate (HR= 6.1; 95%CI 1.3 - 26.9; p= 0.017) analyses. Conclusions . Having a perfusion defect ≥10% of the MVT in the SPECT study predicted with high probability and sensitivity the existence of SCL (>80%); moreover, this group had higher MACE at follow-up.
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Affiliation(s)
- Luisa S Talledo-Paredes
- Servicio de Ayuda al Diagnóstico y Tratamiento. Instituto Nacional Cardiovascular. EsSalud. Lima. Perú. Servicio de Ayuda al Diagnóstico y Tratamiento Instituto Nacional Cardiovascular. EsSalud Lima Perú
- Programa de Maestría de Investigación y Docencia en Salud. Universidad Nacional de San Marcos. Lima, Perú Universidad Nacional Mayor de San Marcos Programa de Maestría de Investigación y Docencia en Salud Universidad Nacional de San Marcos Lima Peru
| | - Delia M T Guerrero-Ramírez
- Servicio de Ayuda al Diagnóstico y Tratamiento. Instituto Nacional Cardiovascular. EsSalud. Lima. Perú. Servicio de Ayuda al Diagnóstico y Tratamiento Instituto Nacional Cardiovascular. EsSalud Lima Perú
| | - Aurelio Mendoza-Paulini
- Servicio de Ayuda al Diagnóstico y Tratamiento. Instituto Nacional Cardiovascular. EsSalud. Lima. Perú. Servicio de Ayuda al Diagnóstico y Tratamiento Instituto Nacional Cardiovascular. EsSalud Lima Perú
| | - Zoila Rodríguez-Urteaga
- Servicio de Ayuda al Diagnóstico y Tratamiento. Instituto Nacional Cardiovascular. EsSalud. Lima. Perú. Servicio de Ayuda al Diagnóstico y Tratamiento Instituto Nacional Cardiovascular. EsSalud Lima Perú
| | - Daniel Angulo-Poblete
- Programa de Maestría de Investigación y Docencia en Salud. Universidad Nacional de San Marcos. Lima, Perú Universidad Nacional Mayor de San Marcos Programa de Maestría de Investigación y Docencia en Salud Universidad Nacional de San Marcos Lima Peru
| | - Josías C Ríos-Ortega
- Servicio de cirugía cardiovascular. Instituto Nacional Cardiovascular. EsSalud. Lima. Perú. Servicio de cirugía cardiovascular Instituto Nacional Cardiovascular. EsSalud Lima Perú
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14
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Khan MS, Arif AW, Doukky R. The prognostic implications of ST-segment and T-wave abnormalities in patients undergoing regadenoson stress SPECT myocardial perfusion imaging. J Nucl Cardiol 2022; 29:810-821. [PMID: 33034037 DOI: 10.1007/s12350-020-02382-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 09/11/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND The prognostic implications of ST-segment and T-wave (ST/T) abnormalities in patients undergoing stress SPECT-myocardial perfusion imaging (MPI) are not well defined. METHODS AND RESULTS This was a single-center, retrospective cohort study of consecutive patients who underwent regadenoson stress SPECT-MPI. Patients with baseline electrocardiogram (ECG) abnormalities that impede ST/T analysis or those with known coronary artery disease were excluded. Patients were categorized as having primary ST abnormalities, secondary ST/T abnormalities due to ventricular hypertrophy or right bundle branch block, T-wave abnormalities, or normal ECG. The primary outcome was major adverse cardiovascular events (MACE) defined as the composite of cardiac death or myocardial infarction. Among 6,059 subjects, 1912 (32%) had baseline ST/T abnormalities. During a mean follow-up of 2.3 ± 1.9 years, the incidence of MACE was significantly higher among patients with secondary ST/T abnormalities compared to those with normal ECG (HR 2.05; 95% confidence interval [CI], 1.04-4.05; P = 0.039). No significant difference in MACE was observed among patients with primary ST abnormalities (HR 1.64; CI 0.87-3.06; P = 0.124) or T-wave abnormalities (HR 1.15; CI 0.62-2.16; P = 0.658) compared with patients who had normal ECG. Among patients with secondary ST/T changes, abnormal MPI was not associated with a significant increase in MACE rates compared to normal MPI (HR 1.18; CI 0.31-4.58; P = 0.808). However, abnormal MPI was associated with higher MACE rates among patients with primary ST abnormalities (HR 4.50; CI 1.44-14.10; P = 0.005) and T-wave abnormalities (HR 3.74; CI 1.20-11.68; P = 0.015). Similarly, myocardial ischemia on regadenoson stress SPECT-MPI was not associated with a significant increase in MACE rates in patients with secondary ST/T abnormalities (HR 1.45; CI 0.38-5.61; P = 0.588), while it was associated with a higher incidence of MACE in patients with primary ST abnormalities (HR 3.012; CI 0.95-9.53; P = 0.049) and T-wave abnormalities (HR 5.06; CI 1.60-15.96; P = 0.002). CONCLUSION While patients with secondary ST/T abnormalities had significantly higher MACE risk, abnormal MPI or presence of myocardial ischemia on regadenoson SPECT-MPI in this group does not add prognostic information. Patients with primary ST abnormalities and T-wave abnormalities do not seem to have a significantly higher MACE risk compared to those with normal ECG; however, abnormal MPI or presence of myocardial ischemia, in these groups, correlates with higher MACE rates.
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Affiliation(s)
| | | | - Rami Doukky
- Department of Medicine, Cook County Health, Chicago, IL, USA.
- Division of Cardiology, Cook County Health, 1901 W. Harrison St., Chicago, IL, 60612, USA.
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA.
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15
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Muscogiuri G, Guglielmo M, Serra A, Gatti M, Volpato V, Schoepf UJ, Saba L, Cau R, Faletti R, McGill LJ, De Cecco CN, Pontone G, Dell’Aversana S, Sironi S. Multimodality Imaging in Ischemic Chronic Cardiomyopathy. J Imaging 2022; 8:jimaging8020035. [PMID: 35200737 PMCID: PMC8877428 DOI: 10.3390/jimaging8020035] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 01/23/2022] [Accepted: 01/27/2022] [Indexed: 02/01/2023] Open
Abstract
Ischemic chronic cardiomyopathy (ICC) is still one of the most common cardiac diseases leading to the development of myocardial ischemia, infarction, or heart failure. The application of several imaging modalities can provide information regarding coronary anatomy, coronary artery disease, myocardial ischemia and tissue characterization. In particular, coronary computed tomography angiography (CCTA) can provide information regarding coronary plaque stenosis, its composition, and the possible evaluation of myocardial ischemia using fractional flow reserve CT or CT perfusion. Cardiac magnetic resonance (CMR) can be used to evaluate cardiac function as well as the presence of ischemia. In addition, CMR can be used to characterize the myocardial tissue of hibernated or infarcted myocardium. Echocardiography is the most widely used technique to achieve information regarding function and myocardial wall motion abnormalities during myocardial ischemia. Nuclear medicine can be used to evaluate perfusion in both qualitative and quantitative assessment. In this review we aim to provide an overview regarding the different noninvasive imaging techniques for the evaluation of ICC, providing information ranging from the anatomical assessment of coronary artery arteries to the assessment of ischemic myocardium and myocardial infarction. In particular this review is going to show the different noninvasive approaches based on the specific clinical history of patients with ICC.
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Affiliation(s)
- Giuseppe Muscogiuri
- Department of Radiology, Istituto Auxologico Italiano IRCCS, San Luca Hospital, University Milano Bicocca, 20149 Milan, Italy
- Correspondence: ; Tel.: +39-329-404-9840
| | - Marco Guglielmo
- Department of Cardiology, Division of Heart and Lungs, Utrecht University, Utrecht University Medical Center, 3584 Utrecht, The Netherlands;
| | - Alessandra Serra
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari-Polo di Monserrato, 09042 Cagliari, Italy; (A.S.); (L.S.); (R.C.)
| | - Marco Gatti
- Radiology Unit, Department of Surgical Sciences, University of Turin, 10124 Turin, Italy; (M.G.); (R.F.)
| | - Valentina Volpato
- Department of Cardiac, Neurological and Metabolic Sciences, Istituto Auxologico Italiano IRCCS, San Luca Hospital, University Milano Bicocca, 20149 Milan, Italy;
| | - Uwe Joseph Schoepf
- Department of Radiology and Radiological Science, MUSC Ashley River Tower, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC 29425, USA; (U.J.S.); (L.J.M.)
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari-Polo di Monserrato, 09042 Cagliari, Italy; (A.S.); (L.S.); (R.C.)
| | - Riccardo Cau
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari-Polo di Monserrato, 09042 Cagliari, Italy; (A.S.); (L.S.); (R.C.)
| | - Riccardo Faletti
- Radiology Unit, Department of Surgical Sciences, University of Turin, 10124 Turin, Italy; (M.G.); (R.F.)
| | - Liam J. McGill
- Department of Radiology and Radiological Science, MUSC Ashley River Tower, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC 29425, USA; (U.J.S.); (L.J.M.)
| | - Carlo Nicola De Cecco
- Division of Cardiothoracic Imaging, Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA 30322, USA;
| | | | - Serena Dell’Aversana
- Department of Radiology, Ospedale S. Maria Delle Grazie—ASL Napoli 2 Nord, 80078 Pozzuoli, Italy;
| | - Sandro Sironi
- School of Medicine and Post Graduate School of Diagnostic Radiology, University of Milano-Bicocca, 20126 Milan, Italy;
- Department of Radiology, ASST Papa Giovanni XXIII, 24127 Bergamo, Italy
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16
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Mendoza-Ibañez OI, Martínez-Lucio TS, Alexanderson-Rosas E, Slart RH. SPECT in Ischemic Heart Diseases. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00015-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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17
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Sidhu GS, Hendel RC. The evolution of the prognostic value of regadenoson SPECT myocardial perfusion imaging. J Nucl Cardiol 2021; 28:2808-2811. [PMID: 32468300 DOI: 10.1007/s12350-020-02208-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 05/21/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Gursukhmandeep S Sidhu
- Section of Cardiology, John W. Deming Department of Medicine, Tulane University Heart & Vascular Institute, Tulane University School of Medicine, New Orleans, LA, USA
| | - Robert C Hendel
- Section of Cardiology, John W. Deming Department of Medicine, Tulane University Heart & Vascular Institute, Tulane University School of Medicine, New Orleans, LA, USA.
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18
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Huang JY, Yen RF, Huang CK, Liu CJ, Cheng MF, Chien KL, Wu YW. Long-term prognostic value of computed tomography-based attenuation correction on thallium-201 myocardial perfusion imaging: A cohort study. PLoS One 2021; 16:e0258983. [PMID: 34699538 PMCID: PMC8547642 DOI: 10.1371/journal.pone.0258983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 10/08/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Myocardial perfusion imaging (MPI) is a well-established diagnostic tool to evaluate coronary artery disease (CAD) and also an effective prognostic tool for patients with CAD. However, few studies investigated the prognostic value of attenuation correction (AC) in MPI, and the results were controversial. OBJECTIVES To investigate the prognostic value of computed tomography (CT)-based AC thallium-201 (Tl-201) MPI. METHODS A total of 108 consecutive patients who underwent Tl-201 MPI and received coronary angiography within 90 days were included. Medical records were reviewed and missing information was completed after telephone contact. The prognostic value was evaluated by Kaplan-Meier analysis, univariable and multivariable Cox proportional hazards model. RESULTS After a mean follow-up of 7.72 ± 3.72 years, 27 patients had died, 41 had been readmitted for cardiovascular (CV)-related events and 44 had reached the composite of death plus CV-related re-admission. Kaplan-Meier curves for all-cause mortality for SSS with a cutoff value of 13 for AC and 16 for non-AC (NAC) images showed a significant difference between the two curves for both AC and NAC images (p = 0.011 for AC and p = 0.021 for NAC). In the multivariable model, SSS and SRS showed similar independent predictive values in predicting all-cause mortality and composite of all-cause mortality plus CV-related re-admission, in both AC and NAC images. Subgroup analysis implicated that AC MPI possibly provided better risk stratification in obese patients. CONCLUSION CT-based AC and NAC MPI showed similar value and were the only significant predictors for the composite of mortality and CV events.
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Affiliation(s)
- Jei-Yie Huang
- Department of Nuclear Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Ruoh-Fang Yen
- Department of Nuclear Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chun-Kai Huang
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chia-Ju Liu
- Department of Nuclear Medicine, National Taiwan University Hospital, Yun-Lin Branch, Yun-Lin County, Taiwan
| | - Mei-Fang Cheng
- Department of Nuclear Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Kuo-Liong Chien
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- * E-mail: (KLC); (YWW)
| | - Yen-Wen Wu
- Department of Nuclear Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Nuclear Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- Division of Cardiology, Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- National Yang Ming Chao Tung University School of Medicine, Taipei, Taiwan
- * E-mail: (KLC); (YWW)
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19
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Nieves RA, Bukhari S, Harinstein ME. Adding value to myocardial perfusion scintigraphy: A prediction tool to predict adverse cardiac outcomes and risk stratify. J Nucl Cardiol 2021; 28:2283-2285. [PMID: 34169472 DOI: 10.1007/s12350-021-02670-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/04/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Ricardo A Nieves
- Heart and Vascular Institute, University of Pittsburgh Medical Center, South Tower 3F, 3E52.2, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Syed Bukhari
- Heart and Vascular Institute, University of Pittsburgh Medical Center, South Tower 3F, 3E52.2, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Matthew E Harinstein
- Heart and Vascular Institute, University of Pittsburgh Medical Center, South Tower 3F, 3E52.2, 200 Lothrop Street, Pittsburgh, PA, 15213, USA.
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20
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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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21
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Rrapo Kaso E, Bourque JM. Regadenoson SPECT MPI post-troponin elevation in two different patient populations: A reliable risk-stratification tool. J Nucl Cardiol 2020; 27:2332-2336. [PMID: 31041679 DOI: 10.1007/s12350-019-01726-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 04/03/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Elona Rrapo Kaso
- Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Jamieson M Bourque
- Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA.
- Department of Radiology, University of Virginia Health System, Charlottesville, VA, USA.
- Departments of Medicine and Radiology, Cardiovascular Imaging Center, University of Virginia Health System, Box 800662, 1215 Lee Street, Charlottesville, VA, 22908, USA.
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22
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Rozanski A, Gransar H, Miller RJH, Hayes SW, Friedman JD, Thomson LEJ, Berman DS. Association between coronary atherosclerotic burden and all-cause mortality among patients undergoing exercise versus pharmacologic stress-rest SPECT myocardial perfusion imaging. Atherosclerosis 2020; 310:45-53. [PMID: 32890806 DOI: 10.1016/j.atherosclerosis.2020.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/26/2020] [Accepted: 07/09/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND AIMS Patients with suspected coronary artery disease who undergo stress SPECT myocardial perfusion imaging (MPI) and require pharmacologic stress are at substantially increased mortality risk compared to those who can exercise. However, the mechanisms underlying this increased risk are not well delineated. To test whether increased atherosclerotic burden accounts for this increased risk, we assessed the association between coronary artery calcium (CAC) scores and mortality risk among patients undergoing exercise versus pharmacologic SPECT MPI. METHODS We assessed all-cause mortality in 2,151 patients, followed for 12.2 ± 3.4 years, after undergoing stress-rest SPECT-MPI and CAC scanning within 3 months of each other. Patients were divided according to their mode of stress testing (exercise or pharmacologic). We further employed propensity analysis to create a subgroup of exercise and pharmacologic subgroups with comparable age, symptoms, and coronary risk factors. RESULTS Despite greater age and worse clinical profiles, pharmacologic and exercise patients had similar CAC scores. However, the hazard ratio (95% CI) for mortality was substantially greater among pharmacologic patients: 2.39 (1.83-3.10). For each level of CAC abnormality, pharmacologic patients had >2-fold increased risk adjusted hazard ratio for all-mortality risk (p < 0.05 for each CAC level). Among propensity-matched exercise versus pharmacologic patients, the same findings were observed. CONCLUSIONS Among patients referred for stress-rest SPECT-MPI and CAC scoring, pharmacologic patients have substantially increased mortality risk compared to exercise patients, despite having comparable levels of coronary atherosclerosis.
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Affiliation(s)
- Alan Rozanski
- Department of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, and the Icahn School of Medicine at Mount Sinai, New York, NY, USA; Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Heidi Gransar
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Robert J H Miller
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Sean W Hayes
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - John D Friedman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Louise E J Thomson
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel S Berman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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23
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Arbab-Zadeh A, Fuster V. From Detecting the Vulnerable Plaque to Managing the Vulnerable Patient: JACC State-of-the-Art Review. J Am Coll Cardiol 2020; 74:1582-1593. [PMID: 31537269 DOI: 10.1016/j.jacc.2019.07.062] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 07/25/2019] [Accepted: 07/26/2019] [Indexed: 01/04/2023]
Abstract
The past decades have seen tremendous progress on elucidating mechanisms leading to acute coronary syndrome and sudden cardiac death. Pathology and imaging studies have identified features of coronary atherosclerosis that precede acute coronary events. However, many factors influence the risk of adverse events from coronary atherosclerotic disease and available data support our transition from focusing on individual "vulnerable plaque," coronary arterial stenosis, and inducible myocardial ischemia to understanding coronary heart disease as multifactorial, chronic disease. The concept of the vulnerable patient has evolved, with the atheroma burden, its metabolic activity, and the disposition to vascular thrombosis building a platform for assessing central aspects of coronary heart disease. In turn, this model has directed us to a focus on controlling the activity of atherosclerotic disease and on modifying the susceptibility of vascular thrombosis which has led to reduced morbidity and mortality from coronary heart disease.
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Affiliation(s)
- Armin Arbab-Zadeh
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Valentin Fuster
- Mount Sinai Heart Center, Icahn School of Medicine at Mount Sinai, New York, New York
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24
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Oruc V, Hage FG. Low-dose stress-only myocardial perfusion imaging. J Nucl Cardiol 2020; 27:558-561. [PMID: 30298369 DOI: 10.1007/s12350-018-1455-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 08/30/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Vedran Oruc
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Fadi G Hage
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
- Division of Cardiovascular Disease, Birmingham Veterans Affairs Medical Center, 306 Lyons Harrison Research Building, 1900 University BLVD, Birmingham, AL, 35294, USA
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Mastrocola LE, Amorim BJ, Vitola JV, Brandão SCS, Grossman GB, Lima RDSL, Lopes RW, Chalela WA, Carreira LCTF, Araújo JRND, Mesquita CT, Meneghetti JC. Update of the Brazilian Guideline on Nuclear Cardiology - 2020. Arq Bras Cardiol 2020; 114:325-429. [PMID: 32215507 PMCID: PMC7077582 DOI: 10.36660/abc.20200087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
| | - Barbara Juarez Amorim
- Universidade Estadual de Campinas (Unicamp), Campinas, SP - Brazil
- Sociedade Brasileira de Medicina Nuclear (SBMN), São Paulo, SP - Brazil
| | | | | | - Gabriel Blacher Grossman
- Hospital Moinhos de Vento, Porto Alegre, RS - Brazil
- Clínica Cardionuclear, Porto Alegre, RS - Brazil
| | - Ronaldo de Souza Leão Lima
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brazil
- Fonte Imagem Medicina Diagnóstica, Rio de Janeiro, RJ - Brazil
- Clínica de Diagnóstico por Imagem (CDPI), Grupo DASA, Rio de Janeiro, RJ - Brazil
| | | | - William Azem Chalela
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brazil
| | | | | | | | - José Claudio Meneghetti
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brazil
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van Rosendael AR, Bax JJ, Arbab-Zadeh A. Noninvasive assessment of coronary atherosclerosis by cardiac computed tomography for risk stratifying patients with suspected coronary heart disease. J Cardiovasc Comput Tomogr 2019; 13:235-241. [PMID: 31563581 DOI: 10.1016/j.jcct.2019.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 08/01/2019] [Accepted: 08/19/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Alexander R van Rosendael
- From the Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, NY, USA; The Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands.
| | - Jeroen J Bax
- From the Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, NY, USA; The Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Armin Arbab-Zadeh
- The Department of Medicine-Division of Cardiology Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Hasbek Z, Ertürk SA, Çakmakçılar A, Gül İ, Yılmaz A. Evaluation of Myocardial Perfusion Imaging SPECT Parameters and Pharmacologic Stress Test with Adenosine Versus Coronary Angiography Findings: Are They Diagnostically Concordant? Mol Imaging Radionucl Ther 2019; 28:53-61. [PMID: 31237135 PMCID: PMC6592312 DOI: 10.4274/mirt.galenos.2019.47450] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objectives: In this study our first aim was to evaluate the diagnostic concordance of myocardial perfusion scintigraphy (MPS) by pharmacological stress test with adenosine (APST) with coronary angiography (CAG). The secondary aim of this study was to evaluate the correlation between CAG findings and automated analysis parameters such as left ventricular ejection fraction, summed stress score (SSS), summed rest score, summed difference score (SDS), stress MPS defect percentage ratio (extent) and transient ischemic dilation (TID) obtained by myocardial perfusion imaging single-photon emission computed tomography (SPECT). Methods: A total of 129 patients (62 male, 67 female, median age: 60.02) undergoing MPS due to suspicion of coronary ischemia who also underwent subsequent CAG in the last year were included in this study, their MPS data and CAG results were compared. Results: There was no statistically significant diagnostic concordance when visual evaluation of MPS, quantitative MPS parameters and exercise treadmill test (ETT) electrocardiography results were used alone. In fact, diagnostic concordance was higher when automated analysis parameters like TID, SSS and extent values were added to MPS SPECT visual analyses. There was diagnostic concordance in 57.9% of APST patients and 41.7% of ETT patients. There was diagnostic concordance in 75.8% of APST patients and 52.6% of ETT patients who were older than 65 years of age. Conclusion: In our study, we found that the use of APST during MPS increases diagnostic concordance with CAG. Therefore, we think that it would be appropriate to use APST in women and elderly patients with limited exercise habits. The CAG diagnostic mismatch is far above what it should be when MPS reporting is only done with visual data, and it is not supported by quantitative data such as TID, SSS, SDS and extent.
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Affiliation(s)
- Zekiye Hasbek
- Cumhuriyet University Faculty of Medicine, Department of Nuclear Medicine, Sivas, Turkey
| | - Seyit Ahmet Ertürk
- Cumhuriyet University Faculty of Medicine, Department of Nuclear Medicine, Sivas, Turkey
| | - Ali Çakmakçılar
- Cumhuriyet University Faculty of Medicine, Department of Nuclear Medicine, Sivas, Turkey
| | - İbrahim Gül
- Cumhuriyet University Faculty of Medicine, Department of Cardiology, Sivas, Turkey
| | - Ahmet Yılmaz
- Cumhuriyet University Faculty of Medicine, Department of Cardiology, Sivas, Turkey
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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.
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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.
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Abstract
PURPOSE OF REVIEW Radionuclide myocardial perfusion imaging (MPI) continues to be the most reliable modality for diagnosis of hemodynamically significant coronary artery disease (CAD). The application of radionuclide MPI using single photon emission computed tomography (SEPCT) and positron emission tomography (PET) for CAD is reviewed, with emphasis on diagnosis and risk stratification. RECENT FINDINGS Contemporary studies have reported the diagnostic and prognostic value of novel imaging protocols, employing stress-first or stress-only approach. In addition, the superior diagnostic value of PET has been established with a role of assessment of myocardial blood flow to improve risk stratification. The utility of MPI in special populations, such as the elderly, women, and diabetic patients has also been recently evaluated. Furthermore, multicenter studies have reported a similar diagnostic and prognostic value of radionuclide MPI compared with other functional and anatomical techniques for CAD. Radionuclide MPI with SPECT and PET are efficacious for diagnosis and prognosis of CAD. Its universal application in varied patient populations highlights its excellent clinical effectiveness.
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Chetrit M, Verma BR, Xu B. Choosing the Appropriate Stress Test for Myocardial Perfusion Imaging. CURRENT CARDIOVASCULAR IMAGING REPORTS 2019. [DOI: 10.1007/s12410-019-9488-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Bouallçgue FB, Nganoa C, Vigne J, Agostini D, Manrique A. Comparative Performances of Dipyridamole and Regadenoson to Detect Myocardial Ischemia using Cardiac Cadmium-Zinc-Telluride Single-Photon Emission Computerized Tomography. J Clin Imaging Sci 2018; 8:51. [PMID: 30546935 PMCID: PMC6251245 DOI: 10.4103/jcis.jcis_71_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 08/21/2018] [Indexed: 11/09/2022] Open
Abstract
Objective: We evaluated the relative performances of dipyridamole (Dip) and regadenoson (Reg) in a cohort of patients referred for coronary artery disease diagnosis or follow-up using myocardial perfusion imaging. Materials and Methods: We retrospectively included 515 consecutive patients referred for 99mTc-sestamibi myocardial perfusion single-photon emission computerized tomography (SPECT) on a cadmium-zinc-telluride (CZT) camera after pharmacologic stress. About three quarters (n = 391, 76%) received Dip. Reg was administrated to patients with chronical respiratory disease or with body mass index (BMI) over 38 kg/m2 (n = 124, 24%). Patients with an abnormal stress scan (92%) underwent a rest imaging on the same day. Qualitative interpretation of perfusion images was achieved using QPS software, and the ischemic area was assessed using the 17-segment model. In patients undergoing a stress-rest protocol, perfusion polar plots were postprocessed using automated in-house software to quantify the extension, intensity, and location of the reversible perfusion defect. Statistical comparison between groups was performed using univariate and multivariate analysis. Results: Qualitative analysis concluded to myocardial ischemia in 70% of the patients (69% in the Dip group, 76% in the Reg group, P = ns). In those patients, the number of involved segments (Dip 2.5 ± 1.6, Reg 2.7 ± 1.6, P = ns) and the proportion of patients with an ischemic area larger than two segments (Dip 30%, Reg 37%, P = ns) were comparable. Automated quantification of the reversible perfusion defect demonstrated similar defect extension, intensity, and severity in the two groups. Defect location was identical at the myocardial segment and vascular territory scales. Conclusions: Reg and Dip showed equal performances for ischemic burden characterization using myocardial CZT SPECT.
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Affiliation(s)
- Fayçal Ben Bouallçgue
- Department of Nuclear Medicine, Montpellier University Hospital, Caen, France.,PhyMedExp, INSERM - CNRS, Montpellier University, Montpellier, Caen, France.,Department of Nuclear Medicine, CHU de Caen, Caen, France
| | | | - Jonathan Vigne
- Department of Nuclear Medicine, CHU de Caen, Caen, France
| | - Denis Agostini
- Department of Nuclear Medicine, CHU de Caen, Caen, France
| | - Alain Manrique
- Department of Nuclear Medicine, CHU de Caen, Caen, France.,Normandie University, UNICAEN, EA 4650 SEILIRM, GIP Cyceron, Caen, France
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Mandour Ali M, Allam AH. The mystery poor prognosticator! Pharmacologic stress MPI prevalence and predictors: Insights from the Middle East. J Nucl Cardiol 2018; 25:1715-1717. [PMID: 29340985 DOI: 10.1007/s12350-017-1157-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 10/24/2017] [Indexed: 11/25/2022]
Affiliation(s)
| | - Adel H Allam
- Cardiology and Cardiovascular Imaging, Al-Azhar University, Cairo, Egypt.
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Kim SJ, Lee SW, Jeong SY, Pak K, Kim K. Diagnostic Performance of Technetium-99m Methoxy-Isobutyl-Isonitrile for Differentiation of Malignant Thyroid Nodules: A Systematic Review and Meta-Analysis. Thyroid 2018; 28:1339-1348. [PMID: 30129898 DOI: 10.1089/thy.2018.0072] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The purpose of the current study was to investigate the diagnostic performance of technetium-99m (Tc-99m) methoxy-isobutyl-isonitrile (MIBI) for differentiation of malignant thyroid nodules (TN) through a systematic review and meta-analysis. METHODS The MEDLINE/PubMed and EMBASE database, from the earliest available date of indexing through January 31, 2018, were searched for studies evaluating the diagnostic performance of Tc-99m MIBI for TN. The sensitivities and specificities were determined across studies, positive and negative likelihood ratios (LR+ and LR-) were calculated, and summary receiver operating characteristic curves were constructed. RESULTS Across 22 studies (2421 patients), the pooled sensitivity for Tc-99m MIBI thyroid scan was 0.87 [confidence interval (CI) 0.76-0.93] with heterogeneity (I2 = 92.3) and a pooled specificity of 0.78 [CI 0.67-0.86] with heterogeneity (I2 = 96.4). LR syntheses gave an overall LR+ of 4.0 [CI 2.5-6.3] and LR- of 0.17 [CI 0.09-0.32]. The pooled diagnostic odds ratio was 24 [CI 63-176]. The hierarchical summary receiver operating characteristic curve indicates that the area under the curve was 0.90 [CI 0.87-0.92]. In meta-regression analysis, no definite variable was the source of the study heterogeneity. CONCLUSION The current meta-analysis shows a moderate sensitivity and specificity of Tc-99m MIBI thyroid scan for differentiation of malignant TN. However, the diagnostic odds ratio was relatively low and the LR scattergram indicated that Tc-99m MIBI thyroid scan is not useful for confirming the presence of malignant TN or for its exclusion. Therefore, Tc-99m MIBI thyroid scans should be used restrictively and interpreted cautiously when assessing TN for malignancy.
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Affiliation(s)
- Seong-Jang Kim
- 1 Department of Nuclear Medicine, Pusan National University Yangsan Hospital , Yangsan, Korea
- 2 BioMedical Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital , Yangsan, Korea
- 3 Department of Nuclear Medicine, College of Medicine, Pusan National University , Yangsan, Korea
| | - Sang-Woo Lee
- 4 Department of Nuclear Medicine, Kyungpook National University Medical Center and School of Medicine , Daegu, Korea
| | - Shin Young Jeong
- 4 Department of Nuclear Medicine, Kyungpook National University Medical Center and School of Medicine , Daegu, Korea
| | - Kyoungjune Pak
- 5 Department of Nuclear Medicine and Biomedical Research Institute, Pusan National University Hospital , Busan, Korea
| | - Keunyoung Kim
- 5 Department of Nuclear Medicine and Biomedical Research Institute, Pusan National University Hospital , Busan, Korea
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Eldirani M, Chehab O, Hassan H, Tamim H, Dakik HA. Variations in the referral patterns to pharmacologic and exercise myocardial perfusion imaging. J Nucl Cardiol 2018; 25:1708-1714. [PMID: 28948527 DOI: 10.1007/s12350-017-1071-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 09/11/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Myocardial perfusion imaging (MPI) is commonly utilized for the non-invasive evaluation of patients with suspected coronary artery disease (CAD). It is either performed with exercise or pharmacologic stress. The objective of this study is to compare the referral patterns and diagnostic findings in patients referred for pharmacologic vs exercise MPI. METHODS AND RESULTS This was a prospective study of 429 consecutive patients who were referred for MPI at the American University of Beirut Medical Center (23% had pharmacologic stress with dipyridamole and 77% had exercise stress testing). Patients referred to pharmacologic stress were older, had a higher percentage of women, and a higher prevalence of diabetes and hypertension. There were more abnormal scans in the pharmacologic stress group (38% vs 20%, P < 0.001), as well as a higher prevalence of ischemia (21% vs 13%, P < 0.001) and impaired left ventricular function with an ejection fraction < 50% (19% vs 7.9%, P < 0.001). The significant predictors for referral to pharmacologic stress by multivariable logistic regression analysis were older age (OR = 2.01 (1.57-2.57), P < 0.001) and diabetes (OR = 2.04 (1.19-3.49), P = 0.009). CONCLUSION Patients referred for pharmacologic stress MPI are at a higher risk than those referred for exercise stress MPI with more CAD risk factors, older age, and a higher prevalence of abnormal MPI findings.
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Affiliation(s)
- Mahmoud Eldirani
- Division of Cardiology, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Omar Chehab
- Division of Cardiology, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Hussein Hassan
- Division of Cardiology, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Hani Tamim
- Division of Cardiology, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Habib A Dakik
- Division of Cardiology, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon.
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Feinstein MJ, Poole B, Engel Gonzalez P, Pawlowski AE, Schneider D, Provias TS, Palella FJ, Achenbach CJ, Lloyd-Jones DM. Differences by HIV serostatus in coronary artery disease severity and likelihood of percutaneous coronary intervention following stress testing. J Nucl Cardiol 2018; 25:872-883. [PMID: 27739037 PMCID: PMC5391305 DOI: 10.1007/s12350-016-0689-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 09/15/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND HIV-infected persons develop coronary artery disease (CAD) more commonly and earlier than uninfected persons; however, the role of non-invasive testing to stratify CAD risk in HIV is not well defined. METHODS AND RESULTS Patients were selected from a single-center electronic cohort of HIV-infected patients and uninfected controls matched 1:2 on age, sex, race, and type of cardiovascular testing performed. Patients with abnormal echocardiographic or nuclear stress testing who subsequently underwent coronary angiography were included. Logistic regressions were used to assess differences by HIV serostatus in two co-primary endpoints: (1) severe CAD (≥70% stenosis of at least one coronary artery) and (2) performance of percutaneous coronary intervention (PCI). HIV-infected patients (N = 189) were significantly more likely to undergo PCI following abnormal stress test when compared with uninfected persons (N = 319) after adjustment for demographics, CAD risk factors, previous coronary intervention, and stress test type (OR 1.85, 95% CI 1.12-3.04, P = 0.003). No associations between HIV serostatus and CAD were statistically significant, although there was a non-significant trend toward greater CAD for HIV-infected patients. CONCLUSIONS HIV-infected patients with abnormal cardiovascular stress testing who underwent subsequent coronary angiography did not have a significantly greater CAD burden than uninfected controls, but were significantly more likely to receive PCI.
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Affiliation(s)
- Matthew J Feinstein
- Division of Cardiovascular Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 N. St. Clair, Suite 600, Chicago, IL, 60611, USA.
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lakeshore Drive, Suite 1400, Chicago, IL, 60611, USA.
| | - Brian Poole
- Department of Medicine, Beth Israel Deaconness Medical Center, Boston, MA, USA
| | - Pedro Engel Gonzalez
- Department of Medicine, Northwestern University Feinberg School of Medicine, 251 E. Huron, Suite 3-150, Chicago, IL, 60611, USA
| | - Anna E Pawlowski
- Northwestern Medicine Enterprise Data Warehouse, Chicago, IL, 60611, USA
| | - Daniel Schneider
- Northwestern Medicine Enterprise Data Warehouse, Chicago, IL, 60611, USA
| | - Tim S Provias
- Division of Cardiovascular Diseases, Northwestern University Feinberg School of Medicine, 676 N. St. Clair, Suite 600, Chicago, IL, 60611, USA
| | - Frank J Palella
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, 251 E. Huron St., Suite 3-150, Chicago, IL, 60611, USA
| | - Chad J Achenbach
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, 251 E. Huron St., Suite 3-150, Chicago, IL, 60611, USA
| | - Donald M Lloyd-Jones
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lakeshore Drive, Suite 1400, Chicago, IL, 60611, USA
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Assessment of myocardial blood flow and coronary flow reserve with positron emission tomography in ischemic heart disease: current state and future directions. Heart Fail Rev 2018; 22:441-453. [PMID: 28593557 DOI: 10.1007/s10741-017-9625-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Positron emission tomography (PET) is a versatile imaging technology that allows assessment of myocardial perfusion, both at a spatially relative scale and also in absolute terms, thereby enabling noninvasive evaluation of myocardial blood flow (MBF) and coronary flow reserve (CFR). Assessment of MBF using FDA-approved PET isotopes, such as 82Rb and 13N-ammonia, has been well validated, and several software packages are currently available, thereby allowing for MBF evaluation to be incorporated into routine workflow in contemporary nuclear laboratories. Incremental diagnostic and prognostic information provided with the knowledge of MBF has the potential for widespread applications. Improving the ability to identify the true burden of obstructive epicardial coronary stenoses and allowing for noninvasive assessment of coronary micro circulatory function can be achieved with MBF assessment. On the other hand, attenuated CFR has been shown to predict adverse cardiovascular prognosis in a variety of clinical settings and patient subgroups. With expanding applications of MBF, this tool promises to provide unique insight into the integrity of the entire coronary vascular bed beyond what is currently available with relative perfusion assessment. This review intends to provide an in-depth discussion of technical and clinical aspects of MBF assessment with PET as it relates to patients with ischemic heart disease.
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Boiten HJ, van Domburg RT, Geleijnse ML, Valkema R, Zijlstra F, Schinkel AFL. Cardiac stress imaging for the prediction of very long-term outcomes: Dobutamine stress echocardiography or dobutamine 99mTc-sestamibi SPECT? J Nucl Cardiol 2018; 25:471-479. [PMID: 27444501 PMCID: PMC5869882 DOI: 10.1007/s12350-016-0521-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 04/18/2016] [Indexed: 12/03/2022]
Abstract
BACKGROUND Both dobutamine stress echocardiography (DSE) and myocardial perfusion imaging (MPI) using single-photon emission computed tomography (SPECT) are frequently used for cardiac risk stratification. The long-term relative prognostic value of these modalities has not been studied. Therefore, this study evaluated the long-term prognostic value of DSE compared to MPI in patients unable to perform exercise testing. METHODS This prospective, single center study included 301 patients (mean age 59 ± 12 years, 56% men) unable to perform exercise tests who underwent DSE and dobutamine stress 99mTc-sestamibi MPI. End points during follow-up were all-cause mortality, cardiac mortality, and nonfatal myocardial infarction (MI). Univariable and multivariable Cox proportional hazards regression models were used to identify independent predictors of outcome. The probability of survival was calculated using the Kaplan-Meier method. RESULTS A total of 182 patients (60%) had an abnormal DSE and 198 (66%) patients had an abnormal MPI. The agreement between DSE and MPI was 82% (κ = 0.62). During a median follow-up of 14 years (range 5-18), 172 deaths (57%) occurred, of which 72 (24%) were due to cardiac causes. Nonfatal MI occurred in 46 patients (15%). The multivariable analysis demonstrated that an abnormal DSE was a significant predictor of cardiac mortality (HR 2.35, 95% CI [1.17-4.73]) and hard cardiac events (HR 2.11, 95% CI [1.25-3.57]). Also, an abnormal MPI result was a significant predictor of cardiac mortality (HR 3.03, 95% CI [1.33-6.95]) and hard cardiac events (HR 2.06, 95% CI [1.12-3.79]). CONCLUSIONS DSE and MPI are comparable in predicting long-term cardiac mortality and hard cardiac events in patients unable to perform exercise testing.
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Affiliation(s)
- Hendrik J Boiten
- Department of Cardiology, Thoraxcenter Room Ba304, Erasmus Medical Center, 's-Gravendijkwal 230, Rotterdam, 3015 CE, The Netherlands.
| | - Ron T van Domburg
- Department of Cardiology, Thoraxcenter Room Ba304, Erasmus Medical Center, 's-Gravendijkwal 230, Rotterdam, 3015 CE, The Netherlands
| | - Marcel L Geleijnse
- Department of Cardiology, Thoraxcenter Room Ba304, Erasmus Medical Center, 's-Gravendijkwal 230, Rotterdam, 3015 CE, The Netherlands
| | - Roelf Valkema
- Department of Nuclear Medicine, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Felix Zijlstra
- Department of Cardiology, Thoraxcenter Room Ba304, Erasmus Medical Center, 's-Gravendijkwal 230, Rotterdam, 3015 CE, The Netherlands
| | - Arend F L Schinkel
- Department of Cardiology, Thoraxcenter Room Ba304, Erasmus Medical Center, 's-Gravendijkwal 230, Rotterdam, 3015 CE, The Netherlands
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Massardo T, Alarcón L, Spuler J. Estratificación de riesgo de enfermedad coronaria con métodos isotópicos. Estado actual de la práctica clínica. Rev Esp Med Nucl Imagen Mol 2017; 36:377-387. [DOI: 10.1016/j.remn.2017.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 06/07/2017] [Accepted: 06/14/2017] [Indexed: 11/28/2022]
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Massardo T, Alarcón L, Spuler J. Risk stratification of coronary artery disease using radionuclides. Current status of clinical practice. Rev Esp Med Nucl Imagen Mol 2017. [DOI: 10.1016/j.remnie.2017.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Prognostic value of a faster, low-radiation myocardial perfusion SPECT protocol in a CZT camera. Int J Cardiovasc Imaging 2017; 33:2049-2056. [DOI: 10.1007/s10554-017-1202-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 06/22/2017] [Indexed: 10/19/2022]
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Argulian E, Po JRF, Uretsky S, Kommaraju KK, Patel S, Agarwal V, Cohen R, Rozanski A. Comparison of the current reasons for undergoing pharmacologic stress during echocardiographic and radionuclide stress testing. J Nucl Cardiol 2017; 24:546-554. [PMID: 26911366 DOI: 10.1007/s12350-016-0398-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 11/28/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Symptom-limited exercise is the preferred method of cardiac stress testing, but pharmacologic testing has been increasing over time. The exact reasons for pharmacologic stress testing have not been rigorously categorized. Thus, we systematically explored the reasons for pharmacologic stress testing in patients referred for cardiac stress imaging. METHODS We studied consecutive patients referred for stress imaging [stress echocardiography or radionuclide myocardial perfusion imaging (MPI)] at Mount Sinai St Luke's hospital between August 2013 and April 2014. Baseline information was obtained using a standardized questionnaire and a trained physician triaged the patient for symptom-limited exercise stress testing or pharmacologic stress testing. RESULTS In total, 551(48%) of our entire stress cohort underwent cardiac imaging following initial exercise testing and 589 (52%) underwent imaging with initial pharmacologic stress testing. Deconditioning and inability to walk (primarily due to musculoskeletal conditions) constituted the top two reasons for performing pharmacologic stress, followed by frailty, left bundle branch block (for MPI), resting wall motion abnormality (for echocardiography), and failed exercise attempts. The reasons for performing pharmacologic stress testing were similar in the MPI and echocardiography patients, despite a much higher level of disease acuity in the MPI group. CONCLUSIONS We have applied a systematic approach for categorizing the reasons for pharmacologic stress. These reasons are heterogeneous, but similar across MPI and echo stress laboratories.
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Affiliation(s)
- Edgar Argulian
- Division of Cardiology, Mount Sinai St. Luke's Hospital, 1111 Amersterdam Avenue, New York, NY, USA.
- The Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | | | - Seth Uretsky
- Division of Cardiology, Mount Sinai St. Luke's Hospital, 1111 Amersterdam Avenue, New York, NY, USA
- The Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Morristown Medical Center, Morristown, NJ, USA
| | - Kiran K Kommaraju
- Division of Cardiology, Mount Sinai St. Luke's Hospital, 1111 Amersterdam Avenue, New York, NY, USA
- The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Suketukumar Patel
- Division of Cardiology, Mount Sinai St. Luke's Hospital, 1111 Amersterdam Avenue, New York, NY, USA
- The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Vikram Agarwal
- Division of Cardiology, Mount Sinai St. Luke's Hospital, 1111 Amersterdam Avenue, New York, NY, USA
- The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Randy Cohen
- Division of Cardiology, Mount Sinai St. Luke's Hospital, 1111 Amersterdam Avenue, New York, NY, USA
- The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alan Rozanski
- Division of Cardiology, Mount Sinai St. Luke's Hospital, 1111 Amersterdam Avenue, New York, NY, USA
- The Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Gonzalez JA, Beller GA. Choosing exercise or pharmacologic stress imaging, or exercise ECG testing alone: How to decide. J Nucl Cardiol 2017; 24:555-557. [PMID: 26846366 DOI: 10.1007/s12350-016-0409-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Accepted: 01/11/2016] [Indexed: 10/22/2022]
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Halawa A. Evaluation of the Cardiovascular Prior to Transplantation; An Endless Debate. ACTA ACUST UNITED AC 2017. [DOI: 10.15406/unoaj.2017.04.00126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Sechtem U, Mahrholdt H, Ong P, Athanasiadis A, Schäufele T. Testing in Patients With Stable Coronary Artery Disease - The Debate Continues. Circ J 2016; 80:802-10. [PMID: 26984588 DOI: 10.1253/circj.cj-16-0220] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The major guidelines on stable coronary artery disease recommend revascularizing patients with large areas of myocardium at risk. The algorithms on how to prove that such high risk is present differ considerably. The opinions on the use of coronary CT (calcium scoring and angiography) vary widely. This review aims to summarize the recommendations of the major guidelines, commenting on differences between the guidelines and discussing whether extending the role of coronary CT angiography should be considered in the light of new CT data.
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Budoff MJ, Raggi P, Beller GA, Berman DS, Druz RS, Malik S, Rigolin VH, Weigold WG, Soman P. Noninvasive Cardiovascular Risk Assessment of the Asymptomatic Diabetic Patient: The Imaging Council of the American College of Cardiology. JACC Cardiovasc Imaging 2016; 9:176-92. [PMID: 26846937 DOI: 10.1016/j.jcmg.2015.11.011] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 11/06/2015] [Indexed: 12/21/2022]
Abstract
Increased cardiovascular morbidity and mortality in patients with type 2 diabetes is well established; diabetes is associated with at least a 2-fold increased risk of coronary heart disease. Approximately two-thirds of deaths among persons with diabetes are related to cardiovascular disease. Previously, diabetes was regarded as a "coronary risk equivalent," implying a high 10-year cardiovascular risk for every diabetes patient. Following the original study by Haffner et al., multiple studies from different cohorts provided varying conclusions on the validity of the concept of coronary risk equivalency in patients with diabetes. New guidelines have started to acknowledge the heterogeneity in risk and include different treatment recommendations for diabetic patients without other risk factors who are considered to be at lower risk. Furthermore, guidelines have suggested that further risk stratification in patients with diabetes is warranted before universal treatment. The Imaging Council of the American College of Cardiology systematically reviewed all modalities commonly used for risk stratification in persons with diabetes mellitus and summarized the data and recommendations. This document reviews the evidence regarding the use of noninvasive testing to stratify asymptomatic patients with diabetes with regard to coronary heart disease risk and develops an algorithm for screening based on available data.
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Affiliation(s)
- Matthew J Budoff
- Department of Medicine, Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, California.
| | - Paolo Raggi
- Mazankowski Alberta Heart Institute, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - George A Beller
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Daniel S Berman
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center and the Cedars-Sinai Heart Institute, Los Angeles, California
| | - Regina S Druz
- Department of Cardiology, Hofstra North Shore-LIJ School of Medicine, Uniondale, New York
| | - Shaista Malik
- Department of Medicine, University of California, Irvine, California
| | - Vera H Rigolin
- Department of Medicine/Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Wm Guy Weigold
- Cardiology Division, MedStar Heart & Vascular Institute, MedStar Washington Hospital Center, Washington, DC
| | - Prem Soman
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Standbridge K, Reyes E. The role of pharmacological stress testing in women. J Nucl Cardiol 2016; 23:997-1007. [PMID: 27515346 DOI: 10.1007/s12350-016-0602-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 05/16/2016] [Accepted: 05/16/2016] [Indexed: 11/24/2022]
Abstract
Pharmacological stress is an alternative method to dynamic exercise that combined with noninvasive imaging allows the detection of flow-limiting coronary artery disease (CAD). It represents the stress procedure of choice in patients who cannot exercise appropriately. In women, pharmacological stress combined with myocardial perfusion scintigraphy (MPS) has demonstrated to be highly accurate for the detection of obstructive CAD and a valuable tool that helps separate patients at low cardiac risk from those with an adverse prognosis. Pharmacological stress with positron emission tomographic (PET) imaging is increasingly used in the investigation of suspected obstructive CAD; available evidence shows that the diagnostic profile and prognostic value of stress PET imaging is similar to that of stress MPS in women.
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Affiliation(s)
- Katherine Standbridge
- Nuclear Medicine Department, Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London, SW3 6NP, United Kingdom
| | - Eliana Reyes
- Nuclear Medicine Department, Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London, SW3 6NP, United Kingdom.
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Gimelli A, Liga R, Pasanisi EM, Casagranda M, Coceani M, Marzullo P. Influence of cardiac stress protocol on myocardial perfusion imaging accuracy: The role of exercise level on the evaluation of ischemic burden. J Nucl Cardiol 2016; 23:1114-1122. [PMID: 25814218 DOI: 10.1007/s12350-015-0101-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 02/16/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Some specifics of cardiac stress protocols, i.e., stressor used or exercise level achieved, may impact myocardial perfusion imaging (MPI) accuracy. METHODS Four-hundred and seventy-five patients were submitted to MPI and coronary angiography. MPI was performed after exercise (303 patients) or dipyridamole stress (172 patients). A coronary stenosis ≥70% was considered significant. In case of exercise test, a peak heart rate (HR) <85% of the maximal age predicted was considered submaximal and categorized as follows: >75% and <85% ("Group 1"); <75% ("Group 2"). RESULTS At coronary angiography, 312/475 (66%) patients showed significant stenosis. In the overall population, MPI showed a high accuracy in unmasking significant coronary stenosis, independently of the stress protocol adopted (AUC .76 for exercise vs .78 for vasodilator; P = NS). However, in case of an exercise stress test, a significant interaction between peak %HR and MPI diagnostic power was evident. While an elevated accuracy was still maintained in "Group 1" patients (AUC .79; P vs maximal exercise = NS), a significant drop was demonstrated in "Group 2" patients (AUC .66; P vs maximal exercise = .012, and P vs "Group 1" = .042). CONCLUSIONS The accuracy of MPI is not influenced by the stress protocol adopted. Exercise MPI maintains an elevated accuracy as long as the %HR remains >75%.
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Affiliation(s)
- Alessia Gimelli
- Fondazione Toscana Gabriele Monasterio, Via Moruzzi 1, 56124, Pisa, Italy
| | - Riccardo Liga
- Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy.
| | | | - Mirta Casagranda
- Fondazione Toscana Gabriele Monasterio, Via Moruzzi 1, 56124, Pisa, Italy
| | - Michele Coceani
- Fondazione Toscana Gabriele Monasterio, Via Moruzzi 1, 56124, Pisa, Italy
| | - Paolo Marzullo
- Fondazione Toscana Gabriele Monasterio, Via Moruzzi 1, 56124, Pisa, Italy
- CNR, Institute of Clinical Physiology, Pisa, Italy
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Spadafora M, Salvatore M, Cuocolo A. Stress protocol and accuracy of myocardial perfusion imaging: Is it better to start from the end? J Nucl Cardiol 2016; 23:1123-1127. [PMID: 25824021 DOI: 10.1007/s12350-015-0119-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 03/10/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Marco Spadafora
- Nuclear Medicine Unit, San Giuseppe Moscati Hospital, Avellino, Italy
| | | | - Alberto Cuocolo
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy.
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50
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Balfour PC, Gonzalez JA, Kramer CM. Non-invasive assessment of low- and intermediate-risk patients with chest pain. Trends Cardiovasc Med 2016; 27:182-189. [PMID: 27717538 DOI: 10.1016/j.tcm.2016.08.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 07/28/2016] [Accepted: 08/16/2016] [Indexed: 01/26/2023]
Abstract
Coronary artery disease (CAD) remains a significant global public health burden despite advancements in prevention and therapeutic strategies. Common non-invasive imaging modalities, anatomic and functional, are available for the assessment of patients with stable chest pain. Exercise electrocardiography is a long-standing method for evaluation for CAD and remains the initial test for the majority of patients who can exercise adequately with a baseline interpretable electrocardiogram. The addition of cardiac imaging to exercise testing provides incremental benefit for accurate diagnosis for CAD and is particularly useful in patients who are unable to exercise adequately and/or have uninterpretable electrocardiograms. Radionuclide myocardial perfusion imaging and echocardiography with exercise or pharmacological stress provide high sensitivity and specificity in the detection and further risk stratification of patients with CAD. Recently, coronary computed tomography angiography has demonstrated its growing role to rule out significant CAD given its high negative predictive value. Although less available, stress cardiac magnetic resonance provides a comprehensive assessment of cardiac structure and function and provides a high diagnostic accuracy in the detection of CAD. The utilization of non-invasive testing is complex due to various advantages and limitations, particularly in the assessment of low- and intermediate-risk patients with chest pain, where no single study is suitable for all patients. This review will describe currently available non-invasive modalities, along with current evidence-based guidelines and appropriate use criteria in the assessment of low- and intermediate-risk patients with suspected, stable CAD.
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Affiliation(s)
- Pelbreton C Balfour
- Department of Medicine (Cardiology), Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA
| | - Jorge A Gonzalez
- Department of Medicine (Cardiology), Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA
| | - Christopher M Kramer
- Department of Medicine (Cardiology), Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA; Department of Radiology, University of Virginia Health System, Charlottesville, VA.
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