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Yokota S, Mouden M, Ottervanger JP, Engbers E, Jager PL, Timmer JR, Knollema S. Coronary calcium score influences referral for invasive coronary angiography after normal myocardial perfusion SPECT. J Nucl Cardiol 2019; 26:602-612. [PMID: 28916890 DOI: 10.1007/s12350-017-1067-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 08/03/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND In patients with normal SPECT but persistent complaints, invasive angiography may exclude obstructive coronary disease. We assessed whether high coronary artery calcium (CAC) scores are associated with increased referral for invasive angiography following normal SPECT. METHODS AND RESULTS 2286 consecutive patients (mean age 60 ± 12, 39% male) with normal SPECT were assessed. All patients underwent simultaneous CAC scoring. Patients were categorized into four groups based on their CAC score: CAC = 0 (n = 694), CAC 1 to 100 (n = 891), CAC 101 to 400 (n = 368), and CAC >400 (n = 333). The decision to perform angiography was left to the discretion of treating physician. Follow-up angiography was confined to the first 60 days after SPECT. Occurrence of MACE (late revascularization, myocardial infarction or death) was recorded. Overall, 100 patients (4.4%) underwent early angiography with increasing rates in higher CAC score groups (1.0%, 2.6%, 8.4%, and 11.7%), respectively, P < .001). A CAC score >400 (OR 3.56, 95% CI 2.19 to 5.77, P < .001) was independently associated with referral to angiography. Similarly, CAC score >400 was an independent predictor for MACE (HR 9.26, 95% CI 5.06 to 16.93). Early angiography did not influence prognosis (HR 1.57, 95% CI 0.91 to 2.73). CONCLUSIONS CAC scoring impacts clinical decision-making and increases referral rates for invasive angiography after normal SPECT.
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Affiliation(s)
- Shu Yokota
- Departments of Cardiology, Isala hospital, Dr. Van Heesweg 2, 8025 AB, Zwolle, The Netherlands
| | - Mohamed Mouden
- Departments of Cardiology, Isala hospital, Dr. Van Heesweg 2, 8025 AB, Zwolle, The Netherlands.
- Nuclear Medicine, Isala hospital, Zwolle, The Netherlands.
| | - Jan Paul Ottervanger
- Departments of Cardiology, Isala hospital, Dr. Van Heesweg 2, 8025 AB, Zwolle, The Netherlands
| | - Elsemiek Engbers
- Departments of Cardiology, Isala hospital, Dr. Van Heesweg 2, 8025 AB, Zwolle, The Netherlands
- Nuclear Medicine, Isala hospital, Zwolle, The Netherlands
| | - Pieter L Jager
- Nuclear Medicine, Isala hospital, Zwolle, The Netherlands
| | - Jorik R Timmer
- Departments of Cardiology, Isala hospital, Dr. Van Heesweg 2, 8025 AB, Zwolle, The Netherlands
| | - Siert Knollema
- Nuclear Medicine, Isala hospital, Zwolle, The Netherlands
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Roifman I, Rezai MR, Wijeysundera HC, Chow BJW, Wright GA, Tu JV. Utilization of cardiac computed tomography angiography and outpatient invasive coronary angiography in Ontario, Canada. J Cardiovasc Comput Tomogr 2015; 9:567-71. [PMID: 26233520 DOI: 10.1016/j.jcct.2015.07.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 06/06/2015] [Accepted: 07/06/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Cardiac computed tomography angiography (coronary CTA) has emerged as a non-invasive method of diagnosing coronary artery disease. The extent of utilization and uptake of this technology since initiation of its funding by the government of Ontario is unknown. OBJECTIVES The aim of our study was to examine coronary CTA utilization and the rates of elective invasive coronary angiography and revascularization before and after funding initiation. METHODS We studied all coronary CTAs performed on adults in Ontario after initiation of funding. We also used an interrupted time series analysis to compare the average monthly rates of invasive angiography and revascularization before and after initiation of funding. RESULTS There was an initial steep increase in age-and sex-standardized rates of coronary CTA from 5.0 to 11.4/100,000 over the first two quarters after funding initiation. Afterwards, there was a gradual increase in utilization from 11.4 to 17.1/100,000 over two subsequent calendar years. There was a significant reduction in both the mean monthly outpatient invasive coronary angiography (from 20.7 to 19.9 per 100,000 (p = 0.0004)) and revascularization (from 4.9 to 4.4 per 100,000 (p < 0.0001)) rates in the three years following introduction of the coronary CTA billing code as compared to the three prior to its introduction. CONCLUSIONS Since the introduction of coronary CTA funding in Ontario, there has been a steady and controlled increase in its utilization. The increasing use of coronary CTA was associated with a reduction in both the rates of invasive angiography and revascularization.
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Affiliation(s)
- Idan Roifman
- Institute for Clinical Evaluative Sciences (ICES), Canada; Schulich Heart Program and the Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Canada; Institute for Health Policy, Management and Evaluation (IHPME), Canada
| | | | - Harindra C Wijeysundera
- Institute for Clinical Evaluative Sciences (ICES), Canada; Schulich Heart Program and the Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Canada; Institute for Health Policy, Management and Evaluation (IHPME), Canada
| | - Benjamin J W Chow
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Graham A Wright
- Schulich Heart Program and the Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Canada; Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Jack V Tu
- Institute for Clinical Evaluative Sciences (ICES), Canada; Schulich Heart Program and the Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Canada; Institute for Health Policy, Management and Evaluation (IHPME), Canada.
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Dean J, Cruz SD, Mehta PK, Merz CNB. Coronary microvascular dysfunction: sex-specific risk, diagnosis, and therapy. Nat Rev Cardiol 2015; 12:406-14. [PMID: 26011377 DOI: 10.1038/nrcardio.2015.72] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Cardiovascular disease is the leading cause of death worldwide. In the presence of signs and symptoms of myocardial ischaemia, women are more likely than men to have no obstructive coronary artery disease (CAD). Women have a greater burden of symptoms than men, and are often falsely reassured despite the presence of ischaemic heart disease because of a lack of obstructive CAD. Coronary microvascular dysfunction should be considered as an aetiology for ischaemic heart disease with signs and symptoms of myocardial ischaemia, but no obstructive CAD. Coronary microvascular dysfunction is defined as impaired coronary flow reserve owing to functional and/or structural abnormalities of the microcirculation, and is associated with an adverse cardiovascular prognosis. Therapeutic lifestyle changes as well as antiatherosclerotic and antianginal medications might be beneficial, but clinical outcome trials are needed to guide treatment. In this Review, we discuss the prevalence, presentation, diagnosis, and treatment of coronary microvascular dysfunction, with a particular emphasis on ischaemic heart disease in women.
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Affiliation(s)
- Jenna Dean
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, A3600, Los Angeles, CA 90048, USA
| | - Sherwin Dela Cruz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, A3600, Los Angeles, CA 90048, USA
| | - Puja K Mehta
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, A3600, Los Angeles, CA 90048, USA
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, A3600, Los Angeles, CA 90048, USA
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Freed BH, Narang A, Bhave NM, Czobor P, Mor-Avi V, Zaran ER, Turner KM, Cavanaugh KP, Chandra S, Tanaka SM, Davidson MH, Lang RM, Patel AR. Prognostic value of normal regadenoson stress perfusion cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2013; 15:108. [PMID: 24359617 PMCID: PMC3878099 DOI: 10.1186/1532-429x-15-108] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 12/10/2013] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Regadenoson is a vasodilator stress agent that selectively activates the A2A receptor. Compared to adenosine, regadenoson is easier to administer and results in fewer side effects. Although extensively studied in patients undergoing nuclear perfusion imaging (MPI), its use for perfusion cardiovascular magnetic resonance (CMR) is not well described. The aim of this study was to determine the prognostic value of a normal regadenoson perfusion CMR in patients with known or suspected coronary artery disease. METHODS Patients with known or suspected coronary artery disease were prospectively enrolled to receive perfusion CMR (Philips 1.5 T) with regadenoson. Three short-axis slices of the left ventricle (LV) were obtained during first pass of contrast using a hybrid GRE-EPI pulse sequence (0.075 mmol/kg Gadolinium-DTPA-BMA at 4 ml/sec). Imaging was performed 1 minute after injection of regadenoson (0.4 mg) and repeated 15 minutes after reversal of hyperemia with aminophylline (125 mg). Perfusion defects were documented if they persisted for ≥ 2 frames after peak enhancement of the LV cavity. CMR was considered abnormal if there was a resting wall motion abnormality, decreased LVEF (<40%), presence of LGE, or the presence of a perfusion defect during hyperemia. All patients were followed for a minimum of 1 year for major adverse cardiovascular event (MACE) defined as coronary revascularization, non-fatal myocardial infarction, and cardiovascular death. RESULTS 149 patients were included in the final analysis. Perfusion defects were noted in 43/149 (29%) patients; 59/149 (40%) had any abnormality on CMR. During the mean follow-up period of 24 ± 9 months, 17/149 (11.4%) patients experienced MACE. The separation in the survival distributions for those with perfusion defects and those without perfusion defects was highly significant (log-rank p = 0.0001). When the absence of perfusion defects was added to the absence of other resting CMR abnormalities, the negative predictive value improved from 96% to 99%. CONCLUSION Regadenoson perfusion CMR provides high confidence for excellent prognosis in patients with normal perfusion.
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Affiliation(s)
- Benjamin H Freed
- Department of Medicine, Northwestern University, Chicago, IL, USA
| | - Akhil Narang
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Nicole M Bhave
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Peter Czobor
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Victor Mor-Avi
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Emily R Zaran
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | | | - Sonal Chandra
- Department of Medicine, Northwestern University, Chicago, IL, USA
| | - Sara M Tanaka
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Roberto M Lang
- Department of Medicine, University of Chicago, Chicago, IL, USA
- Department of Radiology, University of Chicago, MC 5084, 5841 S Maryland Ave., Chicago, IL 60637, USA
| | - Amit R Patel
- Department of Medicine, University of Chicago, Chicago, IL, USA
- Department of Radiology, University of Chicago, MC 5084, 5841 S Maryland Ave., Chicago, IL 60637, USA
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Will robust evidence drive appropriate utilization of CTA? J Cardiovasc Comput Tomogr 2007; 1:27-8. [DOI: 10.1016/j.jcct.2007.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2007] [Accepted: 04/19/2007] [Indexed: 11/22/2022]
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Crean A, Dutka D, Coulden R. Cardiac imaging using nuclear medicine and postitron emission tomography. Radiol Clin North Am 2004; 42:619-34, vii. [PMID: 15193933 DOI: 10.1016/j.rcl.2004.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This article concentrates on specific issues that are of current interest in mainstream nuclear cardiology. These include developments in myocardial perfusion technique, the potential diagnostic benefits of ECG-gating and attenuation correction, nuclear imaging in the diagnosis of hibernating myocardium, and the cost-effectiveness of perfusion imaging in patients with suspected angina.
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Affiliation(s)
- Andrew Crean
- Department of Radiology, Papworth Hospital, Cambridge, CB3 8RE UK
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Abstract
Cost-effectiveness analysis is a method of comparing societal economic value of 2 different strategies. Ideally, it defines accurate test-related (direct and downstream) costs and appropriately converts differential patient outcomes into a dollar value. The likelihood that cost-effectiveness analysis translated into a policy-making tool will enhance health care and/or control costs is dependent on the validity of numerous assumptions about relative costs, patient outcomes, and generalizability of the literature to regional capabilities. The purpose of this report is to review the concept of cost-effectiveness analysis as it applies to stress echocardiography and stress myocardial perfusion imaging for selected patient subsets.
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Affiliation(s)
- N K Chee
- Cardiovascular Consultants, PC, Mid-America Heart Institute, University of Missouri-Kansas City, School of Medicine, USA
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