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Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RY, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease: Executive Summary. J Am Coll Cardiol 2012. [DOI: 10.1016/j.jacc.2012.07.012] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012. [PMID: 23182125 DOI: 10.1016/j.jacc.2012.07.013] [Citation(s) in RCA: 1231] [Impact Index Per Article: 102.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Chan AK, Ilias-Khan NA, Xian H, Inman C, Martin WH. Arm exercise stress perfusion imaging predicts clinical outcome. J Appl Physiol (1985) 2011; 111:1546-53. [PMID: 21852405 DOI: 10.1152/japplphysiol.00725.2011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Treadmill exercise capacity in resting metabolic equivalents (METs) and stress hemodynamic, electrocardiographic (ECG), and myocardial perfusion imaging (MPI) responses are independently predictive of adverse clinical events. However, limited data exist for arm ergometer stress testing (AXT) in patients who cannot perform leg exercise because of lower extremity disabilities. We sought to determine the extent to which AXT METs, hemodynamic, ECG, and MPI responses to arm exercise add independent incremental value to demographic and clinical variables for prediction of all-cause mortality, myocardial infarction (MI), or late coronary revascularization, individually or as a composite. A prospective cohort of 186 patients aged 64 ± 10 (SD) yr, unable to perform lower extremity exercise, underwent AXT MPI for clinical reasons between 1997 and 2002, and were followed for 62 ± 23 mo, to an endpoint of death or 12/31/2006. Average annual rates were 5.4% for mortality, 2.2% for MI, 2.5% for late coronary revascularization, and 8.0% for combined events. After adjustment for age and clinical variables, AXT METs [P < 0.05; hazard ratio (HR) = 0.59; confidence interval (CI) = 0.35-0.84] and abnormal MPI (P < 0.01; HR = 2.48; CI = 2.15-2.81) were independently predictive of mortality. A positive AXT ECG (P < 0.05; HR = 2.61; CI = 2.13-3.10) was predictive of MI. Death and MI combined were prognosticated by METs (P < 0.05; HR = 0.63; CI = 0.41-0.85), MPI (P < 0.05; HR = 1.77; CI = 1.49-2.05), and a positive AXT ECG (P < 0.05; HR = 1.86; CI = 1.55-2.17). In conclusion, for high risk older patients who cannot perform leg exercise because of lower extremity disabilities, AXT METs are as important as MPI for prediction of mortality alone and death and MI combined, and a positive AXT ECG prognosticates MI alone and death and MI combined.
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Affiliation(s)
- Albert K Chan
- St. Louis Veterans Affairs Medical Center and the Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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Lee DS, Verocai F, Husain M, Al Khdair D, Wang X, Freeman M, Iwanochko RM. Cardiovascular outcomes are predicted by exercise-stress myocardial perfusion imaging: Impact on death, myocardial infarction, and coronary revascularization procedures. Am Heart J 2011; 161:900-7. [PMID: 21570520 DOI: 10.1016/j.ahj.2011.01.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Accepted: 01/31/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND The aim of this study was to determine the impact of myocardial perfusion imaging (MPI) on the outcomes of death, myocardial infarction (MI), and late coronary revascularization procedures. METHODS In patients undergoing exercise-stress MPI (January 1, 2003-March 31, 2007), we determined the impact of summed stress score (SSS) and percent left ventricular (LV) ischemia on (a) death or MI and (b) composite of death, MI, or late coronary revascularization occurring more than 90 days post-MPI. RESULTS During 35,007 person-years of follow-up among 9,605 patients (mean ± SD age 54.4 ± 13.2 years, 60.3% men), there were 290 deaths, 175 MIs, and 525 coronary revascularization procedures. Of those who attained ≥10 metabolic equivalents (METS) workload, major stress perfusion defects (SSS ≥7) were present in 4.2% overall and in 3.7% without ST-segment shifts, whereas large ischemic defects (≥10% LV ischemia) were present in 1% overall and 0.7% without ST-segment shifts. For those with 1% to 4%, 5% to 9%, and ≥10% LV ischemia, adjusted hazard ratios were 1.40 (95% CI 1.13-1.73, P = .002), 2.07 (95% CI 1.56-2.74, P < .001), and 3.03 (95% CI 2.21-4.16, P < .001) for the outcome of late revascularization, MI, or death versus no ischemia. Summed stress scores ≥7 were associated with increased risk of death or MI, with an adjusted hazard ratio of 1.57 (95% CI 1.16-2.13, P = .004) compared with those with no stress perfusion defects. CONCLUSION Although workload ≥10 METS conferred lower frequency of major ischemia (≥10%), %LV ischemia predicted the occurrence of cardiovascular events and death (eg, MI, late coronary revascularization, or death). Presence of a large stress perfusion defect (SSS ≥7) predicted increased risk of MI or death.
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Raziei G, Tavakoli A, Seifollahi Asl S, Amoiei M, Javadi H, Assadi M. One-year prognosis of patients with normal myocardial perfusion imaging using technitium-99m sestamibi in suspected coronary artery disease: a single-center experience of 1,047 patients. Perfusion 2011; 26:309-14. [PMID: 21508085 DOI: 10.1177/0267659111403027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The aim of the present study was to evaluate the clinical outcome of a normal stress technetium-99m (99mTc)-Sestamibi single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) with different probabilities of coronary artery disease (CAD). MATERIAL AND METHODS A total of 1,047 subjects with a normal 99mTc-MIBI SPECT were followed up for one year and hard and soft cardiac events were assessed. Hard cardiac events were defined as cardiac death or non-fatal myocardial infarction (MI). Soft cardiac events included the patient's development of recurrent chest pain requiring coronary revascularization or significant stenosis in coronary arteries on angiography. RESULTS Overall, 1,047 patients (248 men and 799 women; mean age: 60.07 ± 12.31, range 29-92) were enrolled. Three hard cardiac events occurred in the groups; two had cardiac arrest and one non-fatal MI. As a result, the annualized hard cardiac event rate was 0.28%, the annualized cardiac mortality rate was 0.19%, and the rate of overall annualized cardiac events was 1.25%. Furthermore, there was a significant difference in cardiac events among patients with various pretest likelihoods of CAD (p value=0.04). CONCLUSION Our data confirmed that patients with a normal 99mTc-Sestamibi myocardial SPECT are associated with a very low incidence of cardiovascular events.
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Affiliation(s)
- Ghasem Raziei
- Department of Nuclear Medicine, Milad Hospital, Tehran, Iran
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Predictive value of myocardial and coronary imaging in the long-term outcome of potential renal transplant recipients. Int J Cardiol 2011; 146:191-6. [DOI: 10.1016/j.ijcard.2009.06.050] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2009] [Revised: 06/23/2009] [Accepted: 06/26/2009] [Indexed: 11/23/2022]
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Marshall AJ, Hutchings F, James AJ, Kelion AD. Prognostic value of a nine-minute treadmill test in patients undergoing myocardial perfusion scintigraphy. Am J Cardiol 2010; 106:1423-8. [PMID: 21059431 DOI: 10.1016/j.amjcard.2010.06.074] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2010] [Revised: 06/28/2010] [Accepted: 06/28/2010] [Indexed: 11/19/2022]
Abstract
Exercise capacity is an important predictor of risk in known or suspected coronary disease. A negative treadmill test to 9 minutes of the Bruce protocol is often used in the screening process for vocational licensing; myocardial perfusion scintigraphy is an alternative for those unable to exercise, with apparent incremental prognostic power above exercise testing alone. We compared exercise test and myocardial perfusion scintigraphic (MPS) findings and risk of hard cardiac events (median 4 years) in patients completing ≥ 9-minute treadmill exercise. Patients undergoing myocardial perfusion scintigraphy who completed a 9-minute Bruce protocol exercise were identified over a 2-year period. Follow-up was performed by telephone, with case-note review when necessary; this was 97% complete. Five hundred sixteen patients were identified (73% men, median age 53 year). One hundred eighty-one (35%) had known coronary disease. One hundred forty-nine (29%) had a "high-risk" exercise test result (limiting chest pain or ST-segment depression), and 69 (13%) had high-risk MPS findings (>10% myocardium ischemic or ejection fraction <40%). Of 367 patients with a reassuring exercise test result, 38 (10.4%) had high-risk MPS findings. Of 149 with a high-risk exercise test, 118 (79%) had reassuring MPS findings. At median follow-up of 49 months, there were 8 cardiac events (1.6%). Only 2 patients with high-risk exercise test results (1.4%) and 1 with high-risk MPS findings (1.5%) had an event. In conclusion, for patients able to manage a 9-minute Bruce protocol, presence/absence of symptoms or electrocardiographic changes is a poor predictor of MPS findings. Irrespective of test findings, however, subsequent cardiac risk is extremely low. Ability to complete a 9-minute Bruce protocol treadmill exercise may itself provide adequate prognostic reassurance for most purposes.
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Affiliation(s)
- Andrew J Marshall
- Nuclear Medicine Department, Harefield Hospital, Royal Brompton & Harefield NHS Trust, Middlesex, United Kingdom
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Peteiro J, Bouzas-Mosquera A, Broullón FJ, Garcia-Campos A, Pazos P, Castro-Beiras A. Prognostic value of peak and post-exercise treadmill exercise echocardiography in patients with known or suspected coronary artery disease. Eur Heart J 2009; 31:187-95. [PMID: 19825812 DOI: 10.1093/eurheartj/ehp427] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
AIMS Although peak may have higher sensitivity than post-treadmill exercise echocardiography (EE) for the detection of coronary artery disease (CAD), its prognostic value remains unknown. We sought to assess the relative values of peak and post-EE for predicting outcome in patients with known/suspected CAD. METHODS AND RESULTS We studied 2947 patients who underwent EE. Wall motion score index (WMSI) was evaluated at rest, peak, and post-exercise. Ischaemia was defined as the development of new or worsening wall motion abnormalities with exercise. Separate analyses for all-cause mortality and major cardiac events (MACE) were performed. Ischaemia developed in 544 patients (18.5%). Among them, ischaemia was detected only at peak exercise in 124 patients (23%), whereas 414 (76%) had ischaemia at peak plus post-exercise imaging and six patients (1%) had ischaemia only at post-exercise. During follow-up, 164 patients died. The 5-year mortality rate was 3.5% in patients without ischaemia, 15.3% in patients with peak ischaemia alone, and 14% in patients with post-exercise ischaemia (P < 0.001 normal vs. ischaemic groups). In the multivariate analysis, post-exercise WMSI was an independent predictor of MACE [hazard ratio (HR) 1.87, 95% confidence interval (CI) 1.09-2.19, P = 0.02]. Peak exercise WMSI was an independent predictor of MACE (HR 2.19, 95% CI 1.30-3.69, P = 0.003) and mortality (HR 1.58, 95% CI 1.07-2.35, P = 0.02). The addition of peak EE results to clinical, resting echocardiography, exercise variables, and post-EE provided incremental prognostic information for MACE (P = 0.04) and mortality (P = 0.04). CONCLUSION Peak treadmill EE provides significant incremental information over post-EE for predicting outcome in patients with known or suspected CAD.
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Affiliation(s)
- Jesús Peteiro
- Department of Cardiology, Complejo Hospitalario Universitario de A Coruña, As Xubias 84, A Coruña, Spain.
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Chatziioannou SN, Moore WH, Dhekne RD, Ford PV. Women with high exercise tolerance and the role of myocardial perfusion imaging. Clin Cardiol 2009; 24:475-80. [PMID: 11403510 PMCID: PMC6655181 DOI: 10.1002/clc.4960240611] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Myocardial perfusion imaging (MPI) provides incremental diagnostic and prognostic information, even in patients with high exercise tolerance. HYPOTHESIS Myocardial perfusion imaging provides significant diagnostic value, specifically in women with high exercise tolerance. METHODS Our study population consisted of all women who underwent exercise MPI in our Department from January 1992 to June 1996 and reached at least Stage IV in the Bruce protocol. Patients were divided into those with known and those with possible coronary artery disease (CAD). All patients were followed for 3 years from the performance of MPI. RESULTS Of 4,803 women who underwent myocardial perfusion imaging, 3,183 had exercise stressing, and of those, 311 reached at least Stage IV in the Bruce protocol. Of these 311 MPI scans, only 23 (7.4%) were abnormal (reversible, fixed, or mixed) and the remaining 288 (92.6%) were normal. Of the 82 patients with known CAD, 13 (15.8%) had an abnormal MPI, while only 10 (4.4%) of the 229 patients with possible CAD. No myocardial infarction or cardiac death occurred within 3 years; one patient with normal MPI needed revascularization. CONCLUSION In women with high exercise tolerance, especially in those without already known CAD, the yield of MPI is very low. Women with high exercise tolerance have an excellent prognosis.
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Affiliation(s)
- S N Chatziioannou
- Department of Radiology, Baylor College of Medicine, Houston, Texas, USA
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Bucerius J, Joe AY, Lindstaedt I, Manka-Waluch A, Reichmann K, Ezziddin S, Palmedo H, Biersack HJ. Single- vs. dual-head SPECT for detection of myocardial ischemia and viability in a large study population. Clin Imaging 2007; 31:228-33. [PMID: 17599615 DOI: 10.1016/j.clinimag.2007.02.025] [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] [Received: 08/10/2006] [Accepted: 02/10/2007] [Indexed: 11/29/2022]
Abstract
BACKGROUND As single-head data acquisition for thallium-201 myocardial SPECT is a frequently used method mainly in the outpatient medical care as well as in smaller hospitals, comparison to dual-head data collection is a still discussed issue mainly with regard to quality control and -assurance. METHODS A total of 1334 patients undergoing thallium-201 myocardial SPECT for diagnosis of myocardial ischemia and/or viability have been retrospectively analyzed. In 554 patients, a single-head gamma camera (360 degrees rotation) has been applied, whereas a dual-head gamma camera (180 degrees rotation) has been used in 780 patients. Four hundred twenty-six patients received both myocardial SPECT as well as coronary angiography. The diagnostic value of both applied acquisition techniques has been analyzed. RESULTS Regarding myocardial viability, positive predictive value for the diagnosis of myocardial scar tissue was significantly higher for dual-head- as compared to single-head acquisition. Among the 426 patients undergoing diagnosis of myocardial ischemia, significant differences have only been found with regard to specificity being higher in the single-head acquisition. Diagnosis of myocardial ischemia related to a distinct myocardial perfusion region showed a significantly higher sensitivity of dual-head acquisition for the left anterior descending perfusion area, whereas specificity was significantly higher for single-head acquisition. CONCLUSIONS Our results indicate a beneficial effect of dual-head data collection with regard to sensitivity of the diagnosis of myocardial ischemia. In contrast, single-head data acquisition was superior with regard to specificity. However, it is justified to preferably apply dual-head data collection in clinical routine due to the shorter acquisition time leading to an evident time benefit of this acquisition technique.
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Affiliation(s)
- Jan Bucerius
- Department of Nuclear Medicine, University of Bonn, Bonn, Germany.
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Metz LD, Beattie M, Hom R, Redberg RF, Grady D, Fleischmann KE. The Prognostic Value of Normal Exercise Myocardial Perfusion Imaging and Exercise Echocardiography. J Am Coll Cardiol 2007; 49:227-37. [PMID: 17222734 DOI: 10.1016/j.jacc.2006.08.048] [Citation(s) in RCA: 323] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2006] [Revised: 08/23/2006] [Accepted: 08/28/2006] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The purpose of this work was to determine the prognostic value of normal exercise myocardial perfusion imaging (MPI) tests and exercise echocardiography tests, and to determine the prognostic value of these imaging modalities in women and men. BACKGROUND Exercise MPI and exercise echocardiography provide prognostic information that is useful in the risk stratification of patients with suspected coronary artery disease (CAD). METHODS We searched the PubMed, Cochrane, and DARE databases between January 1990 and May 2005, and reviewed bibliographies of articles obtained. We included prospective cohort studies of subjects who underwent exercise MPI or exercise echocardiography for known or suspected CAD, and provided data on primary outcomes of myocardial infarction (MI) and cardiac death with at least 3 months of follow-up. Secondary outcomes (unstable angina, revascularization procedures) were abstracted if provided. Studies performed exclusively in patients with CAD were excluded. RESULTS The negative predictive value (NPV) for MI and cardiac death was 98.8% (95% confidence interval [CI] 98.5 to 99.0) over 36 months of follow-up for MPI, and 98.4% (95% CI 97.9 to 98.9) over 33 months for echocardiography. The corresponding annualized event rates were 0.45% per year for MPI and 0.54% per year for echocardiography. In subgroup analyses, annualized event rates were <1% for each MPI isotope, and were similar for women and men. For secondary events, MPI and echocardiography had annualized event rates of 1.25% and 0.95%, respectively. CONCLUSIONS Both exercise MPI and exercise echocardiography have high NPVs for primary and secondary cardiac events. The prognostic utility of both modalities is similar for both men and women.
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Affiliation(s)
- Louise D Metz
- Department of Medicine, New York University School of Medicine, New York, New York, USA
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Myocardial Perfusion Imaging Utilizing Single Photon Emission Computed Tomography Techniques. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Affiliation(s)
- T M Bateman
- Cardiac and Vascular Radiologic Imaging, Mid America Heart Institute, Department of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
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Beller GA, Watson DD. Risk stratification using stress myocardial perfusion imaging: don't neglect the value of clinical variables. J Am Coll Cardiol 2004; 43:209-12. [PMID: 14736439 DOI: 10.1016/j.jacc.2003.11.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- George A Beller
- Cardiovascular Division and Nuclear Cardiology Laboratory, University of Virginia Health System, Charlottesville, Virginia 22908-0158,
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Froelicher V, Shetler K, Ashley E. Better decisions through science: exercise testing scores. Curr Probl Cardiol 2003. [DOI: 10.1016/j.cpcardiol.2003.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Ortega A, Castro-Beiras JM, Moreno R, Mateo A, Muela A, Asín E, Crespo A. [Clinical predictors of the presence of perfusion defects in more than than one territory in myocardial scintigraphy with GATED-SPECT]. REVISTA ESPANOLA DE MEDICINA NUCLEAR 2003; 22:20-5. [PMID: 12550029 DOI: 10.1016/s0212-6982(03)72136-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Extension of perfusion defects is associated with outcome in patients undergoing myocardial scintigraphy. The study aimed to identify the clinical characteristics that can predict the existence of perfusion defects in more than one territory in patients referred for myocardial scintigraphy with GATED-SPECT. PATIENTS AND METHODS A total of 193 patients undergoing myocardial scintigraphy with GATED-SPECT (99mTc-tetrofosmine) were studied. Clinical variables and scintigraphy results were studied to determine what clinical variables are associated with perfusion defects in more than one territory. RESULTS The number of territories with perfusion defects per patient was 1.1 0.8 and 29% had perfusion defects in > 1 territory. Patients with greater probability of having perfusion defects in > 1 territory were those with previous myocardial infarction (44% vs 21%, p = 0.030) and males (33% vs 10%, p = 0.006). In addition, patients with > 2 coronary risk factors had a statistical tendency to have defects in > 1 territory (47% vs 20%, p = 0.057). Only 15% of the patients with one of these three characteristics had perfusion defects in > 1 territory in comparison with 45% and 83% in those with 2 or 3 factors, respectively. CONCLUSION Considering 3 simple clinical characteristics (male gender, previous infarction and existence of > 2 coronary risk factors), it is possible to predict which patients are more likely to show perfusion defects in > 1 territory during GATED-SPECT myocardial scintigraphy.
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Affiliation(s)
- A Ortega
- Servicio de Medicina Nuclear e Instituto de Enfermedades del Corazón, Hospital Ramón y Cajal, Madrid, Spain
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Ashley E, Myers J, Froelicher V. Exercise testing scores as an example of better decisions through science. Med Sci Sports Exerc 2002; 34:1391-8. [PMID: 12165697 DOI: 10.1097/00005768-200208000-00023] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The application of common statistical techniques to clinical and exercise test data has the potential to become a useful tool for assisting in the diagnosis of coronary artery disease, assessing prognosis, and reducing the cost of evaluating patients with suspected coronary disease. Since general practitioners function as gatekeepers and decide which patients must be referred to the cardiologist, they need to optimally use the basic tools they have available (i.e., history, physical exam, and the exercise test). METHODS Review of the literature with a focus on the scientific techniques for aiding the decision-making process. RESULTS Scores derived from multivariable statistical techniques considering clinical and exercise data have demonstrated superior discriminating power when compared using receiver-operating-characteristic curves with the ST segment response. In addition, by stratifying patients as to probability of disease and prognosis, they provide a management strategy. While computers as part of information management systems can calculate complicated equations to provide scores, physicians are reluctant to trust them. Thus, these scores have been represented as nomograms or simple additive tables so physicians are comfortable with their application. Scores have also been compared with physician judgment and been found to estimate the presence of coronary disease and prognosis as well as expert cardiologists, and often better than nonspecialists. CONCLUSION Multivariate scores can empower the clinician to assure the cardiac patient with access to appropriate and cost-effective cardiological care.
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Affiliation(s)
- Euan Ashley
- Cardiology Division (111C), Veterans Affairs Palo Alto Health Care System, Stanford University, 3801 Miranda Avenue, Palo Alto, CA 94304, USA
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Abstract
Statistical tools can be used to create scores for assisting in the diagnosis of coronary artery disease and assessing prognosis. General practitioners and internists frequently function as gatekeepers, deciding which patients must be referred to the cardiologist. Therefore, they need to use the basic tools they have available (ie, history, physical examination and the exercise test) in an optimal fashion. Scores derived from multivariable statistical techniques considering clinical and exercise data have demonstrated superior discriminating power compared with diagnosis only using the ST segment response. In addition, by stratifying patients as to probability of disease and prognosis, they provide a more practical management strategy than a response of normal or abnormal. Although computers, as part of information management systems, can calculate complicated equations and derive these scores, physicians are reluctant to trust them. However, when represented as nomograms or simple additive discrete pieces of information, scores are more readily accepted. The scores have been compared with physician judgment and have been found to estimate the presence of coronary disease and prognosis as well as expert cardiologists and often better than nonspecialists. However, the discriminating power of specific variables from the medical history and exercise test remains unclear because of inadequate study design and differences in study populations. Should expired gases be substituted for estimated METs? Should ST/heart rate index be used instead of putting ST depression and heart rate separately into the models? Should right-sided chest leads and heart rate in recovery be considered? There is a need for further evaluation of these easily obtained variables to improve the accuracy of prediction algorithms, especially in women. The portability and reliability of scores must be ensured because access to specialized care must be safeguarded. Assessment of the clinical and exercise test data and application of the newer scores can empower the clinician to assure the cardiac patient access to appropriate and cost-effective cardiologic care.
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Affiliation(s)
- Victor Froelicher
- Cardiology Division, Veterans Affairs Palo Alto Health Care System, Stanford University, Palo Alto, CA 94304, USA.
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Abstract
Multivariable analysis of clinical and exercise test data has the potential to become a useful tool for assisting in the diagnosis of coronary artery disease, assessing prognosis, and reducing the cost of evaluating patients with suspected coronary disease. Since general practitioners are functioning as gatekeepers and decide which patients must be referred to the cardiologist, they need to use the basic tools they have available (i.e. history, physical examination and the exercise test), in an optimal fashion. Scores derived from multivariable statistical techniques considering clinical and exercise data have demonstrated superior discriminating power compared with simple classification of the ST response. In addition, by stratifying patients as to probability of disease and prognosis, they provide a management strategy. While computers, as part of information management systems, can run complicated equations and derive these scores, physicians are reluctant to trust them. Thus, these scores have been represented as nomograms or simple additive tables so physicians are comfortable with their application. Their results have also been compared with physician judgment and found to estimate the presence of coronary disease and prognosis as well as expert cardiologists and often better than nonspecialists. However, the discriminating power of specific variables from the medical history and exercise test remains unclear because of inadequate study design and differences in study populations. Should expired gases be substituted for estimated metabolic equivalents (METs)? Should ST/heart rate (HR) index be used instead of putting these measurements separately into the models? Should right-sided chest leads and HR in recovery be considered? There is a need for further evaluation of these routinely obtained variables to improve the accuracy of prediction algorithms especially in women. The portability and reliability of these equations must be demonstrated since access to specialised care must be safe-guarded. Hopefully, sequential assessment of the clinical and exercise test data and application of the newer generation of multivariable equations can empower the clinician to assure the cardiac patient access to appropriate and cost-effective cardiological care.
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Affiliation(s)
- K Shetler
- Cardiology Division, Veterans Affairs Palo Alto Healthcare System, Stanford University, California 94304, USA
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Borm JJJ, Bouwsma H, van der Wall EE, Pauwels EKJ. The prognostic value of myocardial perfusion scintigraphy: investigators, are you (mis)leading us? Eur J Nucl Med Mol Imaging 2001; 28:1439-46. [DOI: 10.1007/s002590100606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Borm JJ, Bouwsma H, van der Wall EE, Pauwels EK. The prognostic value of myocardial perfusion scintigraphy: investigators, are you (mis)leading us? EUROPEAN JOURNAL OF NUCLEAR MEDICINE 2001; 28:1299-305. [PMID: 11585287 DOI: 10.1007/s002590100557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Karlson BW, Sjölin M, Lindqvist J, Caidahl K, Herlitz J. Ten-year mortality rate in relation to observations at a bicycle exercise test in patients with a suspected or confirmed ischemic event but no or only minor myocardial damage: influence of subsequent revascularization. Am Heart J 2001; 141:977-84. [PMID: 11376313 DOI: 10.1067/mhj.2001.115437] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
AIM Our purpose was to describe symptoms and electrocardiographic findings at a bicycle exercise test 4 weeks after hospitalization for a suspected or confirmed acute ischemic event but either no or only minor myocardial necrosis and its relationship to long-term prognosis and subsequent revascularization. METHODS In all patients a symptom-limited bicycle exercise test was performed 4 weeks after discharge from the hospital. The total mortality rate over 10 years was registered. RESULTS In all, 770 patients participated in the evaluation. The median age was 63 years, and 34% were women. The most frequent reason for stopping the exercise test was fatigue (69%) followed by dyspnea (33%) and angina pectoris (15%). Angina pectoris was observed in 24% of the patients. ST-segment depression >or=1 mm was observed in 50% and ST-segment depression >or=2 mm was observed in 15% of the patients. The 10-year mortality rate in patients with ST-segment depression >or=2 mm was 24.7%, in patients with ST-segment depression 1.0 to 1.9 mm 33.5%, and in patients with ST-segment depression <1 mm 26.9% (not significant [NS]). Patients with symptoms of angina pectoris had a 10-year mortality rate of 29.4% compared with 27.9% among patients without such symptoms (NS). Patients who had either a drop in systolic blood pressure or failure to raise systolic blood pressure (13%) had a 10-year mortality rate of 36.2% compared with 27.2% among patients without such signs (NS). However, there was a significant association between maximum exercise capacity (in watts) and mortality (P < .0001): 53.8% in the lowest quartile (30-70 W) and 10.2% in the highest (>120 w). When clinical history was considered simultaneously, a low exercise capacity remained as a strong independent predictor of death together with age and a history of either acute myocardial infarction, smoking, or diabetes mellitus. Mechanical revascularization during the subsequent 5 years interacted only with angina pectoris and prognosis; thus patients who had angina during the exercise test had a worse prognosis than those without if they were not being revascularized. CONCLUSION Among patients hospitalized with a suspected or confirmed acute ischemic event but either no or only minor myocardial necrosis, we found the maximum working capacity at a symptom-limited bicycle exercise test to be independently associated with the long-term prognosis but not other signs of myocardial ischemia. Further predictors for long-term prognosis were age, a history of acute myocardial infarction, current smoking, and diabetes mellitus. Mechanical revascularization during the subsequent 5 years interacted with the influence of symptoms of angina during test and prognosis.
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Affiliation(s)
- B W Karlson
- Division of Cardiology, Sahlgrenska University Hospital, Göteborg, Sweden
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Affiliation(s)
- M E Tavel
- Indiana Heart Institute, Care Group, Inc, Indianapolis, IN, USA.
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