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Massalha S, Keidar Z. Image fusion: the beauty of the truth from the inside and out. J Nucl Cardiol 2022; 29:3278-3280. [PMID: 35381963 DOI: 10.1007/s12350-022-02955-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 03/06/2022] [Indexed: 01/14/2023]
Affiliation(s)
- Samia Massalha
- Department of Cardiology, Rambam Health Care Campus, Haifa, Israel
| | - Zohar Keidar
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel.
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2
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Diagnostic strategies in suspected chronic coronary syndrome - The case for a hybrid approach. J Cardiovasc Comput Tomogr 2021; 16:41-42. [PMID: 34607783 DOI: 10.1016/j.jcct.2021.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 11/21/2022]
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3
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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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4
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Kutty S, Bisselou Moukagna KS, Craft M, Shostrom V, Xie F, Porter TR. Clinical Outcome of Patients With Inducible Capillary Blood Flow Abnormalities During Demand Stress in the Presence or Absence of Angiographic Coronary Disease. Circ Cardiovasc Imaging 2018; 11:e007483. [DOI: 10.1161/circimaging.117.007483] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Shelby Kutty
- Division of Cardiology and Pediatric Cardiology, Departments of Internal Medicine and Pediatrics, University of Nebraska Medical Center, Omaha, NE
| | - Karl Stessy Bisselou Moukagna
- Division of Cardiology and Pediatric Cardiology, Departments of Internal Medicine and Pediatrics, University of Nebraska Medical Center, Omaha, NE
| | - Mary Craft
- Division of Cardiology and Pediatric Cardiology, Departments of Internal Medicine and Pediatrics, University of Nebraska Medical Center, Omaha, NE
| | - Valerie Shostrom
- Division of Cardiology and Pediatric Cardiology, Departments of Internal Medicine and Pediatrics, University of Nebraska Medical Center, Omaha, NE
| | - Feng Xie
- Division of Cardiology and Pediatric Cardiology, Departments of Internal Medicine and Pediatrics, University of Nebraska Medical Center, Omaha, NE
| | - Thomas R. Porter
- Division of Cardiology and Pediatric Cardiology, Departments of Internal Medicine and Pediatrics, University of Nebraska Medical Center, Omaha, NE
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5
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Simonsen JA, Mickley H, Johansen A, Hess S, Thomassen A, Gerke O, Jensen LO, Hallas J, Vach W, Hoilund-Carlsen PF. Outcome of revascularisation in stable coronary artery disease without ischaemia: a Danish registry-based follow-up study. BMJ Open 2017; 7:e016169. [PMID: 28801416 PMCID: PMC5629720 DOI: 10.1136/bmjopen-2017-016169] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES In stable coronary artery disease (CAD), coronary revascularisation may reduce mortality of patients with a certain amount of left ventricular myocardial ischaemia. However, revascularisation does not always follow the guidance suggested by ischaemia testing. We compared outcomes in patients without ischaemia who had either revascularisation or medical treatment. DESIGN AND POPULATION Based on registries, 1327 consecutive patients with normal myocardial perfusion scintigraphy (MPS) and 278 with fixed perfusion defects were followed for a median of 6.1 years. Most patients received medical therapy alone (Med), but 26 (2%) with a normal MPS and 15 (5%) with fixed perfusion defects underwent revascularisation (Revasc). OUTCOME MEASURES Incidence rates of all-cause death (ACD) and rates of cardiac death/myocardial infarction (CD/MI). RESULTS With a normal MPS, the ACD rate was 6.2%/year in the Revasc group versus 1.9%/year in the Med group (p=0.01); the CD/MI rates were 6.9%/year and 0.6%/year, respectively (p<0.00001). Results persisted after adjustment for predictors of revascularisation, in particular angina score, and in comparisons of matched Revasc and Med patients. With fixed defects, the ACD rate was 9.1%/year in the Revasc group and 6.7%/year in the Med group (p=0.44); the CD/MI rate was 5.0%/year versus 4.2%/year, respectively (p=0.69). If adjusted for angiographic variables or analysed in matched subsets, differences remained insignificant. CONCLUSIONS With normal MPS, revascularisation conferred a higher risk, even after adjustment for predictors of revascularisation. With fixed defects, the Revascversus Med difference was close to equipoise. Hence, in patients with stable CAD without ischaemia, we could not find evidence to justify exceptional revascularisation.
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Affiliation(s)
| | - Hans Mickley
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Allan Johansen
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | - Søren Hess
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | - Anders Thomassen
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | - Oke Gerke
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
- Centre of Health Economics Research, University of Southern Denmark, Odense, Denmark
| | - Lisette O Jensen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Jesper Hallas
- Department of Clinical Pharmacology, Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Werner Vach
- Clinical Epidemiology, Institute for Medical Biometry and Statistics, Medical Faculty – Medical Center, University of Freiburg, Freiburg, Germany
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6
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Grondin J, Waase M, Gambhir A, Bunting E, Sayseng V, Konofagou EE. Evaluation of Coronary Artery Disease Using Myocardial Elastography with Diverging Wave Imaging: Validation against Myocardial Perfusion Imaging and Coronary Angiography. ULTRASOUND IN MEDICINE & BIOLOGY 2017; 43:893-902. [PMID: 28256343 PMCID: PMC5385294 DOI: 10.1016/j.ultrasmedbio.2017.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 12/19/2016] [Accepted: 01/04/2017] [Indexed: 05/27/2023]
Abstract
Myocardial elastography (ME) is an ultrasound-based technique that can image 2-D myocardial strains. The objectives of this study were to illustrate that 2-D myocardial strains can be imaged with diverging wave imaging and differ, on average, between normal and coronary artery disease (CAD) patients. In this study, 66 patients with symptoms of CAD were imaged with myocardial elastography before a nuclear stress test or an invasive coronary angiography. Radial cumulative strains were estimated in all patients. The end-systolic radial strain in the total cross section of the myocardium was significantly higher in normal patients (17.9 ± 8.7%) than in patients with reversible perfusion defect (6.2 ± 9.3%, p < 0.001) and patients with significant (-0.9 ± 7.4%, p < 0.001) and non-significant (3.7 ± 5.7%, p < 0.01) lesions. End-systolic radial strain in the left anterior descending, left circumflex and right coronary artery territory was found to be significantly higher in normal patients than in CAD patients. These preliminary findings indicate that end-systolic radial strain measured with ME is higher on average in healthy persons than in CAD patients and that ME has the potential to be used for non-invasive, radiation-free early detection of CAD.
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Affiliation(s)
- Julien Grondin
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Marc Waase
- Department of Medicine, Columbia University, New York, New York, USA
| | - Alok Gambhir
- Department of Medicine, Columbia University, New York, New York, USA
| | - Ethan Bunting
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Vincent Sayseng
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Elisa E Konofagou
- Department of Biomedical Engineering, Columbia University, New York, New York, USA; Department of Radiology, Columbia University, New York, New York, USA.
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7
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Lee DS, Husain M, Wang X, Austin PC, Iwanochko RM. Cardiovascular outcomes after pharmacologic stress myocardial perfusion imaging. Am Heart J 2016; 174:138-46. [PMID: 26995380 DOI: 10.1016/j.ahj.2016.01.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 01/16/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND While pharmacologic stress single photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) is used for noninvasive evaluation of patients who are unable to perform treadmill exercise, its impact on net reclassification improvement (NRI) of prognosis is unknown. METHODS We evaluated the prognostic value of pharmacologic stress MPI for prediction of cardiovascular death or non-fatal myocardial infarction (MI) within 1 year at a single-center, university-based laboratory. We examined continuous and categorical NRI of pharmacologic SPECT-MPI for prediction of outcomes beyond clinical factors alone. RESULTS Six thousand two hundred forty patients (median age 66 years [IQR 56-74], 3466 men) were studied and followed for 5963 person-years. SPECT-MPI variables associated with increased risk of cardiovascular death or non-fatal MI included summed stress score, stress ST-shift, and post-stress resting left ventricular ejection fraction ≤50%. Compared to a clinical model which included age, sex, cardiovascular disease, risk factors, and medications, model χ(2) (210.5 vs. 281.9, P < .001) and c-statistic (0.74 vs. 0.78, P < .001) were significantly increased by addition of SPECT-MPI predictors (summed stress score, stress ST-shift and stress resting left ventricular ejection fraction). SPECT-MPI predictors increased continuous NRI by 49.4% (P < .001), reclassifying 66.5% of patients as lower risk and 32.8% as higher risk of cardiovascular death or non-fatal MI. Addition of MPI predictors to clinical factors using risk categories, defined as <1%, 1% to 3%, and >3% annualized risk of cardiovascular death or non-fatal MI, yielded a 15.0% improvement in NRI (95% CI 7.6%-27.6%, P < .001). CONCLUSIONS Pharmacologic stress MPI substantially improved net reclassification of cardiovascular death or MI risk beyond that afforded by clinical factors.
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Affiliation(s)
- Douglas S Lee
- Robert J. Burns Nuclear Cardiology Laboratory, University of Toronto, Toronto, Canada; Joint Department of Medical Imaging and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Canada; Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, Canada.
| | - Mansoor Husain
- Robert J. Burns Nuclear Cardiology Laboratory, University of Toronto, Toronto, Canada; Joint Department of Medical Imaging and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Canada; Ted Rogers Centre for Heart Research, University of Toronto, Toronto, Canada
| | - Xuesong Wang
- Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, Canada
| | - Peter C Austin
- Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, Canada
| | - Robert M Iwanochko
- Robert J. Burns Nuclear Cardiology Laboratory, University of Toronto, Toronto, Canada; Joint Department of Medical Imaging and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Canada
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Reyes E, Underwood SR. Coronary anatomy and function: a story of Yin and Yang. Eur Heart J Cardiovasc Imaging 2015; 16:831-3. [DOI: 10.1093/ehjci/jev138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Buechel RR, Kaufmann BA, Tobler D, Wild D, Zellweger MJ. Non-invasive nuclear myocardial perfusion imaging improves the diagnostic yield of invasive coronary angiography. Eur Heart J Cardiovasc Imaging 2015; 16:842-7. [PMID: 25914037 DOI: 10.1093/ehjci/jev095] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 03/19/2015] [Indexed: 01/11/2023] Open
Abstract
AIMS Several studies reported on the moderate diagnostic yield of elective invasive coronary angiography (ICA) regarding the presence of coronary artery disease (CAD), but limited data are available on how prior testing for ischaemia may contribute to improve the diagnostic yield in an every-day clinical setting. This study aimed to assess the value and use of cardiac myocardial perfusion single photon emission computed tomography (MPS) in patient selection prior to elective ICA. METHODS AND RESULTS The rate of MPS within 90 days prior to elective ICA was assessed and the non-invasive test results were correlated with the presence of obstructive CAD on ICA (defined as stenosis of ≥50% of a major epicardial coronary vessel). Multivariate logistic regression analysis was performed to identify predictors of obstructive CAD. A total of 7530 consecutive patients were included. At catheterization, 3819 (50.7%) were diagnosed as having obstructive CAD. Patients with a positive result on MPS (performed in 23.5% of patients) were significantly more likely to have obstructive CAD as assessed by ICA than those who did not undergo non-invasive testing (74.4 vs. 45.6%, P < 0.001). Furthermore, a pathological MPS result was a strong, independent predictor for CAD findings among traditional risk factors and symptoms. CONCLUSION In an every-day clinical setting, the use of MPS substantially increases the diagnostic yield of elective ICA and provides incremental value over clinical risk factors and symptoms in predicting obstructive CAD, thus emphasizing its importance in the decision-making process leading to the use of diagnostic catheterization.
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Affiliation(s)
- Ronny R Buechel
- Department of Nuclear Medicine, University Hospital Zurich, Switzerland
| | - Beat A Kaufmann
- Department of Cardiology, University Hospital Basel, Switzerland
| | - Daniel Tobler
- Department of Cardiology, University Hospital Basel, Switzerland
| | - Damian Wild
- Department of Radiology, Division of Nuclear Medicine, University Hospital Basel, Switzerland
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Yokota S, Ottervanger JP, Mouden M, Timmer JR, Knollema S, Jager PL. Prevalence, location, and extent of significant coronary artery disease in patients with normal myocardial perfusion imaging. J Nucl Cardiol 2014; 21:284-90. [PMID: 24469846 DOI: 10.1007/s12350-013-9837-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 11/27/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND False-negative myocardial perfusion imaging (MPI) can by due to left main (LM) or three-vessel disease causing "balanced ischemia". However, so far prevalence of LM or three-vessel-disease in patients with normal MPI is unclear. We assessed prevalence, location, and extent of significant coronary artery disease (CAD) in patients with normal MPI. METHODS Between 2006 and 2010, 256 patients with normal MPI who had invasive angiography because of persisting or worsening of the same initial symptoms were studied. Significant CAD was defined as stenosis > 70% or LM > 50%. RESULTS A total of 93 patients (36%) had significant CAD. Significant CAD was observed more frequently in males, higher age and those with typical angina complaints. Significant LM disease was present in 7%, three-vessel disease in 10%, two-vessel disease in 22%, and single vessel disease (not left main) in 61%. In those with single vessel disease, the location was the LAD in 40%, the RCA in 30%, and the LCX in 30%. CONCLUSIONS In selected patients with normal MPI, one-third had significant CAD. The majority of these patients had single vessel disease (not left main). LM or three vessel disease, causing "balanced ischemia", is a less common cause of false-negative MPI.
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Affiliation(s)
- Shu Yokota
- Department of Cardiology, Isala Klinieken, Dokter Van Heesweg 2, 8025 AB, Zwolle, The Netherlands
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11
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Myocardial perfusion imaging with a cadmium zinc telluride-based gamma camera versus invasive fractional flow reserve. Eur J Nucl Med Mol Imaging 2013; 41:956-62. [DOI: 10.1007/s00259-013-2630-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Accepted: 11/06/2013] [Indexed: 11/25/2022]
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de Graaf FR, van Velzen JE, de Boer SM, van Werkhoven JM, Kroft LJ, de Roos A, Sieders A, de Grooth GJ, Jukema JW, Schuijf JD, Bax JJ, Schalij MJ, van der Wall EE. Non-invasive computed tomography coronary angiography as a gatekeeper for invasive coronary angiography. Int J Cardiovasc Imaging 2012; 29:221-8. [PMID: 22576679 PMCID: PMC3550696 DOI: 10.1007/s10554-012-0059-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2011] [Accepted: 04/20/2012] [Indexed: 10/30/2022]
Abstract
To determine the rate of subsequent invasive coronary angiography (ICA) and revascularization in relation to computed tomography coronary angiography (CTA) results. In addition, independent determinants of subsequent ICA and revascularization were evaluated. CTA studies were performed using a 64-row (n = 413) or 320-row (n = 224) multidetector scanner. The presence and severity of CAD were determined on CTA. Following CTA, patients were followed up for 1 year for the occurrence of ICA and revascularization. A total of 637 patients (296 male, 56 ± 12 years) were enrolled and 578 CTA investigations were available for analysis. In patients with significant CAD on CTA, subsequent ICA rate was 76%. Among patients with non-significant CAD on CTA, subsequent ICA rate was 20% and among patients with normal CTA results, subsequent ICA rate was 5.7% (p < 0.001). Of patients with significant CAD on CTA, revascularization rate was 47%, as compared to a revascularization rate of 0.6% in patients with non-significant CAD on CTA and no revascularizations in patients with a normal CTA results (p < 0.001). Significant CAD on CTA and significant three-vessel or left main disease on CTA were identified as the strongest independent predictors of ICA and revascularization. CTA results are strong and independent determinants of subsequent ICA and revascularization. Consequently, CTA has the potential to serve as a gatekeeper for ICA to identify patients who are most likely to benefit from revascularization and exclude patients who can safely avoid ICA.
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Affiliation(s)
- Fleur R de Graaf
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
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13
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Pazhenkottil AP, Nkoulou RN, Ghadri JR, Herzog BA, Küest SM, Husmann L, Wolfrum M, Goetti R, Buechel RR, Gaemperli O, Lüscher TF, Kaufmann PA. Impact of cardiac hybrid single-photon emission computed tomography/computed tomography imaging on choice of treatment strategy in coronary artery disease. Eur Heart J 2011; 32:2824-9. [PMID: 21804107 PMCID: PMC3214723 DOI: 10.1093/eurheartj/ehr232] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIMS Cardiac hybrid imaging by fusing single-photon emission computed tomography (SPECT) myocardial perfusion imaging with coronary computed tomography angiography (CCTA) provides important complementary diagnostic information for coronary artery disease (CAD) assessment. We aimed at assessing the impact of cardiac hybrid imaging on the choice of treatment strategy selection for CAD. METHODS AND RESULTS Three hundred and eighteen consecutive patients underwent a 1 day stress/rest (99m)Tc-tetrofosmin SPECT and a CCTA on a separate scanner for evaluation of CAD. Patients were divided into one of the following three groups according to findings in the hybrid images obtained by fusing SPECT and CCTA: (i) matched finding of stenosis by CCTA and corresponding reversible SPECT defect; (ii) unmatched CCTA and SPECT finding; (iii) normal finding by both CCTA and SPECT. Follow-up was confined to the first 60 days after hybrid imaging as this allows best to assess treatment strategy decisions including the revascularization procedure triggered by its findings. Hybrid images revealed matched, unmatched, and normal findings in 51, 74, and 193 patients. The revascularization rate within 60 days was 41, 11, and 0% for matched, unmatched, and normal findings, respectively (P< 0.001 for all inter-group comparisons). CONCLUSION Cardiac hybrid imaging with SPECT and CCTA provides an added clinical value for decision making with regard to treatment strategy for CAD.
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Affiliation(s)
- Aju P Pazhenkottil
- Department of Radiology, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, CH-8091 Zurich, Switzerland
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Lo KY, Leung KF, Chu CM, Loke KL, Chan CK, Yue CS. Prognostic value of adenosine stress myocardial perfusion by cardiac magnetic resonance imaging in patients with known or suspected coronary artery disease. QJM 2011; 104:425-32. [PMID: 21217114 DOI: 10.1093/qjmed/hcq238] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Cardiac magnetic resonance imaging (CMR) has been intensely researched in recent years, and its high diagnostic accuracy for myocardial ischemia has been demonstrated. However, its prognostic information is very limited. AIM We sought to assess the value of adenosine stress myocardial perfusion by CMR in predicting cardiac events in patients with known or suspected coronary artery disease (CAD). DESIGN Retrospective study. METHODS From January 2003 to December 2008, we retrospectively reviewed consecutive patients with or without history of CAD referred for evaluation of suspected myocardial ischemia who had undergone adenosine stress CMR in our hospital. End points were cardiac death or non-fatal myocardial infarction (MI). RESULTS After a mean follow-up of 3.2 ± 1.6 years in 203 patients, 15 (7.4%) cardiac events occurred. The 4-year event-free survival was 96.2% for patients with normal stress CMR perfusion and 71.5% for those with abnormal stress CMR perfusion. Univariate analysis showed that both adenosine-induced reversible perfusion defect and delayed gadolinium enhancement by CMR were significant predictors of cardiac events [Hazard ratio (HR) 9.31; 95% Confidence Interval (95% CI) 3.18-27.3; and HR 9.24; 95% CI 3.27-26.08; P < 0.001, respectively). By multivariate analysis, adenosine-induced reversible perfusion defect remained an independent predictor of cardiac events (HR 7.77; 95% CI 2.50-24.18; P < 0.001). In a stepwise multivariate model (Cox regression), an abnormal stress CMR perfusion result had significant incremental predictive value over clinical risk factors and resting regional wall motion abnormality (RWMA) (P < 0.001). CONCLUSION In patients with known or suspected CAD, adenosine stress CMR could be used to identify patients at high risk for subsequent cardiac death or nonfatal MI. A normal CMR perfusion was associated with a very low long-term event rate and excellent long-term prognosis. In addition, stress CMR perfusion provided important incremental prognostic information over clinical risk factors and RWMA.
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Affiliation(s)
- K Y Lo
- Department of Medicine and Geriatrics, United Christian Hospital, G8C, 130 Hip Wo Street, Kwun Tong, Hong Kong.
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15
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Kiriyama T, Toba M, Fukushima Y, Hayashi H, Takano H, Mizuno K, Kumita SI. Discordance Between the Morphological and Physiological Information of 64-Slice MSCT Coronary Angiography and Myocardial Perfusion Imaging in Patients With Intermediate to High Probability of Coronary Artery Disease. Circ J 2011; 75:1670-7. [DOI: 10.1253/circj.cj-10-1123] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Tomonari Kiriyama
- Department of Radiology, Graduate School of Radiology, Nippon Medical School
| | - Masahiro Toba
- Department of Radiology, Graduate School of Radiology, Nippon Medical School
| | | | - Hiromitsu Hayashi
- Department of Radiology, Graduate School of Radiology, Nippon Medical School
| | - Hitoshi Takano
- Department of Internal Medicine (Division of Cardiology, Hepatology, Geriatrics, and Integrated Medicine), Nippon Medical School
| | - Kyoichi Mizuno
- Department of Internal Medicine (Division of Cardiology, Hepatology, Geriatrics, and Integrated Medicine), Nippon Medical School
| | - Shin-ichiro Kumita
- Department of Radiology, Graduate School of Radiology, Nippon Medical School
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16
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Influence of small caliber coronary arteries on the diagnostic accuracy of adenosine stress cardiac magnetic resonance imaging. Clin Res Cardiol 2010; 100:201-8. [PMID: 20862587 PMCID: PMC3040827 DOI: 10.1007/s00392-010-0229-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2010] [Accepted: 09/07/2010] [Indexed: 01/10/2023]
Abstract
Background and aims Positive predictive value (PPV) of adenosine stress cardiac magnetic resonance (CMR) for coronary artery disease (CAD) is unsatisfactory. We investigated the impact of coronary caliber variability on this limitation in CMR performance. Methods and results 206 consecutive patients with myocardial ischemia during CMR and subsequent coronary angiography (CA) were studied. Patients were examined in a 1.5-T scanner. After adenosine infusion, myocardial first-pass sequence using gadolinium-based contrast agent was performed and compared with rest perfusion. CAD was invasively confirmed in 165 [true positive (TP); PPV, 80.1%] and ruled out in 41 patients [false positive (FP)]. TP and FP were comparable for pre-test risk and CMR findings. We found a significant association between FP CMR and the presence of a small caliber coronary vessel (proximal diameter < one standard deviation below the mean) supplying the area of ischemia (chi-square 42.6, p < 0.0001). A small caliber artery ipsilateral to the ischemic region was a predictive parameter for FP versus TP discrimination (ROC area, 0.84 ± 0.04 vs. 0.59 ± 0.05; p < 0.0001). Further increment in diagnostic accuracy was achieved by including proximal ipsilateral/contralateral coronary diameter ratios (ROC area, 0.90 ± 0.03; p < 0.03). Conclusions Small caliber coronary arteries found as normal variations in right-dominant or left-dominant circulation may account for hypoperfusion in the absence of coronary stenosis and thus may cause FP adenosine stress CMR results. Non-invasive assessment of proximal coronary diameters in the vessel supplying the area of ischemia could reduce FP rates, raise the diagnostic accuracy of CMR for CAD and minimize subsequent superfluous CA.
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Pilz G, Eierle S, Heer T, Klos M, Ali E, Scheck R, Wild M, Bernhardt P, Hoefling B. Negative predictive value of normal adenosine-stress cardiac MRI in the assessment of coronary artery disease and correlation with semiquantitative perfusion analysis. J Magn Reson Imaging 2010; 32:615-21. [DOI: 10.1002/jmri.22289] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Pilz G, Patel PA, Fell U, Ladapo JA, Rizzo JA, Fang H, Gunnarsson C, Heer T, Hoefling B. Adenosine-stress cardiac magnetic resonance imaging in suspected coronary artery disease: a net cost analysis and reimbursement implications. Int J Cardiovasc Imaging 2010; 27:113-21. [PMID: 20524070 PMCID: PMC3035783 DOI: 10.1007/s10554-010-9645-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2010] [Accepted: 05/21/2010] [Indexed: 11/30/2022]
Abstract
The health and economic implications of new imaging technologies are increasingly relevant policy issues. Cardiac magnetic resonance imaging (CMR) is currently not or not sufficiently reimbursed in a number of countries including Germany, presumably because of a limited evidence base. It is unknown, however, whether it can be effectively used to facilitate medical decision-making and reduce costs by serving as a gatekeeper to invasive coronary angiography. We investigated whether the application of CMR in patients suspected of having coronary artery disease (CAD) reduces costs by averting referrals to cardiac catheterization. We used propensity score methods to match 218 patients from a CMR registry to a previously studied cohort in which CMR was demonstrated to reliably identify patients who were low-risk for major cardiac events. Covariates over which patients were matched included comorbidity profiles, demographics, CAD-related symptoms, and CAD risk as measured by Morise scores. We determined the proportion of patients for whom cardiac catheterization was deferred based upon CMR findings. We then calculated the economic effects of practice pattern changes using data on cardiac catheterization and CMR costs. CMR reduced the utilization of cardiac catheterization by 62.4%. Based on estimated catheterization costs of € 619, the utilization of CMR as a gatekeeper reduced per-patient costs by a mean of € 90. Savings were realized until CMR costs exceeded € 386. Cost savings were greatest for patients at low-risk for CAD, as measured by baseline Morise scores, but were present for all Morise subgroups with the exception of patients at the highest risk of CAD. CMR significantly reduces the utilization of cardiac catheterization in patients suspected of having CAD. Per-patient savings range from € 323 in patients at lowest risk of CAD to € 58 in patients at high-risk but not in the highest risk stratum. Because a negative CMR evaluation has high negative predictive value, its application as a gatekeeper to cardiac catheterization should be further explored as a treatment option.
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Affiliation(s)
- Guenter Pilz
- Department of Cardiology, Clinic Agatharied, Academic Teaching Hospital, University of Munich, Hausham, Germany.
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Karlsberg RP, Budoff MJ, Thomson LEJ, Friedman JD, Berman DS. Reduction in downstream test utilization following introduction of coronary computed tomography in a cardiology practice. Int J Cardiovasc Imaging 2010; 26:359-66. [PMID: 19967562 PMCID: PMC2846332 DOI: 10.1007/s10554-009-9547-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Accepted: 11/18/2009] [Indexed: 12/22/2022]
Abstract
To compare utilization of non-invasive ischemic testing, invasive coronary angiography (ICA), and percutaneous coronary intervention (PCI) procedures before and after introduction of 64-slice multi-detector row coronary computed tomographic angiography (CCTA) in a large urban primary and consultative cardiology practice. We utilized a review of electronic medical records (NotesMD) and the electronic practice management system (Megawest) encompassing a 4-year period from 2004 to 2007 to determine the number of exercise treadmill (TME), supine bicycle exercise echocardiography (SBE), single photon emission computed tomography (SPECT) myocardial perfusion stress imaging (MPI), coronary calcium score (CCS), CCTA, ICA, and PCI procedures performed annually. Test utilization in the 2 years prior to and 2 years following availability of CCTA were compared. Over the 4-year period reviewed, the annual utilization of ICA decreased 45% (2,083 procedures in 2004 vs. 1,150 procedures in 2007, P < 0.01) and the percentage of ICA cases requiring PCI increased (19% in 2004 vs. 28% in 2007, P < 0.001). SPECT MPI decreased 19% (3,223 in 2004 vs. 2,614 in 2007 P < 0.02) and exercise stress treadmill testing decreased 49% (471 in 2004 vs. 241 in 2007 P < 0.02). Over the same period, there were no significant changes in measures of practice volume (office and hospital) or the annual incidence of PCI (405 cases in 2004 vs. 326 cases in 2007) but a higher percentage of patients with significant disease undergoing PCI 19% in 2004 vs. 29% in 2007 P < 0.01. Implementation of CCTA resulted in a significant decrease in ICA and a corresponding significant increase in the percentage of ICA cases requiring PCI, indicating that CCTA resulted in more accurate referral for ICA. The reduction in unnecessary ICA is associated with avoidance of potential morbidity and mortality associated with invasive diagnostic testing, reduction of downstream SPECT MPI and TME as well as substantial savings in health care dollars.
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Affiliation(s)
- Ronald P Karlsberg
- Cardiovascular Research Foundation of Southern California, Beverly Hills, CA, USA.
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Gaemperli O, Husmann L, Schepis T, Koepfli P, Valenta I, Jenni W, Alkadhi H, Lüscher TF, Kaufmann PA. Coronary CT angiography and myocardial perfusion imaging to detect flow-limiting stenoses: a potential gatekeeper for coronary revascularization? Eur Heart J 2009; 30:2921-9. [PMID: 19684023 DOI: 10.1093/eurheartj/ehp304] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
AIMS To evaluate the diagnostic accuracy of a combined non-invasive assessment of coronary artery disease with coronary CT angiography (CTA) and myocardial perfusion imaging (MPI) for the detection of flow-limiting coronary stenoses and its potential as a gatekeeper for invasive examination and treatment. METHODS AND RESULTS In 78 patients (mean age 65 +/- 9 years) referred for coronary angiography (CA), additional CTA and MPI (using single-photon emission-computed tomography) were performed and the findings not communicated. Detection of flow-limiting stenoses (justifying revascularization) by the combination of CTA and MPI (CTA/MPI) was compared with the combination of quantitative coronary angiography (QCA) plus MPI (QCA/MPI), which served as standard of reference. The findings of both combinations were related to the treatment strategy (revascularization vs. medical treatment) chosen in the catheterization laboratory based on the CA findings. Sensitivity, specificity, positive and negative predictive value, and accuracy of CTA/MPI for the detection of flow-limiting coronary stenoses were 100% each. More than half of revascularization procedures (21/40, 53%) was performed in patients without flow-limiting stenoses and 76% (47/62) of revascularized vessels were not associated with ischaemia on MPI. CONCLUSION The combined non-invasive approach CTA/MPI has an excellent accuracy to detect flow-limiting coronary stenoses compared with QCA/MPI and its use as a gatekeeper appears to make a substantial part of revascularization procedures redundant.
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Affiliation(s)
- Oliver Gaemperli
- Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, CH-8091 Zurich, Switzerland
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Menon M, Lesser JR, Hara H, Birkett R, Knickelbine T, Longe T, Flygenring B, Henry J, Schwartz R. Multidetector CT coronary angiography for patient triage to invasive coronary angiography: Performance and cost in ambulatory patients with equivocal or suspected inaccurate noninvasive stress tests. Catheter Cardiovasc Interv 2009; 73:497-502. [DOI: 10.1002/ccd.21816] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Hines JL, Danciu SC, Shah M, Borg MJ, Biga C. Use of multidetector computed tomography after mildly abnormal myocardial perfusion stress testing in a large single-specialty cardiology practice. J Cardiovasc Comput Tomogr 2008; 2:372-8. [DOI: 10.1016/j.jcct.2008.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2008] [Revised: 08/14/2008] [Accepted: 09/20/2008] [Indexed: 11/28/2022]
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Hutyra M, Skala T, Kaminek M, Nemec P. ECHOCARDIOGRAPHIC AND CARDIAC SINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY PREDICTORS OF LEFT VENTRICLE REVERSE REMODELING AFTER SURGICAL REVASCULARIZATION IN PATIENTS WITH ISCHEMIC CARDIOMYOPATHY AND LEFT VENTRICLE SYSTOLIC DYSFUNCTION. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2008; 152:129-37. [DOI: 10.5507/bp.2008.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Muscular Tenderness in the Anterior Chest Wall in Patients With Stable Angina Pectoris is Associated With Normal Myocardial Perfusion. J Manipulative Physiol Ther 2008; 31:344-7. [DOI: 10.1016/j.jmpt.2008.04.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2007] [Revised: 02/28/2008] [Accepted: 03/06/2008] [Indexed: 11/18/2022]
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Pilz G, Jeske A, Klos M, Ali E, Hoefling B, Scheck R, Bernhardt P. Prognostic value of normal adenosine-stress cardiac magnetic resonance imaging. Am J Cardiol 2008; 101:1408-12. [PMID: 18471450 DOI: 10.1016/j.amjcard.2008.01.019] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2007] [Revised: 01/16/2008] [Accepted: 01/16/2008] [Indexed: 10/22/2022]
Abstract
We investigated the prognostic value of normal adenosine stress cardiac magnetic resonance (CMR) in suspected coronary artery disease (CAD). Prospectively enrolled in the study were 218 patients with suspected CAD, no stress hypoperfusion, and no delayed enhancement in CMR, and consecutively deferred coronary angiography. The primary end point was a 12-month rate of major adverse cardiac events (MACE; cardiovascular mortality, myocardial infarction, revascularization, hospitalization due to cardiovascular event). CMR indication was symptomatic angina (Canadian Cardiovascular Society II in 42% and III in 7%) or evaluation of myocardial ischemia in patients with arrhythmia, syncope, and/or equivocal stress tests and cardiovascular risk factors (51%). As the main result, the 12-month MACE rate was 2/218 (1 stent implantation, 1 bypass surgery) and CMR negative predictive value 99.1%. There was no cardiac death or myocardial infarction. In conclusion, normal adenosine stress CMR predicts a very low MACE rate and an excellent 1-year prognosis in patients with suspected CAD. Our results provide clinical reassurance that patients at risk for CAD-associated MACE were not missed by CMR. Hence, CMR may serve as a reliable noninvasive gatekeeper to reduce the number of redundant coronary angiographies.
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van Werkhoven JM, Schuijf JD, Jukema JW, Kroft LJ, Stokkel MP, Dibbets-Schneider P, Pundziute G, Scholte AJ, van der Wall EE, Bax JJ. Anatomic correlates of a normal perfusion scan using 64-slice computed tomographic coronary angiography. Am J Cardiol 2008; 101:40-5. [PMID: 18157963 DOI: 10.1016/j.amjcard.2007.07.046] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2007] [Revised: 07/09/2007] [Accepted: 07/09/2007] [Indexed: 10/22/2022]
Abstract
Both myocardial perfusion imaging (MPI) and multislice computed tomography (MSCT) are currently used to detect coronary artery disease (CAD). However, MSCT permits early detection of atherosclerosis while myocardial perfusion is still normal. In addition, MPI results can be normal despite the presence of high-risk CAD (left main and balanced 3-vessel CAD). In this study, the range of anatomic findings using MSCT in patients with normal MPI results was evaluated. In 180 patients presenting with chest pain, MPI (with gated single-photon emission computed tomography) and 64-slice MSCT were performed. In patients with normal MPI results, prevalences of completely normal coronary arteries, nonobstructive CAD, and obstructive CAD were determined using MSCT. The occurrence of high-risk CAD, including left main and 3-vessel disease, was also evaluated. Normal MPI and adequate MSCT findings were obtained in 97 patients (54%; 50% women; average age 58 +/- 12 years; 5% with known CAD). A total of 38 patients (39%) showed normal coronary anatomy, whereas nonsignificant and significant CAD were observed in 37 (38%) and 18 patients (19%), respectively. Importantly, only 4 patients (4%) presented with high-risk CAD using 64-slice MSCT, 2 with left main and 2 with 3-vessel disease. In conclusion, a normal MPI result can be associated with a wide range of anatomic observations and cannot exclude the presence of both nonobstructive and obstructive CAD. However, importantly, the prevalence of high-risk CAD was rare.
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Høilund-Carlsen PF, Johansen A, Vach W, Christensen HW, Møldrup M, Haghfelt T. How well does standard clinician evaluation identify low likelihood of ischaemic or coronary heart disease? Int J Cardiol 2008; 123:177-9. [PMID: 17292987 DOI: 10.1016/j.ijcard.2006.11.112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2006] [Accepted: 11/12/2006] [Indexed: 11/22/2022]
Abstract
Guidelines claim that patients with a low likelihood of coronary artery disease can be reliably identified clinically by a simple set of rules. Among 385 patients referred for coronary angiography because of suspected stable angina pectoris we found by myocardial perfusion scintigraphy in three selected low likelihood groups reversible perfusion defects in 23%-29% of male and 11%-17% of female patients. Rates of significant angiographic disease were similar. These data question the validity of current clinical practice for identifying low likelihood of disease in this category of patients.
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Utsunomiya D, Tomiguchi S, Yamashita Y. Role of cardiac computed tomography in patients with suspected coronary artery disease: interaction with nuclear cardiology. ACTA ACUST UNITED AC 2007; 25:493-501. [DOI: 10.1007/s11604-007-0178-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2007] [Accepted: 07/20/2007] [Indexed: 10/22/2022]
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Høilund-Carlsen PF, Johansen A, Vach W, Christensen HW, Møldrup M, Haghfelt T. High probability of disease in angina pectoris patients: is clinical estimation reliable? Can J Cardiol 2007; 23:641-7. [PMID: 17593989 PMCID: PMC2651943 DOI: 10.1016/s0828-282x(07)70226-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2006] [Accepted: 11/02/2006] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND According to most current guidelines, stable angina pectoris patients with a high probability of having coronary artery disease can be reliably identified clinically. OBJECTIVES To examine the reliability of clinical evaluation with or without an at-rest electrocardiogram (ECG) in patients with a high probability of coronary artery disease. PATIENTS AND METHODS A prospective series of 357 patients referred for coronary angiography (CA) for suspected stable angina pectoris were examined by a trained physician who judged their type of pain and Canadian Cardiovascular Society grade of pain. Pretest likelihood of disease was estimated, and all patients underwent myocardial perfusion scintigraphy (MPS) followed by CA an average of 78 days later. For analysis, the investigators focused on the approximate groups of patients with more severe disease, ie, typical angina (n=187), Canadian Cardiovascular Society grade 2 pain or higher (n=176) or high (higher than 85%) estimated pretest likelihood of disease (n=142). RESULTS In the three groups, 34% to 39% of male patients and 65% to 69% of female patients had normal MPS, while 37% to 38% and 60% to 71%, respectively, had insignificant findings on CA. Of the patients who had also an abnormal at-rest ECG, 14% to 21% of men and 42% to 57% of women had normal MPS. Sex-related differences were statistically significant. CONCLUSIONS Clinical prediction appears to be unreliable. Addition of at-rest ECG data results in some improvement, particularly in male patients, but it makes the high probability groups so small that the addition appears to be of limited clinical relevance.
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Hessian RC, Beanlands RSB. Angina pectoris: Has the cornerstone of symptomatic coronary artery disease been moved? Can J Cardiol 2007; 23:648-50. [PMID: 17593990 PMCID: PMC2651944 DOI: 10.1016/s0828-282x(07)70230-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Renee C Hessian
- Correspondence and reprints: Dr Renee C Hessian, Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario K1Y 4W7. Telephone 613-761-4377, fax 613-761-5022, e-mail
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Gershlick AH, de Belder M, Chambers J, Hackett D, Keal R, Kelion A, Neubauer S, Pennell DJ, Rothman M, Signy M, Wilde P. Role of non-invasive imaging in the management of coronary artery disease: an assessment of likely change over the next 10 years. A report from the British Cardiovascular Society Working Group. Heart 2007; 93:423-31. [PMID: 17401065 PMCID: PMC1861505 DOI: 10.1136/hrt.2006.108779] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Coronary angiography has been the gold standard for determining the severity, extent and prognosis of coronary atheromatous disease for the past 15-20 years. However, established non-invasive testing (such as myocardial perfusion scintigraphy and stress echocardiography) and newer imaging modalities (multi-detector x ray computed tomography and cardiovascular magnetic resonance) now need to be considered increasingly as a challenge to coronary angiography in contemporary practice. An important consideration is the degree to which appropriate use of such techniques impacts on the need for coronary angiography over the next 10-15 years. This review aims to determine the role of the various investigation techniques in the management of coronary artery disease and their resource implications, and should help determine future service provision, accepting that we are in a period of significant technological change.
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Affiliation(s)
- A H Gershlick
- Department of Cardiology, University of Leicester, Glenfield Hospital, Leicester, UK
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Johansen A, Høilund-Carlsen PF, Vach W, Christensen HW, Møldrup M, Haghfelt T. To what degree is amelioration of angina following coronary revascularization associated with improvement in myocardial perfusion? Clin Physiol Funct Imaging 2006; 26:263-70. [PMID: 16939502 DOI: 10.1111/j.1475-097x.2006.00685.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To examine the association between changes in chest pain and changes in perfusion following revascularization as assessed by clinical evaluation and myocardial perfusion imaging (MPI) in patients with stable angina. DESIGN In a prospective series of 380 patients (58.8 +/- 8.8 years) referred to angiography because of known or suspected stable angina, changes in chest discomfort and changes in perfusion after 2 years were assessed in 144 patients, who underwent revascularization, and 236, who did not. The decision to treat invasively was made without knowledge of the result of MPI. RESULTS In revascularized patients, the presence of typical/atypical angina was reduced from 93% to 36% and the improvement was associated with improvement in perfusion. A small improvement in perfusion induced a high frequency of change from angina to no pain, whereas a further reduction caused little extra change. In non-revascularized patients the change in chest discomfort was not related to changes in perfusion, which were rarely present. CONCLUSION Alleviation of chest discomfort 2 years after revascularization is associated with improvements in perfusion. This association appeared to be an all-or-nothing phenomenon. Non-revascularized patients also exhibited improvements in chest discomfort despite insignificant changes in perfusion.
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Affiliation(s)
- Allan Johansen
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark.
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Pilz G, Bernhardt P, Klos M, Ali E, Wild M, Höfling B. Clinical implication of adenosine-stress cardiac magnetic resonance imaging as potential gatekeeper prior to invasive examination in patients with AHA/ACC class II indication for coronary angiography. Clin Res Cardiol 2006; 95:531-8. [PMID: 16897145 DOI: 10.1007/s00392-006-0422-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2006] [Accepted: 06/16/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Real world cardiology is faced with a low diagnostic yield of coronary angiography (CXA) in patients presenting with ACC/AHA class II CXA indication. Our aim was to analyze the clinical implication of a Cardiac MR (CMR) protocol including adenosine stress perfusion in this patient population. We examined whether CMR could enhance appropriate CXA indication and thus reduce the rate of pure diagnostic CXA. In addition, we compared the relative impact of CMR exam components (perfusion, function and viability assessment) in achieving this target. METHODS 176 patients were referred for CXA with class II indication. 171 underwent complete additional CMR exam in a 1.5-T whole body CMR-scanner for myocardial function, ischemia and viability prior to CXA. The routine protocol for assessment of CAD consisted of functional imaging (long and short axes), adenosine stress- and rest-perfusion in short axis orientation and "late enhancement" imaging in long and short axes. Images were analyzed by two independent and blinded investigators. Interobserver differences were resolved by a third reader. RESULTS There was a high association between CMR results and subsequent invasive findings (chi square for CMR perfusion deficit and stenosis >70% in CXA: 113.7, p<0.0001). 109 (63.7%) of our patients had relevant perfusion deficits as seen by CMR and matching coronary artery stenosis >70%. Four (2.3%) patients had false negative CMR findings. In 58 patients (33.9%) no relevant coronary artery stenosis could be observed, correctly predicted by CMR in 48 cases; in 10 (5.8%) patients CMR provided false positive results. Sensitivity of CMR to detect relevant CAD (>70% luminal narrowing) was 0.96, specificity 0.83, positive predictive value 0.92 and negative predictive value 0.92. Of the CMR components, perfusion deficit was the strongest independent predictor (odds ratio 132.3, p < 0.0001). CONCLUSION In a great number of patients being referred to cath lab with ACC/AHA class II indication for CXA, CMR provides a high accuracy for decision making regarding appropriateness of the invasive exam. CMR prior to CXA could substantially reduce pure diagnostic coronary angiographies in patients with intermediate probability for CAD, in our patient-cohort from approximately 34% to 6%. Further studies are warranted to identify rare false negative CMR results.
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Affiliation(s)
- Guenter Pilz
- Department of Cardiology, Clinic Agatharied, Academic Teaching Hospital of the University of Munich, St.-Agatha-Str. 1, 83734, Hausham, Germany.
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Jensen JK, Øvrehus K, Møldrup M, Mickley H, Høilund-Carlsen PF. Redefinition of the Q wave -- is there a clinical problem? Am J Cardiol 2006; 97:974-6. [PMID: 16563898 DOI: 10.1016/j.amjcard.2005.10.042] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2005] [Revised: 10/07/2005] [Accepted: 10/07/2005] [Indexed: 11/29/2022]
Abstract
This study evaluated the potential consequences of the redefined joint European/American electrocardiographic criteria for an established myocardial infarction (MI). New and previous diagnostic Q-wave criteria were used in patients with stable angina pectoris. Seventy-nine patients with and 77 patients without a documented previous MI were compared using the results of myocardial perfusion imaging at rest as a reference. With the new Q-wave criteria, 71% of the former group and 40% of the latter had evidence of established MI compared with 33% and 3% when using the previous criteria (p <0.0001). Sensitivity, specificity, and positive and negative predictive values were 71%, 60%, 64%, and 67% for the new criteria versus 33%, 97%, 93%, and 59% with the previous criteria. These data suggest that that the new Q-wave criteria may be too nonspecific, resulting in an inappropriately high number of false-positive results.
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Affiliation(s)
- Jesper K Jensen
- Department of Cardiology, Odense University Hospital, Odense, Denmark.
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Reyes E, Underwood SR. Myocardial perfusion scintigraphy: an important step between clinical assessment and coronary angiography in patients with stable chest painThe opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology. Eur Heart J 2005; 27:3-4. [PMID: 16267072 DOI: 10.1093/eurheartj/ehi627] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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