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Rozanski A, Gransar H, Sakul S, Miller RJH, Han D, Hayes SW, Friedman JD, Thomson LEJ, Berman DS. Increasing frequency of dyspnea among patients referred for cardiac stress testing. J Nucl Cardiol 2023; 30:2303-2313. [PMID: 37861920 DOI: 10.1007/s12350-023-03375-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/09/2023] [Indexed: 10/21/2023]
Abstract
OBJECTIVE To assess the frequency, change in prevalence, and prognostic significance of dyspnea among contemporary patients referred for cardiac stress testing. PATIENTS AND METHODS We evaluated the prevalence of dyspnea and its relationship to all-cause mortality among 33,564 patients undergoing stress/rest SPECT-MPI between January 1, 2002 and December 31, 2017. Dyspnea was assessed as a single-item question. Patients were divided into three temporal groups. RESULTS The overall prevalence of dyspnea in our cohort was 30.2%. However, there was a stepwise increase in the temporal prevalence of dyspnea, which was present in 25.6% of patients studied between 2002 and 2006, 30.5% of patients studied between 2007 and 2011, and 38.7% of patients studied between 2012 and 2017. There was a temporal increase in the prevalence of dyspnea in each age, symptom, and risk factor subgroup. The adjusted hazard ratio for mortality was higher among patients with dyspnea vs those without dyspnea both among all patients, and within each chest pain subgroup. CONCLUSIONS Dyspnea has become increasingly prevalent among patients referred for cardiac stress testing and is now present among nearly two-fifths of contemporary cohorts referred for stress-rest SPECT-MPI. Prospective study is needed to standardize the assessment of dyspnea and evaluate the reasons for its increasing prevalence.
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Affiliation(s)
- Alan Rozanski
- Division of Cardiology and Department of Medicine, Mount Sinai Morningside Hospital, Mount Sinai Heart, and the Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Heidi Gransar
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sakul Sakul
- Division of Cardiology and Department of Medicine, Mount Sinai Morningside Hospital, Mount Sinai Heart, and the Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Robert J H Miller
- Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Donghee Han
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - 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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Rozanski A, Miller RJH, Han D, Gransar H, Slomka P, Dey D, Hayes SB, Friedman J, Thomson LB, Berman DS. The prevalence and predictors of inducible myocardial ischemia among patients referred for radionuclide stress testing. J Nucl Cardiol 2022; 29:2839-2849. [PMID: 34608604 DOI: 10.1007/s12350-021-02797-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/30/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND The frequency of inducible myocardial ischemia has declined in contemporary stress test cohorts, suggesting a need to re-evaluate its optimal use. To-date, however, a comprehensive analysis of the most potent predictors of myocardial ischemia among cardiac stress test patients has not been conducted. METHODS We assessed 27,615 patients referred for stress-rest SPECT myocardial perfusion imaging between January 1, 2004 and December 31, 2017. Chi-square analysis was used to ascertain the most potent predictors of ischemia. RESULTS Among our cohort, CAD status (presence/absence of known CAD), rest left ventricular ejection fraction (LVEF), and typical angina were the most potent predictors of ischemia. The frequency of ischemia was only 6.6% among patients with an LVEF > 55% but 38.1% for patients with LVEF < 45% (P < 0.001). The frequency of myocardial ischemia was fourfold higher among patients with known CAD vs no known CAD (28.0% vs 6.5%, P < 0.001) and approximately threefold higher among patients with typical angina vs patients with atypical symptoms (P < 0.001). CONCLUSIONS The frequency of myocardial ischemia varies markedly according to the common clinical parameters and is particularly high among patients with known CAD, low LVEF, and typical angina. These observations may be used to develop more cost-effective strategies for referring patients for cardiac stress testing.
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Affiliation(s)
- Alan Rozanski
- Division of Cardiology and Department of Medicine, Mount Sinai Morningside Hospital, Mount Sinai Heart and the Icahn School of Medicine at Mount Sinai, 1111 Amsterdam Avenue, New York, NY, 10025, USA.
| | - Robert J H Miller
- Division of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada
| | - Donghee Han
- 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
| | - Piotr Slomka
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Damini Dey
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sean B Hayes
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - John Friedman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Louise B 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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Al-Mallah MH, Dilsizian V. The Impact of Revascularization on Mortality: A Debate on Patient Selection Bias vs Entry Bias. J Am Coll Cardiol 2022; 80:216-218. [PMID: 35835494 DOI: 10.1016/j.jacc.2022.04.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 04/25/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Mouaz H Al-Mallah
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA.
| | - Vasken Dilsizian
- University of Maryland School of Medicine, Baltimore, Maryland, USA
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4
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Rozanski A, Miller RJH, Gransar H, Han D, Slomka P, Dey D, Hayes SW, Friedman JD, Thomson L, Berman DS. Benefit of Early Revascularization Based on Inducible Ischemia and Left Ventricular Ejection Fraction. J Am Coll Cardiol 2022; 80:202-15. [PMID: 35835493 DOI: 10.1016/j.jacc.2022.04.052] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/04/2022] [Accepted: 04/14/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND The utility of performing early myocardial revascularization among patients presenting with inducible myocardial ischemia and low left ventricular ejection fraction (LVEF) is currently unknown. OBJECTIVES In this study, we sought to assess the relationship between stress-induced myocardial ischemia, revascularization, and all-cause mortality (ACM) among patients with normal vs low LVEF. METHODS We evaluated 43,443 patients undergoing stress-rest single-photon emission computed tomography myocardial perfusion imaging from 1998 to 2017. Median follow-up was 11.4 years. Myocardial ischemia was assessed for its interaction between early revascularization and mortality. A propensity score was used to adjust for nonrandomization to revascularization, followed by multivariable Cox modeling adjusted for the propensity score and clinical variables to predict ACM. RESULTS The frequency of myocardial ischemia varied markedly according to LVEF and angina, ranging from 6.7% among patients with LVEF ≥55% and no typical angina to 64.0% among patients with LVEF <45% and typical angina (P < 0.001). Among 39,883 patients with LVEF ≥45%, early revascularization was associated with increased mortality risk among patients without ischemia and lower mortality risk among patients with severe (≥15%) ischemia (HR: 0.70; 95% CI: 0.52-0.95). Among 3,560 patients with LVEF <45%, revascularization was not associated with mortality benefit among patients with no or mild ischemia, and was associated with decreased mortality among patients with moderate (10%-14%) (HR: 0.67; 95% CI: 0.49-0.91) and severe (≥15%) (HR: 0.55; 95% CI: 0.38-0.80) ischemia. CONCLUSIONS Within this cohort, early myocardial revascularization was associated with a significant reduction in mortality among both patients with normal LVEF and severe inducible myocardial ischemia and patients with low LVEF and moderate or severe inducible myocardial ischemia.
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Ahmad T, Linares J, Valencia DN, Agarwal A. Severe Shivering as an Adverse Effect of Regadenoson Myocardial Perfusion Imaging. Cureus 2021; 13:e14091. [PMID: 33927915 PMCID: PMC8075772 DOI: 10.7759/cureus.14091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Regadenoson myocardial perfusion imaging (MPI) is a widely used screening study for patients with an intermediate pretest probability of coronary artery disease (CAD). Via selective agonism of the adenosine A2A receptor, regadenoson can induce coronary steal, revealing stenotic vessel territory through transient ischemia. Common side effects of this medication include chest pain, shortness of breath, nausea, vomiting, atrioventricular block, seizure, and allergic reactions. Here we present a case of severe shivering and chest tightness after the administration of regadenoson, along with a physiologic explanation and treatment.
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Affiliation(s)
- Tanjeev Ahmad
- Department of Internal Medicine, Division of Cardiovascular Medicine, Boonshoft School of Medicine, Wright State University, Dayton, USA
| | - Juan Linares
- Department of Internal Medicine, Division of Cardiovascular Medicine, Kettering Medical Center, Dayton, USA.,Department of Internal Medicine, Division of Cardiovascular Medicine, Boonshoft School of Medicine, Wright State University, Dayton, USA.,Department of Cardiology, Dayton Veterans Affairs Medical Center, Dayton, USA
| | - Damian N Valencia
- Department of Internal Medicine, Division of Cardiovascular Medicine, Kettering Medical Center, Dayton, USA.,Department of Internal Medicine, Division of Cardiovascular Medicine, Boonshoft School of Medicine, Wright State University, Dayton, USA.,Department of Cardiology, Dayton Veterans Affairs Medical Center, Dayton, USA
| | - Ajay Agarwal
- Department of Cardiology, Dayton Veterans Affairs Medical Center, Dayton, USA.,Department of Internal Medicine, Division of Interventional Cardiology, Boonshoft School of Medicine, Wright State University, Dayton, USA
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Carmona-Abellan M, Trzeciak M, Fernández MR, Echeveste B, Imaz L, Luquin MR, Riverol M. Blood Pressure and Risk of Cognitive Impairment: The Role of Vascular Disease in Neurodegeneration. Brain Sci 2021; 11:385. [PMID: 33803713 DOI: 10.3390/brainsci11030385] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 03/12/2021] [Accepted: 03/14/2021] [Indexed: 02/06/2023] Open
Abstract
(1) Background: Both cerebral vascular disorders and cognitive decline increase in incidence with age. The role of cerebral vascular disease and hemodynamic changes in the development of cognitive deficits is controversial. The objective of this study was to assess the cardiovascular response during cardiac stress testing in neurologically asymptomatic individuals who developed cognitive impairment several years after previous cardiac stress testing. (2) Methods: This was a retrospective cohort study of patients who underwent cardiac stress testing between January 2001 and December 2010. Patients were followed up until May 2015, and we selected those who developed cognitive dysfunction including dementia, mild cognitive impairment, and subjective cognitive decline, after the stress test. Heart rate and blood pressure both at rest and at peak exercise, and the mean R-R interval at rest were recorded. For each patient who developed cognitive impairment, we selected one matched control who did not show cognitive decline by the end of the follow-up period. (3) Results: From the cohort of 7224 patients, 371 developed cognitive impairment; of these, 186 (124 men) met the inclusion criteria, and 186 of the other patients were selected as matched controls. During follow-up, cognitive impairment appeared 6.2 ± 4.7 years after the cardiac stress test. These patients who had subsequently developed cognitive impairment had significantly lower at-rest systolic, diastolic, and mean blood pressure than controls (p < 0.05). Further, compared with controls, their maximum heart rate was significantly higher at peak exercise. (4) Conclusion: The results from this study suggest that differences in cardiovascular response to stress might be present in individuals who develop cognitive decline. These findings challenge the possibility of assessing blood pressure and heart rate variability at rest and during cardiac stress as potential risk factors associated with cognitive impairment.
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Abelhad NI, Kiser KJ, Hughes A, Hust MA, Sayan EG, Prakash SK. Prevalence and clinical characteristics of inappropriate myocardial perfusion imaging tests at a community hospital. BMJ Open Qual 2019; 8:e000487. [PMID: 31363501 PMCID: PMC6629399 DOI: 10.1136/bmjoq-2018-000487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 04/04/2019] [Accepted: 04/27/2019] [Indexed: 11/04/2022] Open
Affiliation(s)
- Nadia Isabel Abelhad
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Kendall J Kiser
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Andres Hughes
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Michael A Hust
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Enrique Garcia Sayan
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Siddharth K Prakash
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
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Rozanski A, Berman D. Optimizing the Assessment of Patient Clinical Risk at the Time of Cardiac Stress Testing. JACC Cardiovasc Imaging 2019; 13:616-623. [PMID: 31326497 DOI: 10.1016/j.jcmg.2019.01.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 01/14/2019] [Accepted: 01/16/2019] [Indexed: 12/21/2022]
Abstract
Due to a marked temporal decline in inducible myocardial ischemia over recent decades, most diagnostic patients now referred for cardiac stress testing have nonischemic studies. Among nonischemic patients, however, long-term risk is heterogeneous and highly influenced by a variety of clinical parameters. Herein, we review 8 factors that can govern long-term clinical risk: coronary risk factor burden; patient symptoms; exercise capacity and exercise test responses; the need for pharmacologic stress testing; autonomic function; musculoskeletal status; subclinical atherosclerosis; and psychosocial risk. To capture the clinical benefit provided by both assessing myocardial ischemia and these additional parameters, the authors propose that a cardiac stress tests report have an additional component beyond statements as to the likelihood of obstructive coronary artery disease and/or magnitude of ischemia. This added component could be a comment section designed to make referring physicians aware of aspects of long-term risk that may influence clinical management and potentially lead to changes in the intensity of risk factor management, frequency of follow-up, need for further testing, or other management decisions. In this manner, the increasingly frequent normal stress test result might more commonly influence treatment recommendations and even patient behavior, thus leading to improvement in patient outcomes even in the setting of normal stress test results.
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Affiliation(s)
- Alan Rozanski
- Department of Cardiology, Mount Sinai St. Luke's and Mount Sinai Heart, New York, New York.
| | - Daniel Berman
- Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
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Abstract
Patients with advanced chronic kidney disease have an enormous burden of cardiovascular morbidity and mortality, but, paradoxically, their representation in randomized trials for the evaluation and management of coronary artery disease has been limited. Clinicians therefore are faced with the conundrum of synergizing evidence from observational studies, expert opinion, and extrapolation from the general population to provide care to this complex and clinically distinct patient population. In this review, we address clinical risk stratification of patients with chronic kidney disease and end-stage kidney disease using traditional cardiovascular risk factors, noninvasive functional and structural cardiac imaging, invasive coronary angiography, and cardiovascular biomarkers. We highlight the unique characteristics of this population, including the high competing risk of all-cause mortality relative to the risk of major adverse cardiac events, likely owing to important contributions from nonatherosclerotic mechanisms. We further discuss the management of coronary artery disease in patients with chronic kidney disease and end-stage kidney disease, including evidence pertaining to medical management, coronary revascularization with percutaneous coronary intervention, and coronary artery bypass grafting. Our discussion includes considerations of drug-eluting versus bare metal stents for percutaneous coronary intervention and off-pump versus on-pump coronary artery bypass graft surgery. Finally, we address currently ongoing randomized trials, from which clinicians are optimistic about receiving guidance regarding the best strategies to incorporate into their practice for the evaluation and management of coronary artery disease in this high-risk population.
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Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center, University of Minnesota School of Medicine, Minneapolis, Minnesota.
| | - Tara I Chang
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
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Ladapo JA, Pfeifer JM, Pitcavage JM, Williams BA, Choy-Shan AA. Quantifying Sex Differences in Cardiovascular Care Among Patients Evaluated for Suspected Ischemic Heart Disease. J Womens Health (Larchmt) 2018; 28:698-704. [PMID: 30543478 DOI: 10.1089/jwh.2018.7018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Background: Cardiovascular care sex differences are controversial. We examined sex differences in management and clinical outcomes among patients undergoing noninvasive testing for ischemic heart disease (IHD). Methods: In a rural integrated healthcare system, we identified adults age 40-79 without diagnosed IHD who underwent initial evaluation with a cardiac stress test with imaging or coronary computed tomographic angiography (CTA), 2013-2014. We assessed sex differences in statin/aspirin therapy, revascularization, and adverse cardiovascular events. The 2013 American College of Cardiology/American Heart Association statin guidelines and U.S. Preventive Services Task Force aspirin guidelines were applied. Results: Among 2213 patients evaluated for IHD, median age was 57 years, 48.8% were women, and 9% had a positive stress test/CTA. Women were more likely to be missing lipid values than men (p < 0.001). Mean ASCVD risk score at baseline was 7.2% in women versus 12.4% in men (p < 0.001). There was no significant sex difference in statin therapy at baseline or 60-day follow-up. Women were less likely than men to be taking aspirin at baseline (adj. diff. = -8.5%; 95% CI, -4.2 to -12.9) and follow-up (adj. diff. = -7.7%; 95% CI, -3.3 to -12.1). There were no sex differences in revascularization after accounting for obstructive CAD or adverse cardiovascular outcomes during median follow-up of 33 months. Conclusion: In this contemporary cohort of patients with suspected IHD, women were less likely to receive lipid testing and aspirin therapy, but not statin therapy. Women did not experience worse outcomes. Sex differences in statin therapy reported by others may be due to inadequate accounting for baseline risk.
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Affiliation(s)
- Joseph A Ladapo
- 1 Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | | | | | - Alana A Choy-Shan
- 3 Department of Medicine, New York University School of Medicine, New York, New York
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Herzog CA, Natwick T, Li S, Charytan DM. Comparative Utilization and Temporal Trends in Cardiac Stress Testing in U.S. Medicare Beneficiaries With and Without Chronic Kidney Disease. JACC Cardiovasc Imaging 2018; 12:1420-1426. [PMID: 29909107 DOI: 10.1016/j.jcmg.2018.04.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 04/04/2018] [Accepted: 04/13/2018] [Indexed: 12/28/2022]
Abstract
OBJECTIVES The authors aimed to analyze temporal trends in cardiac stress testing in U.S. Medicare beneficiaries from 2008 to 2012, types of stress testing, and comparative utilization related to the presence and severity of chronic kidney disease (CKD). BACKGROUND A long-held perception depicts patients with CKD as being treated less intensively for cardiovascular disease than nonrenal patients. We wondered whether use of diagnostic testing for ischemic heart disease is affected by the presence of CKD. METHODS Using the 20% Medicare sample, we assembled yearly cohorts of Medicare beneficiaries (∼4,500,000 per year) from 2008 to 2012. Beneficiaries 66 years or older undergoing a first cardiac stress test, with no previous history of coronary revascularization and no acute coronary syndrome within 60 days, were identified, as was the type of stress test. We analyzed temporal trends and compared testing rates related to CKD stage versus no CKD. A Poisson regression model estimated the likelihood of stress testing in 2012 by CKD stage, adjusted for demographic characteristics and comorbid conditions. RESULTS Approximately 480,000 older patients (∼29,000 with CKD) underwent stress tests in 2008, progressively declining to ∼400,000 in 2012 (∼38,000 with CKD). In 2008 to 2012, 78% to 80% of all stress testing in non-CKD patients used nuclear imaging, as did 87% to 88% in CKD patients. Rates of stress testing declined progressively for non-CKD and CKD patients in 2008 to 2012: 11.5 to 9.4 per 100 patient-years and 16.8 to 13.4 per 100 patient-years, respectively. The adjusted Poisson model, with non-CKD as the reference, showed an increasing likelihood of stress testing with worsening CKD: incidence rate ratio 1.01 for stages 1 to 2 (p = NS), 1.05 for stage 3 (p < 0.0001), 1.01 for stage 4 (p = NS), 1.04 for stage 5 nondialysis (p = NS), and 1.15 for stage 5 dialysis (p < 0.0001). CONCLUSIONS Overall rates of cardiac stress testing (over three-fourths using nuclear imaging) declined in 2008 to 2012 among Medicare beneficiaries 66 years or older but were consistently higher for CKD than for non-CKD patients. The effect of screening algorithms for transplant candidates was unknown. Our data refute underutilization of cardiac stress testing in CKD patients.
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Affiliation(s)
- Charles A Herzog
- Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota; Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota.
| | - Tanya Natwick
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Shuling Li
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - David M Charytan
- Department of Medicine, Brigham & Women's Hospital, Boston, Massachusetts
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12
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Ladapo JA, Coles A, Dolor RJ, Mark DB, Cooper L, Lee KL, Goldberg J, Shapiro MD, Hoffmann U, Douglas PS. Quantifying sociodemographic and income disparities in medical therapy and lifestyle among symptomatic patients with suspected coronary artery disease: a cross-sectional study in North America. BMJ Open 2017; 7:e016364. [PMID: 28965093 PMCID: PMC5640109 DOI: 10.1136/bmjopen-2017-016364] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES To evaluate potential gaps in preventive medical therapy and healthy lifestyle practices among symptomatic patients with suspected coronary artery disease (CAD) seeing primary care physicians and cardiologists and how gaps vary by sociodemographic characteristics and baseline cardiovascular risk. DESIGN Cross-sectional study assessing potential preventive gaps. PARTICIPANTS 10 003 symptomatic outpatients evaluated by primary care physicians, cardiologists or other specialists for suspected CAD. SETTING PROspective Multicenter Imaging Study for Evaluation of Chest Painfrom 2010 to 2014. MEASURES Primary measures were absence of an antihypertensive, statin or angiotensin-converting enzyme inhibitor/angiotensin receptor blocker for renal protection in patients with hypertension, dyslipidaemia or diabetes, respectively, and being sedentary, smoking or being obese. RESULTS Preventive treatment gaps affected 14% of patients with hypertension, 36% of patients with dyslipidaemia and 32% of patients with diabetes. Overall, 49% of patients were sedentary, 18% currently smoked and 48% were obese. Women were significantly more likely to not take a statin for dyslipidaemia and to be sedentary. Patients with lower socioeconomic status were also significantly more likely to not take a statin. Compared with Whites, Blacks were significantly more likely to be obese, while Asians were less likely to smoke or be obese. High-risk patients sometimes experienced larger preventive care gaps than low-risk patients. For patients with dyslipidaemia, the presence of a treatment gap was associated with a higher risk of an adverse event (HR 1.35, 95% CI 1.02 to 1.82). CONCLUSIONS Among contemporary, symptomatic patients with suspected CAD, significant gaps exist in preventive care and lifestyle practices, and high-risk patients sometimes had larger gaps. Differences by sex, age, race/ethnicity, socioeconomic status and geography are modest but contribute to disparities and have implications for improving opulation health. For patients with dyslipidaemia, the presence of a treatment gap was associated with a higher risk of an adverse event. CLINICAL TRIAL REGISTRATION Clinical Trials.gov identifier NCT01174550.
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Affiliation(s)
- Joseph A Ladapo
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Adrian Coles
- Department of Medicine, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rowena J Dolor
- Department of Medicine, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Daniel B Mark
- Department of Medicine, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Lawton Cooper
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Kerry L Lee
- Department of Medicine, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Udo Hoffmann
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Pamela S Douglas
- Department of Medicine, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
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13
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Yang HJ, Dey D, Sykes J, Klein M, Butler J, Kovacs MS, Sobczyk O, Sharif B, Bi X, Kali A, Cokic I, Tang R, Yumul R, Conte AH, Tsaftaris SA, Tighiouart M, Li D, Slomka PJ, Berman DS, Prato FS, Fisher JA, Dharmakumar R. Arterial CO 2 as a Potent Coronary Vasodilator: A Preclinical PET/MR Validation Study with Implications for Cardiac Stress Testing. J Nucl Med 2017; 58:953-960. [PMID: 28254864 DOI: 10.2967/jnumed.116.185991] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 01/31/2017] [Indexed: 11/16/2022] Open
Abstract
Myocardial blood flow (MBF) is the critical determinant of cardiac function. However, its response to increases in partial pressure of arterial CO2 (PaCO2), particularly with respect to adenosine, is not well characterized because of challenges in blood gas control and limited availability of validated approaches to ascertain MBF in vivo. Methods: By prospectively and independently controlling PaCO2 and combining it with 13N-ammonia PET measurements, we investigated whether a physiologically tolerable hypercapnic stimulus (∼25 mm Hg increase in PaCO2) can increase MBF to that observed with adenosine in 3 groups of canines: without coronary stenosis, subjected to non-flow-limiting coronary stenosis, and after preadministration of caffeine. The extent of effect on MBF due to hypercapnia was compared with adenosine. Results: In the absence of stenosis, mean MBF under hypercapnia was 2.1 ± 0.9 mL/min/g and adenosine was 2.2 ± 1.1 mL/min/g; these were significantly higher than at rest (0.9 ± 0.5 mL/min/g, P < 0.05) and were not different from each other (P = 0.30). Under left-anterior descending coronary stenosis, MBF increased in response to hypercapnia and adenosine (P < 0.05, all territories), but the effect was significantly lower than in the left-anterior descending coronary territory (with hypercapnia and adenosine; both P < 0.05). Mean perfusion defect volumes measured with adenosine and hypercapnia were significantly correlated (R = 0.85) and were not different (P = 0.12). After preadministration of caffeine, a known inhibitor of adenosine, resting MBF decreased; and hypercapnia increased MBF but not adenosine (P < 0.05). Conclusion: Arterial blood CO2 tension when increased by 25 mm Hg can induce MBF to the same level as a standard dose of adenosine. Prospectively targeted arterial CO2 has the capability to evolve as an alternative to current pharmacologic vasodilators used for cardiac stress testing.
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Affiliation(s)
- Hsin-Jung Yang
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, California.,Department of Bioengineering, University of California, Los Angeles, California
| | - Damini Dey
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, California.,Department of Bioengineering, University of California, Los Angeles, California
| | - Jane Sykes
- University of Western Ontario, Lawson Health Research Institute, London, Ontario, Canada
| | - Michael Klein
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - John Butler
- University of Western Ontario, Lawson Health Research Institute, London, Ontario, Canada
| | - Michael S Kovacs
- University of Western Ontario, Lawson Health Research Institute, London, Ontario, Canada
| | - Olivia Sobczyk
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Behzad Sharif
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Xiaoming Bi
- MR R&D, Siemens Healthcare, Los Angeles, California
| | - Avinash Kali
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, California.,Department of Bioengineering, University of California, Los Angeles, California
| | - Ivan Cokic
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Richard Tang
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Roya Yumul
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, California.,Department of Medicine, University of California, Los Angeles, California
| | - Antonio H Conte
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Sotirios A Tsaftaris
- School of Engineering, Institute of Digital Communications, University of Edinburgh, Edinburgh, United Kingdom; and
| | - Mourad Tighiouart
- Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Debiao Li
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, California.,Department of Bioengineering, University of California, Los Angeles, California
| | - Piotr J Slomka
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, California.,Department of Medicine, University of California, Los Angeles, California
| | - Daniel S Berman
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, California.,Department of Medicine, University of California, Los Angeles, California
| | - Frank S Prato
- University of Western Ontario, Lawson Health Research Institute, London, Ontario, Canada
| | - Joseph A Fisher
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Rohan Dharmakumar
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, California .,Department of Bioengineering, University of California, Los Angeles, California.,Department of Medicine, University of California, Los Angeles, California
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14
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Hammad TA, Yousefzai R, Venkatachalam S, Lowry A, Gornik HL, Jaber W, Bartholomew JR, Kim SH, Cerqueira M, Gray BH, Blackstone EH, Shishehbor MH. The association between ischemic and jeopardized myocardia and all-cause mortality in patients with peripheral artery disease. Vasc Med 2016; 21:113-9. [PMID: 26797315 DOI: 10.1177/1358863x15623629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Peripheral artery disease (PAD) is associated with increased mortality and concomitant coronary artery disease (CAD). However, it is unclear whether uncovering the presence of functional coronary ischemia by single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) would further help stratifying that excess risk. From January 2000 to 2009, 4294 individuals underwent cardiac stress testing within 180 days of ankle-brachial index (ABI) measurements. Of these, 645 had PAD and SPECT MPI stress testing. Abnormal ABI was defined as ⩽ 0.9 or prior lower extremity arterial revascularization. Myocardial ischemic burden and total jeopardized myocardium were represented by the summed difference score (SDS) and summed stress score (SSS), respectively. Univariate and multivariable Cox proportional hazard analyses were used to study the impact of SDS and SSS on all-cause mortality. Additionally, using a hierarchical approach, we examined the step-wise addition of post-stress test coronary and lower extremity arterial revascularizations as time-varying covariates on outcomes. We found no significant difference in all-cause mortality between patients with ischemic myocardium (SDS > 0) and those without (SDS = 0) (adjusted HR: 0.94, 95% CI: 0.53-1.69; p = 0.84). Similarly, the presence of jeopardized myocardium (SSS > 0) did not have a significant impact on mortality (adjusted HR: 1.16, 95% CI: 0.67-2.00; p = 0.59). Moreover, adjustment for post-testing coronary and lower extremity arterial revascularizations did not affect our results. In conclusion, ischemic and jeopardized myocardia are not predictors of all-cause mortality in PAD; thus, SPECT MPI does not appear to be a useful risk stratification tool in these patients.
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Affiliation(s)
- Tarek A Hammad
- Medicine Institute, Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Rayan Yousefzai
- Heart and Vascular Institute, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Sridhar Venkatachalam
- Medicine Institute, Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Ashley Lowry
- Heart and Vascular Institute, Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Heather L Gornik
- Heart and Vascular Institute, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Wael Jaber
- Heart and Vascular Institute, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - John R Bartholomew
- Heart and Vascular Institute, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Soo Hyun Kim
- Heart and Vascular Institute, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Manuel Cerqueira
- Heart and Vascular Institute, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Bruce H Gray
- Department of Vascular Surgery, Greenville Hospital System, Greenville, SC, USA
| | - Eugene H Blackstone
- Heart and Vascular Institute, Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Mehdi H Shishehbor
- Heart and Vascular Institute, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
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