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Parwani P, Chen T, Allen B, Kallianos K, Ng MY, Kozor R, Aremu OO, Farooqi KM, Secinaro A, Ricci F, Moharem-Elgamal S, Liberato G, Narang A, Ojha V, Ducci CB, Plein S, Ordovas KG. Challenges and opportunities for early career medical professionals in cardiovascular magnetic resonance (CMR) imaging: a white paper from the Society for Cardiovascular Magnetic Resonance. J Cardiovasc Magn Reson 2023; 25:65. [PMID: 37968709 PMCID: PMC10652595 DOI: 10.1186/s12968-023-00968-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 09/15/2023] [Indexed: 11/17/2023] Open
Abstract
The early career professionals in the field of Cardiovascular Magnetic Resonance (CMR) face unique challenges and hurdles while establishing their careers in the field. The Society for Cardiovascular Magnetic Resonance (SCMR) has expanded the role of the early career section within the society to foster the careers of future CMR leaders. This paper aims to describe the obstacles and available opportunities for the early career CMR professionals worldwide. Societal opportunities and actions targeted at the professional advancement of the early career CMR imagers are needed to ensure continuous growth of CMR as an imaging modality globally.
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Affiliation(s)
- Purvi Parwani
- Division of Cardiology, Department of Medicine, Loma Linda University Health, Loma Linda, CA, USA.
| | - Tiffany Chen
- Department of Clinical Medicine, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Bradley Allen
- Department of Radiology, Northwestern University, Chicago, IL, USA
| | - Kimberly Kallianos
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Ming-Yen Ng
- Department of Diagnostic Radiology, The University of Hong Kong, Hong Kong Special Administrative Region, China
- Department of Medical Imaging, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Rebecca Kozor
- Cardiology Department, Royal North Shore Hospital and Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Olukayode O Aremu
- Division of Cardiology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Hatter Institute for Cardiovascular Research in Africa, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kanwal M Farooqi
- Department of Pediatrics, Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Aurelio Secinaro
- Advanced Cardiovascular Imaging Unit, Department of Imaging, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Fabrizio Ricci
- Institute of Advanced Biomedical Technologies, Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
- Clinical Research Center, Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Sarah Moharem-Elgamal
- Cardiology Department, Liverpool Heart and Chest Hospital, Liverpool, UK
- Cardiology Department, National Heart Institute, Giza, Egypt
| | - Gabriela Liberato
- Diagnostic Imaging Department, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
- Department of Radiology, Sirio Libanês Hospital, São Paulo, Brazil
| | - Akhil Narang
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Vineeta Ojha
- Department of Radiology, Mahajan Imaging, Pushpawati Singhania Research Institute (PSRI), New Delhi, India
| | | | - Sven Plein
- Department of Biomedical Imaging Science, University of Leeds and Kings College London, London, UK
| | - Karen G Ordovas
- Department of Radiology, University of Washington, Seattle, WA, USA
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Silva TQAC, Pezel T, Jerosch-Herold M, Coelho-Filho OR. The Role and Advantages of Cardiac Magnetic Resonance in the Diagnosis of Myocardial Ischemia. J Thorac Imaging 2023; 38:235-246. [PMID: 36917509 DOI: 10.1097/rti.0000000000000701] [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: 03/15/2023]
Abstract
Ischemic heart disease continues to be the leading cause of death and disability worldwide. For the diagnosis of ischemic heart disease, some form of cardiac stress test involving exercise or pharmacological stimulation continues to play an important role, despite advances within modalities like computer tomography for the noninvasive detection and characterization of epicardial coronary lesions. Among noninvasive stress imaging tests, cardiac magnetic resonance (CMR) combines several capabilities that are highly relevant for the diagnosis of ischemic heart disease: assessment of wall motion abnormalities, myocardial perfusion imaging, and depiction of replacement and interstitial fibrosis markers by late gadolinium enhancement techniques and T1 mapping. On top of these qualities, CMR is also well tolerated and safe in most clinical scenarios, including in the presence of cardiovascular implantable devices, while in the presence of renal disease, gadolinium-based contrast should only be used according to guidelines. CMR also offers outstanding viability assessment and prognostication of cardiovascular events. The last 2019 European Society of Cardiology guidelines for chronic coronary syndromes has positioned stress CMR as a class I noninvasive imaging technique for the diagnosis of coronary artery disease in symptomatic patients. In the present review, we present the current state-of-the-art assessment of myocardial ischemia by stress perfusion CMR, highlighting its advantages and current shortcomings. We discuss the safety, clinical, and cost-effectiveness aspects of gadolinium-based CMR-perfusion imaging for ischemic heart disease assessment.
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Affiliation(s)
- Thiago Quinaglia A C Silva
- Discipline of Cardiology, Faculty of Medical Science-State University of Campinas-UNICAMP, Campinas, São Paulo, Brazil
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Théo Pezel
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD
- Department of Cardiology, University of Paris, CHU Lariboisière, Inserm, UMRS 942, Paris, France
| | - Michael Jerosch-Herold
- Noninvasive Cardiovascular Imaging Program and Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | - Otávio R Coelho-Filho
- Discipline of Cardiology, Faculty of Medical Science-State University of Campinas-UNICAMP, Campinas, São Paulo, Brazil
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3
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Screever EM, Gorter TM, Willems TP, Aboumsallem JP, Suthahar N, Mahmoud B, van Veldhuisen DJ, de Boer RA, Meijers WC. Diffuse Myocardial Fibrosis on Cardiac Magnetic Resonance Imaging Is Related to Galectin-3 and Predicts Outcome in Heart Failure. Biomolecules 2023; 13:410. [PMID: 36979345 PMCID: PMC10046101 DOI: 10.3390/biom13030410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/14/2023] [Accepted: 02/16/2023] [Indexed: 02/25/2023] Open
Abstract
AIMS Ongoing adverse remodeling is a hallmark of heart failure (HF), which might be reflected by either focal or diffuse myocardial fibrosis. Therefore, in (pre)clinical settings, we used immunohistochemistry or cardiac magnetic resonance imaging (CMR) to investigate the association of (focal or diffuse) fibrosis with cardiac biomarkers and adverse events in HF. METHODS AND RESULTS In C57Bl/6J mice, we determined the presence and extent of myocardial fibrosis 6 weeks post-myocardial infarction (MI). Furthermore, we studied 159 outpatient HF patients who underwent CMR, and determined focal and diffuse fibrosis by late gadolinium enhancement (LGE) and post-contrast T1 time of the non-LGE myocardium, respectively. HF patients were categorized based on the presence of LGE, and by the median post-contrast T1 time. Kaplan-Meier and Cox regression analyses were used to determine the association of fibrosis with HF hospitalization and all-cause mortality. LGE was detected in 61 (38%) patients. Cardiac biomarker levels were comparable between LGE-positive and LGE-negative patients. LGE-positive patients with a short T1 time had elevated levels of both NT-proBNP and galectin-3 (1611 vs. 453 ng/L, p = 0.026 and 20 vs. 15 μg/L, p = 0.004, respectively). This was not observed in LGE-negative patients. Furthermore, a short T1 time in LGE-positive patients was associated with a higher risk of adverse events (log-rank p = 0.01). CONCLUSION This study implies that cardiac biomarkers reflect active remodeling of the non-infarcted myocardium of patients with focal myocardial scarring. Diffuse fibrosis, in contrast to focal scarring, might have a higher prognostic value regarding adverse outcomes in HF patients.
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Affiliation(s)
- Elles M. Screever
- Department of Cardiology, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Thomas M. Gorter
- Department of Cardiology, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Tineke P. Willems
- Department of Radiology, University Medical Center Groningen, 9700 RB Groningen, The Netherlands
| | - Joseph Pierre Aboumsallem
- Department of Cardiology, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Navin Suthahar
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Belend Mahmoud
- Department of Cardiology, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Dirk J. van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Rudolf A. de Boer
- Department of Cardiology, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Wouter C. Meijers
- Department of Cardiology, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
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4
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Zhou W, Sin J, Yan AT, Wang H, Lu J, Li Y, Kim P, Patel AR, Ng MY. Qualitative and Quantitative Stress Perfusion Cardiac Magnetic Resonance in Clinical Practice: A Comprehensive Review. Diagnostics (Basel) 2023; 13:diagnostics13030524. [PMID: 36766629 PMCID: PMC9914769 DOI: 10.3390/diagnostics13030524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/11/2023] [Accepted: 01/28/2023] [Indexed: 02/05/2023] Open
Abstract
Stress cardiovascular magnetic resonance (CMR) imaging is a well-validated non-invasive stress test to diagnose significant coronary artery disease (CAD), with higher diagnostic accuracy than other common functional imaging modalities. One-stop assessment of myocardial ischemia, cardiac function, and myocardial viability qualitatively and quantitatively has been proven to be a cost-effective method in clinical practice for CAD evaluation. Beyond diagnosis, stress CMR also provides prognostic information and guides coronary revascularisation. In addition to CAD, there is a large body of literature demonstrating CMR's diagnostic performance and prognostic value in other common cardiovascular diseases (CVDs), especially coronary microvascular dysfunction (CMD). This review focuses on the clinical applications of stress CMR, including stress CMR scanning methods, practical interpretation of stress CMR images, and clinical utility of stress CMR in a setting of CVDs with possible myocardial ischemia.
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Affiliation(s)
- Wenli Zhou
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, No. 600, Yishan Road, Shanghai 200233, China
| | - Jason Sin
- Department of Diagnostic Radiology, The University of Hong Kong, Hong Kong SAR, China
| | - Andrew T. Yan
- St. Michael’s Hospital, University of Toronto, Toronto, ON M5B 1W8, Canada
| | | | - Jing Lu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, No. 600, Yishan Road, Shanghai 200233, China
| | - Yuehua Li
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, No. 600, Yishan Road, Shanghai 200233, China
| | - Paul Kim
- Department of Medicine, University of California San Diego, San Diego, CA 92093, USA
| | - Amit R. Patel
- Department of Cardiovascular Medicine, University of Virginia, Charlottesville, VA 22903, USA
| | - Ming-Yen Ng
- Department of Medical Imaging, HKU-Shenzhen Hospital, Shenzhen 518009, China
- Department of Diagnostic Radiology, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
- Correspondence:
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The Merits, Limitations, and Future Directions of Cost-Effectiveness Analysis in Cardiac MRI with a Focus on Coronary Artery Disease: A Literature Review. J Cardiovasc Dev Dis 2022; 9:jcdd9100357. [PMID: 36286309 PMCID: PMC9604922 DOI: 10.3390/jcdd9100357] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/12/2022] [Accepted: 10/14/2022] [Indexed: 11/17/2022] Open
Abstract
Cardiac magnetic resonance (CMR) imaging has a wide range of clinical applications with a high degree of accuracy for many myocardial pathologies. Recent literature has shown great utility of CMR in diagnosing many diseases, often changing the course of treatment. Despite this, it is often underutilized possibly due to perceived costs, limiting patient factors and comfort, and longer examination periods compared to other imaging modalities. In this regard, we conducted a literature review using keywords “Cost-Effectiveness” and “Cardiac MRI” and selected articles from the PubMed MEDLINE database that met our inclusion and exclusion criteria to examine the cost-effectiveness of CMR. Our search result yielded 17 articles included in our review. We found that CMR can be cost-effective in quality-adjusted life years (QALYs) in select patient populations with various cardiac pathologies. Specifically, the use of CMR in coronary artery disease (CAD) patients with a pretest probability below a certain threshold may be more cost-effective compared to patients with a higher pretest probability, although its use can be limited based on geographic location, professional society guidelines, and differing reimbursement patterns. In addition, a stepwise combination of different imaging modalities, with conjunction of AHA/ACC guidelines can further enhance the cost-effectiveness of CMR.
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6
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Pandya A, Yu YJ, Ge Y, Nagel E, Kwong RY, Bakar RA, Grizzard JD, Merkler AE, Ntusi N, Petersen SE, Rashedi N, Schwitter J, Selvanayagam JB, White JA, Carr J, Raman SV, Simonetti OP, Bucciarelli-Ducci C, Sierra-Galan LM, Ferrari VA, Bhatia M, Kelle S. Evidence-based cardiovascular magnetic resonance cost-effectiveness calculator for the detection of significant coronary artery disease. J Cardiovasc Magn Reson 2022; 24:1. [PMID: 34986851 PMCID: PMC8734365 DOI: 10.1186/s12968-021-00833-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 11/30/2021] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Although prior reports have evaluated the clinical and cost impacts of cardiovascular magnetic resonance (CMR) for low-to-intermediate-risk patients with suspected significant coronary artery disease (CAD), the cost-effectiveness of CMR compared to relevant comparators remains poorly understood. We aimed to summarize the cost-effectiveness literature on CMR for CAD and create a cost-effectiveness calculator, useable worldwide, to approximate the cost-per-quality-adjusted-life-year (QALY) of CMR and relevant comparators with context-specific patient-level and system-level inputs. METHODS We searched the Tufts Cost-Effectiveness Analysis Registry and PubMed for cost-per-QALY or cost-per-life-year-saved studies of CMR to detect significant CAD. We also developed a linear regression meta-model (CMR Cost-Effectiveness Calculator) based on a larger CMR cost-effectiveness simulation model that can approximate CMR lifetime discount cost, QALY, and cost effectiveness compared to relevant comparators [such as single-photon emission computed tomography (SPECT), coronary computed tomography angiography (CCTA)] or invasive coronary angiography. RESULTS CMR was cost-effective for evaluation of significant CAD (either health-improving and cost saving or having a cost-per-QALY or cost-per-life-year result lower than the cost-effectiveness threshold) versus its relevant comparator in 10 out of 15 studies, with 3 studies reporting uncertain cost effectiveness, and 2 studies showing CCTA was optimal. Our cost-effectiveness calculator showed that CCTA was not cost-effective in the US compared to CMR when the most recent publications on imaging performance were included in the model. CONCLUSIONS Based on current world-wide evidence in the literature, CMR usually represents a cost-effective option compared to relevant comparators to assess for significant CAD.
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Affiliation(s)
- Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 718 Huntington Ave, 2nd Floor, Boston, MA, 02115, USA.
| | - Yuan-Jui Yu
- National Taiwan University Hospital, Taipei, Taiwan
| | - Yin Ge
- Cardiovascular Division of the Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Eike Nagel
- Institute for Experimental and Translational Cardiovascular Imaging, DZHK (German Centre for Cardiovascular Research) Centre for Cardiovascular Imaging, Partner Site RheinMain, University Hospital Frankfurt/Main, Frankfurt am Main, Germany
| | - Raymond Y Kwong
- Cardiovascular Division of the Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Rafidah Abu Bakar
- Department of Cardiology, National Heart Institute, Kuala Lumpur, Malaysia
| | - John D Grizzard
- Department of Radiology, Virginia Commonwealth University Medical Center, Main Hospital, Richmond, VA, USA
| | - Alexander E Merkler
- Department of Neurology, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY, USA
| | - Ntobeko Ntusi
- Department of Medicine, University of Cape Town & Groote Schuur Hospital, Cape Town, South Africa
| | - Steffen E Petersen
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, London, UK
| | - Nina Rashedi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Juerg Schwitter
- Division of Cardiology, Cardiovascular Department, CMR Center University Hospital, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, UniL, Lausanne, Switzerland
| | - Joseph B Selvanayagam
- Department of Medicine, School of Medicine and Public Health, Flinders University, Adelaide, Australia
- Department of Heart Health, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - James A White
- Division of Cardiology, Department of Cardiac Sciences, Stephenson Cardiac Imaging Centre, University of Calgary, Calgary, Canada
| | - James Carr
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Subha V Raman
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Orlando P Simonetti
- Departments of Internal Medicine and Radiology, The Ohio State University, Columbus, OH, USA
| | - Chiara Bucciarelli-Ducci
- Royal Brompton and Harefield Hospitals, Guys' and St Thomas NHS Hospitals and School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - Lilia M Sierra-Galan
- Cardiovascular Division, Department of Cardiology, American British Cowdray Medical Center, Mexico City, Mexico
| | - Victor A Ferrari
- Cardiovascular Division and Penn Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania Medical Center, Philadelphia, PA, USA
| | - Mona Bhatia
- Department of Imaging, Fortis Escorts Heart Institute, New Delhi, India
| | - Sebastian Kelle
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
- Department of Internal Medicine and Cardiology, DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, German Heart Institute Berlin (DHZB), Berlin, Germany
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Cardiovasc Comput Tomogr 2022; 16:54-122. [PMID: 34955448 DOI: 10.1016/j.jcct.2021.11.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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8
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 78:e187-e285. [PMID: 34756653 DOI: 10.1016/j.jacc.2021.07.053] [Citation(s) in RCA: 299] [Impact Index Per Article: 99.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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9
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 144:e368-e454. [PMID: 34709879 DOI: 10.1161/cir.0000000000001029] [Citation(s) in RCA: 118] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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10
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Hammer M, Mian M, Elhadad L, Li M, Roifman I. Appropriate utilization of cardiac computed tomography for the assessment of stable coronary artery disease. BMC Cardiovasc Disord 2021; 21:154. [PMID: 33771107 PMCID: PMC7995786 DOI: 10.1186/s12872-021-01957-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 03/15/2021] [Indexed: 11/23/2022] Open
Abstract
Background Appropriate use criteria (AUC) have been developed in response to growth in cardiac imaging utilization and concern regarding associated costs. Cardiac computed tomography angiography (CCTA) has emerged as an important modality in the evaluation of coronary artery disease, however its appropriate utilization in actual practice is uncertain. Our objective was to determine the appropriate utilization of CCTA in a large quaternary care institution and to compare appropriate utilization pre and post publication of the 2013 AUC guidelines. We hypothesized that the proportion of appropriate CCTA utilization will be similar to those of other comparable cardiac imaging modalities and that there would be a significant increase in appropriate use post AUC publication. Methods We employed a retrospective cohort study design of 2577 consecutive patients undergoing CCTA between January 1, 2012 and December 30, 2016. An appropriateness category was assigned for each CCTA. Appropriateness classifications were compared pre- and post- AUC publication via the chi-square test. Results Overall, 83.5% of CCTAs were deemed to be appropriate based on the AUC. Before the AUC publication, 75.0% of CCTAs were classified as appropriate whereas after the AUC publication, 88.0% were classified as appropriate (p < 0.001). The increase in appropriate utilization, when extrapolated to the Medicare population of the United States, was associated with potential cost savings of approximately $57 million per year. Conclusions We report a high rate of appropriate use of CCTA and a significant increase in the proportion of CCTAs classified as appropriate after the AUC publication.
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Affiliation(s)
- Michael Hammer
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Muhtashim Mian
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Levi Elhadad
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Mary Li
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Idan Roifman
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada. .,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Canada. .,Medicine and Medical Imaging, Adjunct Scientist, Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Room M315, Toronto, ON, M4N-3M5, Canada.
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11
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Jafari P, Goudarzi R, Amiresmaeili M, Rashidinejad H. The optimal diagnostic strategies for patient with coronary artery diseases and stable chest pain syndrome: a cost-effectiveness analysis. Egypt Heart J 2020; 72:82. [PMID: 33226507 PMCID: PMC7683761 DOI: 10.1186/s43044-020-00111-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 10/20/2020] [Indexed: 11/22/2022] Open
Abstract
Background Numerous invasive and noninvasive diagnostic tests with different cost and effectiveness exist for detection of coronary artery disease. This diversity leads to unnecessary utilization of health services. For this reason, this study focused on the cost-effectiveness analysis of diagnostic strategies for coronary artery disease from the perspective of the health care system with 1-year time horizon. Results Incremental cost effectiveness ratios of all strategies were less than the threshold except for the electrocardiography-computed tomography angiography-coronary angiography strategy, and cost of the cardiac magnetic resonance imaging-based strategy was higher than the cost of other strategies. Also, the number of correct diagnosis in the electrocardiography-coronary angiography strategy was higher than the other strategies, and its ICER was 15.197 dollars per additional correct diagnosis. Moreover, the sensitivity analysis found that the probability of doing MRI and sensitivity of the exercise electrocardiography had impact on the results. Conclusion The most cost-effective strategy for acute patient is ECG-CA strategy, and for chronic patient, the most cost-effective strategies are electrocardiography-single photon emission computed tomography-coronary angiography and electrocardiography-exercise electrocardiography-coronary angiography. Applying these strategies in the same clinical settings may lead to a better utilization of resources.
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Affiliation(s)
- Parvin Jafari
- Social Determinants of Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Reza Goudarzi
- Health Services Management Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran.
| | - Mohammadreza Amiresmaeili
- Department of Health Management and Economics, Faculty of Management and Medical Informatics, Kerman University of Medical Sciences, Kerman, Iran
| | - Hamidreza Rashidinejad
- Cardiovascular Research center,institute of basic and clinical physiology science., Kerman University of Medical Sciences, Kerman, Iran
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Robles-Zurita JA, Briggs A, Rana D, Quayyum Z, Oldroyd KG, Zeymer U, Desch S, de Waha-Thiele S, Thiele H. Economic evaluation of culprit lesion only PCI vs. immediate multivessel PCI in acute myocardial infarction complicated by cardiogenic shock: the CULPRIT-SHOCK trial. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2020; 21:1197-1209. [PMID: 33029668 PMCID: PMC7561561 DOI: 10.1007/s10198-020-01235-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 09/16/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND The CULPRIT-SHOCK trial compared two treatment strategies for patients with acute myocardial infarction and multivessel coronary artery disease complicated by cardiogenic shock: (a) culprit vessel only percutaneous coronary intervention (CO-PCI), with additional staged revascularisation if indicated, and (b) immediate multivessel PCI (MV-PCI). METHODS A German societal and national health service perspective was considered for three different analyses. The cost utility analysis (CUA) estimated costs and quality adjusted life years (QALYs) based on a pre-trial decision analytic model taking a lifelong time horizon. In addition, a within trial CUA estimated QALYs and costs for 1 year. Finally, the cost effectiveness analysis (CEA) used the composite primary outcome, mortality and renal failure at 30-day follow-up, and the within trial costs. Econometric and survival analysis on the trial data was used for the estimation of the model parameters. Subgroup analysis was performed following an economic protocol. RESULTS The lifelong CUA showed an incremental cost effectiveness ratio (ICER), CO-PCI vs. MV-PCI, of €7010 per QALY and a probability of CO-PCI being the most cost-effective strategy > 64% at a €30,000 threshold. The ICER for the within trial CUA was €14,600 and the incremental cost per case of death/renal failure avoided at 30-day follow-up was €9010. Cost-effectiveness improved with patient age and for those without diabetes. CONCLUSIONS The estimates of cost-effectiveness for CO-PCI vs. MV-PCI have been shown to change depending on the time horizon and type of economic evaluation performed. The results favoured a long-term horizon analysis for avoiding underestimation of QALY gains from the CO-PCI arm.
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Affiliation(s)
- Jose Antonio Robles-Zurita
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK.
| | - Andrew Briggs
- London School of Hygiene & Tropical Medicine, London, UK
| | - Dikshyanta Rana
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK
| | - Zahidul Quayyum
- BRAC James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Keith G Oldroyd
- West of Scotland Regional Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, UK
| | - Uwe Zeymer
- Klinikum Ludwigshafen and Institut für Herzinfarktforschung, Ludwigshafen, Germany
| | - Steffen Desch
- Heart Center Leipzig, University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Suzanne de Waha-Thiele
- University Heart Center Lübeck, University Hospital Schleswig-Holstein (UKSH), Lübeck, Germany
| | - Holger Thiele
- Heart Center Leipzig, University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
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Cardiac-CT and cardiac-MR cost-effectiveness: a literature review. Radiol Med 2020; 125:1200-1207. [PMID: 32970273 DOI: 10.1007/s11547-020-01290-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 09/08/2020] [Indexed: 01/18/2023]
Abstract
Cardiovascular diseases are still among the first causes of death worldwide with a huge impact on healthcare systems. Within these conditions, the correct diagnosis of coronary artery disease with the most appropriate imaging-based evaluations is of utmost importance. The sustainability of the healthcare systems, considering the high economic burden of modern cardiac imaging equipments, makes cost-effective analysis an important tool, currently used for weighing different costs and health outcomes, when policy makers have to allocate funds and to prioritize interventions, getting the most out of their financial resources. This review aims at evaluating cost-effective analysis in the more recent literature, focused on the role of Calcium Score, coronary computed tomography angiography and cardiac magnetic resonance.
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An audit of MRI machines and services in Ghana. Radiography (Lond) 2020; 27:127-131. [PMID: 32723619 DOI: 10.1016/j.radi.2020.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/02/2020] [Accepted: 07/03/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Magnetic resonance imaging (MRI) is a useful medical imaging modality for the diagnosis and management of patients. However, the huge costs associated with establishing and operating MRI means it may not be readily accessible and affordable for hospitals in developing countries. Little is currently known about the availability of MRI machines in Ghana. Such information may assist in informing future health service development within the country. This study reports on the findings and implications of an audit of MRI machines in Ghana. METHODS A quantitative descriptive cross-sectional survey was conducted involving all MRI machines in Ghana. Data obtained was analyzed using the Statistical Package for Social Sciences (SPSS) version 23. Independent-samples t-test was conducted to compare the mean cost of MRI examinations between privately-owned and state-owned MRI machines in Ghana. RESULTS 18 MRI machines, spread across five regions, are available in Ghana. 15 (83.3%) of the MRI machines are located in the Greater-Accra and Ashanti regions. MRI examinations are more expensive in privately-owned machines compared to state-owned machines (p < 0.05). Four state-owned machines have been non-operational for between three-six years resulting in a revenue loss of GHC 36 million (US$7.2 million). CONCLUSION There are few MRI machines in Ghana and the majority are concentrated in the two largest regions. The increase in MRI machines over the past decade can be attributed to private investment in the sector. IMPLICATIONS FOR PRACTICE This study will inform the Ghana Health Service and other healthcare policy makers in Ghana to increase investment in MRI machines to ensure equitable regional distribution of MRI machines so that patients across Ghana would have access to the diagnostic benefits associated with MRI machines.
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von Spiczak J, Mannil M, Model H, Schwemmer C, Kozerke S, Ruschitzka F, Alkadhi H, Manka R. Multimodal Multiparametric Three-dimensional Image Fusion in Coronary Artery Disease: Combining the Best of Two Worlds. Radiol Cardiothorac Imaging 2020; 2:e190116. [PMID: 33778554 PMCID: PMC7977970 DOI: 10.1148/ryct.2020190116] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 09/19/2019] [Accepted: 09/26/2019] [Indexed: 11/11/2022]
Abstract
PURPOSE To allow for comprehensive noninvasive diagnostics of coronary artery disease (CAD) by using three-dimensional (3D) image fusion of CT coronary angiography, CT-derived fractional flow reserve (CT FFR), whole-heart dynamic 3D cardiac MRI perfusion, and 3D cardiac MRI late gadolinium enhancement (LGE). MATERIALS AND METHODS Seventeen patients (54 years ± 10 [standard deviation], one female) who underwent cardiac CT and cardiac MRI were included (combined subcohort of three prospective trials). Software facilitating multimodal 3D image fusion was developed. Postprocessing of CT data included segmentation of the coronary tree and heart contours, calculation of CT FFR values, and color coding of the coronary tree according to CT FFR. Postprocessing of cardiac MRI data included segmentation of the left ventricle (LV) in cardiac MRI perfusion and cardiac MRI LGE, co-registration of cardiac MRI to CT data, and projection of cardiac MRI perfusion and LGE values onto the high spatial resolution LV from CT. RESULTS Image quality was rated as good to excellent (scores: 2.5-2.6; 3 = excellent). CT coronary angiography revealed significant stenoses in seven of 17 cases (41%). CT FFR was possible in 16 of 17 cases (94%) and showed pathologic flow in seven of 17 cases (41%), six of which coincided with cases revealing significant stenoses at CT coronary angiography. Cardiac MRI perfusion identified eight of 17 patients (47%) with hypoperfusion (ischemic burden of 17% ± 5). Cardiac MRI LGE showed myocardial scar in three of 17 cases (18%, scar burden of 7% ± 4). Conventional two-dimensional readout of CT coronary angiography and cardiac MRI resulted in eight of 17 cases (47%) with uncertain findings. Most of these divergent findings could be solved when adding information from CT FFR and 3D image fusion (six of eight, 75%). CONCLUSION Multimodal 3D cardiac image fusion is feasible and may help with comprehensive noninvasive CAD diagnostics.Supplemental material is available for this article.© RSNA, 2020.
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Affiliation(s)
- Jochen von Spiczak
- From the Institute of Diagnostic and Interventional Radiology (J.v.S., M.M., H.M., H.A., R.M.) and Department of Cardiology, University Heart Center (F.R., R.M.), University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland; Siemens Healthineers, Forchheim, Germany (C.S.); and Institute for Biomedical Engineering, ETH Zurich and University of Zurich, Zurich, Switzerland (J.v.S., S.K., R.M.)
| | - Manoj Mannil
- From the Institute of Diagnostic and Interventional Radiology (J.v.S., M.M., H.M., H.A., R.M.) and Department of Cardiology, University Heart Center (F.R., R.M.), University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland; Siemens Healthineers, Forchheim, Germany (C.S.); and Institute for Biomedical Engineering, ETH Zurich and University of Zurich, Zurich, Switzerland (J.v.S., S.K., R.M.)
| | - Hanna Model
- From the Institute of Diagnostic and Interventional Radiology (J.v.S., M.M., H.M., H.A., R.M.) and Department of Cardiology, University Heart Center (F.R., R.M.), University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland; Siemens Healthineers, Forchheim, Germany (C.S.); and Institute for Biomedical Engineering, ETH Zurich and University of Zurich, Zurich, Switzerland (J.v.S., S.K., R.M.)
| | - Chris Schwemmer
- From the Institute of Diagnostic and Interventional Radiology (J.v.S., M.M., H.M., H.A., R.M.) and Department of Cardiology, University Heart Center (F.R., R.M.), University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland; Siemens Healthineers, Forchheim, Germany (C.S.); and Institute for Biomedical Engineering, ETH Zurich and University of Zurich, Zurich, Switzerland (J.v.S., S.K., R.M.)
| | - Sebastian Kozerke
- From the Institute of Diagnostic and Interventional Radiology (J.v.S., M.M., H.M., H.A., R.M.) and Department of Cardiology, University Heart Center (F.R., R.M.), University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland; Siemens Healthineers, Forchheim, Germany (C.S.); and Institute for Biomedical Engineering, ETH Zurich and University of Zurich, Zurich, Switzerland (J.v.S., S.K., R.M.)
| | - Frank Ruschitzka
- From the Institute of Diagnostic and Interventional Radiology (J.v.S., M.M., H.M., H.A., R.M.) and Department of Cardiology, University Heart Center (F.R., R.M.), University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland; Siemens Healthineers, Forchheim, Germany (C.S.); and Institute for Biomedical Engineering, ETH Zurich and University of Zurich, Zurich, Switzerland (J.v.S., S.K., R.M.)
| | - Hatem Alkadhi
- From the Institute of Diagnostic and Interventional Radiology (J.v.S., M.M., H.M., H.A., R.M.) and Department of Cardiology, University Heart Center (F.R., R.M.), University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland; Siemens Healthineers, Forchheim, Germany (C.S.); and Institute for Biomedical Engineering, ETH Zurich and University of Zurich, Zurich, Switzerland (J.v.S., S.K., R.M.)
| | - Robert Manka
- From the Institute of Diagnostic and Interventional Radiology (J.v.S., M.M., H.M., H.A., R.M.) and Department of Cardiology, University Heart Center (F.R., R.M.), University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland; Siemens Healthineers, Forchheim, Germany (C.S.); and Institute for Biomedical Engineering, ETH Zurich and University of Zurich, Zurich, Switzerland (J.v.S., S.K., R.M.)
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Lum YH, McKenzie S, Brown M, Hamilton-Craig C. Impact of cardiac magnetic resonance imaging on heart failure patients referred to a tertiary advanced heart failure unit: improvements in diagnosis and management. Intern Med J 2019; 49:203-211. [DOI: 10.1111/imj.14087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 08/01/2018] [Accepted: 08/16/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Ying H. Lum
- Faculty of Medicine; University of Queensland; Brisbane, Queensland Australia
| | - Scott McKenzie
- Faculty of Medicine; University of Queensland; Brisbane, Queensland Australia
- Cardiology, The Prince Charles Hospital; Brisbane, Queensland Australia
| | - Martin Brown
- Faculty of Medicine; University of Queensland; Brisbane, Queensland Australia
- Faculty of Medicine and Health Sciences; Macquarie University; Sydney, New South Wales Australia
| | - Christian Hamilton-Craig
- Faculty of Medicine; University of Queensland; Brisbane, Queensland Australia
- Cardiology, The Prince Charles Hospital; Brisbane, Queensland Australia
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Kaushal N, Wijeysundera HC, Connelly KA, Roifman I. Appropriate utilization of cardiac magnetic resonance for the assessment of heart failure and potential associated cost savings. J Magn Reson Imaging 2018; 49:e132-e138. [PMID: 29573034 DOI: 10.1002/jmri.26015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 03/02/2018] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The rapid growth in cardiac imaging utilization has led to the development of appropriate use criteria (AUC) in an effort to control costs. Recently, cardiac MRI has developed into a valuable modality in the evaluation of cardiac disease. However, there are no studies examining the appropriate use of cardiac MRI in clinical practice. PURPOSE To determine the appropriate utilization of cardiac MRI in a large quaternary care institution and to compare percentages of appropriate utilization pre- and postpublication of the AUC document. We hypothesized that percentages of appropriate cardiac MRI utilization will be similar to those of other comparable cardiac imaging modalities and that there would be a significant change in appropriate use pre- and post-AUC publication. STUDY TYPE Retrospective cohort study. POPULATION In all, 2032 consecutive patients undergoing cardiac MRI for the assessment of heart failure between 2012-2016. FIELD STRENGTH 1.5T. ASSESSMENT Data were collected and an appropriateness category was assigned for each cardiac MRI. STATISTICAL TESTS Rates of major cardiac risk factors were compared between those undergoing cardiac MRIs pre- and post-AUC using the chi-square and the Mann-Whitney tests for categorical and continuous variables, respectively. Appropriateness classification was compared pre- and post-AUC publication using the chi-square test. RESULTS There were no significant differences in the prevalence of major cardiovascular risk factors before and after publication of the AUC. 95.5% of all cardiac MRIs were appropriate based on the AUC. Further, there was a significant difference when comparing the appropriateness classification before and after publication of the AUC (P = 0.0003), potentially associated with annual cost savings of ∼$14.8 million. DATA CONCLUSION We report a very high percentage of appropriate use of cardiac MRI and a significant increase in the proportion of tests classified as appropriate after AUC publication. LEVEL OF EVIDENCE 3 Technical Efficacy: Stage 5 J. Magn. Reson. Imaging 2019;49:e132-e138.
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Affiliation(s)
- Nishchay Kaushal
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Harindra C Wijeysundera
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, ON, Canada
| | - Kim A Connelly
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.,St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Idan Roifman
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, ON, Canada
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Fusion of CT coronary angiography and whole-heart dynamic 3D cardiac MR perfusion: building a framework for comprehensive cardiac imaging. Int J Cardiovasc Imaging 2017; 34:649-660. [DOI: 10.1007/s10554-017-1260-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 10/19/2017] [Indexed: 10/18/2022]
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CMR First-Pass Perfusion for Suspected Inducible Myocardial Ischemia. JACC Cardiovasc Imaging 2017; 9:1338-1348. [PMID: 27832901 DOI: 10.1016/j.jcmg.2016.09.010] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 08/26/2016] [Accepted: 09/08/2016] [Indexed: 01/28/2023]
Abstract
Cardiovascular magnetic resonance (CMR) has evolved from a pioneering research tool to an established noninvasive imaging method for detecting inducible myocardial perfusion deficits. In this consensus document, experts of different imaging techniques summarize the existing body of evidence regarding CMR perfusion as a viable complement to other established noninvasive tools for the assessment of perfusion and discuss the advantages and pitfalls of the technique. A rapid, standardized CMR perfusion protocol is described, which is safe, clinically feasible, and cost-effective for centers with contemporary magnetic resonance equipment. CMR perfusion can be recommended as a routine diagnostic tool to identify inducible myocardial ischemia.
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Olveres J, Nava R, Escalante-Ramírez B, Vallejo E, Kybic J. Left ventricle Hermite-based segmentation. Comput Biol Med 2017; 87:236-249. [PMID: 28618336 DOI: 10.1016/j.compbiomed.2017.05.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 05/26/2017] [Accepted: 05/27/2017] [Indexed: 10/19/2022]
Abstract
In recent years, computed tomography (CT) has become a standard technique in cardiac imaging because it provides detailed information that may facilitate the diagnosis of the conditions that interfere with correct heart function. However, CT-based cardiac diagnosis requires manual segmentation of heart cavities, which is a difficult and time-consuming task. Thus, in this paper, we propose a novel technique to segment endocardium and epicardium boundaries based on a 2D approach. The proposal computes relevant information of the left ventricle and its adjacent structures using the Hermite transform. The novelty of the work is that the information is combined with active shape models and level sets to improve the segmentation. Our database consists of mid-third slices selected from 28 volumes manually segmented by expert physicians. The segmentation is assessed using Dice coefficient and Hausdorff distance. In addition, we introduce a novel metric called Ray Feature error to evaluate our method. The results show that the proposal accurately discriminates cardiac tissue. Thus, it may be a useful tool for supporting heart disease diagnosis and tailoring treatments.
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Affiliation(s)
- Jimena Olveres
- Facultad de Ingeniería, Universidad Nacional Autónoma de México, Mexico.
| | - Rodrigo Nava
- Faculty of Electrical Engineering, Czech Technical University in Prague, Czech Republic
| | | | | | - Jan Kybic
- Faculty of Electrical Engineering, Czech Technical University in Prague, Czech Republic
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Toward a Framework for Benefit-Risk Assessment in Diagnostic Imaging: Identifying Scenario-specific Criteria. Acad Radiol 2017; 24:538-549. [PMID: 28372958 DOI: 10.1016/j.acra.2017.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 02/10/2017] [Accepted: 02/11/2017] [Indexed: 12/12/2022]
Abstract
RATIONALE AND OBJECTIVES Diagnostic imaging has many effects and there is no common definition of value in diagnostic radiology. As benefit-risk trade-offs are rarely made explicit, it is not clear which framework is used in clinical guideline development. We describe initial steps toward the creation of a benefit-risk framework for diagnostic radiology. MATERIALS AND METHODS We performed a literature search and an online survey of physicians to identify and collect benefit-risk criteria (BRC) relevant to diagnostic imaging tests. We operationalized a process for selection of BRC with the use of four clinical use case scenarios that vary by diagnostic alternatives and clinical indication. Respondent BRC selections were compared across clinical scenarios and between radiologists and nonradiologists. RESULTS Thirty-six BRC were identified and organized into three domains: (1) those that account for differences attributable only to the test or device (n = 17); (2) those that account for clinical management and provider experiences (n = 12); and (3) those that capture patient experience (n = 7). Forty-eight survey participants selected 22 criteria from the initial list in the survey (9-11 per case). Engaging ordering physicians increased the number of criteria selected in each of the four clinical scenarios presented. We developed a process for standardizing selection of BRC in guideline development. CONCLUSION These results suggest that a process relying on elements of comparative effectiveness and the use of standardized BRC may ensure consistent examination of differences among alternatives by way of making explicit implicit trade-offs that otherwise enter the decision-making space and detract from consistency and transparency. These findings also highlight the need for multidisciplinary teams that include input from ordering physicians.
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Yaghi S, Liberman AL, Atalay M, Song C, Furie KL, Kamel H, Bernstein RA. Cardiac magnetic resonance imaging: a new tool to identify cardioaortic sources in ischaemic stroke. J Neurol Neurosurg Psychiatry 2017; 88:31-37. [PMID: 27659922 DOI: 10.1136/jnnp-2016-314023] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 08/19/2016] [Accepted: 09/06/2016] [Indexed: 12/27/2022]
Abstract
Stroke of undetermined aetiology or 'cryptogenic' stroke accounts for 30-40% of ischaemic strokes despite extensive diagnostic evaluation. The role and yield of cardiac imaging is controversial. Cardiac MRI (CMR) has been used for cardiac disorders, but its use in cryptogenic stroke is not well established. We reviewed the literature (randomised trials, exploratory comparative studies and case series) on the use of CMR in the diagnostic evaluation of patients with ischaemic stroke. The literature on the use of CMR in the diagnostic evaluation of ischaemic stroke is sparse. However, studies have demonstrated a potential role for CMR in the diagnostic evaluation of patients with cryptogenic stroke to identify potential aetiologies such as cardiac thrombi, cardiac tumours, aortic arch disease and other rare cardiac anomalies. CMR can also provide data on certain functional and structural parameters of the left atrium and the left atrial appendage which have been shown to be associated with ischaemic stroke risk. CMR is a non-invasive modality that can help identify potential mechanisms in cryptogenic stroke and patients who may be targeted for enrolment into clinical trials comparing anticoagulation to antiplatelet therapy in secondary stroke prevention. Prospective studies are needed to compare the value of CMR as compared to transthoracic and transesophageal echocardiography in the diagnostic evaluation of cryptogenic stroke.
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Affiliation(s)
- Shadi Yaghi
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Ava L Liberman
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael Atalay
- Department of Radiology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Christopher Song
- Division of Cardiology, Department of Internal Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Karen L Furie
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Hooman Kamel
- Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, New York, USA
| | - Richard A Bernstein
- Department of Neurology, Feinberg School of Medicine of Northwestern University, Chicago, Illinois, USA
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van Waardhuizen CN, Khanji MY, Genders TS, Ferket BS, Fleischmann KE, Hunink MM, Petersen SE. Comparative cost-effectiveness of non-invasive imaging tests in patients presenting with chronic stable chest pain with suspected coronary artery disease: a systematic review. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2016; 2:245-260. [DOI: 10.1093/ehjqcco/qcw029] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 05/27/2016] [Indexed: 02/05/2023]
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Guaricci AI, Brunetti ND, Marra MP, Tarantini G, di Biase M, Pontone G. Diagnosis and prognosis of ischemic heart disease. J Cardiovasc Med (Hagerstown) 2015; 16:653-62. [DOI: 10.2459/jcm.0000000000000267] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Cardiovascular magnetic resonance for the assessment of coronary artery disease. Int J Cardiol 2015; 193:84-92. [DOI: 10.1016/j.ijcard.2014.11.098] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 10/13/2014] [Accepted: 11/10/2014] [Indexed: 11/20/2022]
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Dunet V, Barras H, Boulanger X, Monney P, Qanadli SD, Meuli R, Schwitter J, Beigelman-Aubry C. Impact of extracardiac findings during cardiac MR on patient management and outcome. Med Sci Monit 2015; 21:1288-96. [PMID: 25943552 PMCID: PMC4548703 DOI: 10.12659/msm.893599] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Cardiac magnetic resonance (CMR) is increasingly used to assess heart diseases. Relevant non-cardiac diseases may also be incidentally found on CMR images. The aim of this study was to determine the prevalence and nature of incidental extra-cardiac findings (IEF) and their clinical impact in non-selected patients referred for CMR. Material/Methods MR images of 762 consecutive patients (515 men, age: 56±18 years) referred for CMR were prospectively interpreted by 2 radiologists blinded for any previous imaging study. IEFs were classified as major when requiring treatment, follow-up, or further investigation. Clinical follow-up was performed by checking hospital information records and by calling referring physicians. The 2 endpoints were: 1) non-cardiac death and new treatment related to major IEFs, and 2) hospitalization related to major IEFs during follow-up. Results Major IEFs were proven in 129 patients (18.6% of the study population), 14% of those being unknown before CMR. During 15±6 month follow-up, treatment of confirmed major IEFs was initiated in 1.4%, and no non-cardiac deaths occurred. Hospitalization occurred in 8 patients (1.0% of the study population) with confirmed major IEFs and none occurred in the remaining 110 patients with unconfirmed/unexplored major IEFs (p<0.001). Conclusions Screening for major IEFs in a population referred for routine CMR changed management in 1.4% of patients. Major IEFs unknown before CMR but without further exploration, however, carried a favorable prognosis over a follow-up period of 15 months.
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Affiliation(s)
- Vincent Dunet
- Department of Radiology, Division of Radiodiagnostics and interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Heloise Barras
- Department of Radiology, Division of Radiodiagnostics and interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Xavier Boulanger
- Department of Radiology, Division of Radiodiagnostics and interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Pierre Monney
- Cardiac MR Center, Lausanne University Hospital, Lausanne, Switzerland
| | - Salah D Qanadli
- Department of Radiology, Division of Radiodiagnostics and interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Reto Meuli
- Department of Radiology, Division of Radiodiagnostics and interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Juerg Schwitter
- Cardiac MR Center, Lausanne University Hospital, Lausanne, Switzerland
| | - Catherine Beigelman-Aubry
- Department of Radiology, Division of Radiodiagnostics and interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland
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Genders TS, Petersen SE, Pugliese F, Dastidar AG, Fleischmann KE, Nieman K, Hunink MM. The optimal imaging strategy for patients with stable chest pain: a cost-effectiveness analysis. Ann Intern Med 2015; 162:474-84. [PMID: 25844996 DOI: 10.7326/m14-0027] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The optimal imaging strategy for patients with stable chest pain is uncertain. OBJECTIVE To determine the cost-effectiveness of different imaging strategies for patients with stable chest pain. DESIGN Microsimulation state-transition model. DATA SOURCES Published literature. TARGET POPULATION 60-year-old patients with a low to intermediate probability of coronary artery disease (CAD). TIME HORIZON Lifetime. PERSPECTIVE The United States, the United Kingdom, and the Netherlands. INTERVENTION Coronary computed tomography (CT) angiography, cardiac stress magnetic resonance imaging, stress single-photon emission CT, and stress echocardiography. OUTCOME MEASURES Lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. RESULTS OF BASE-CASE ANALYSIS The strategy that maximized QALYs and was cost-effective in the United States and the Netherlands began with coronary CT angiography, continued with cardiac stress imaging if angiography found at least 50% stenosis in at least 1 coronary artery, and ended with catheter-based coronary angiography if stress imaging induced ischemia of any severity. For U.K. men, the preferred strategy was optimal medical therapy without catheter-based coronary angiography if coronary CT angiography found only moderate CAD or stress imaging induced only mild ischemia. In these strategies, stress echocardiography was consistently more effective and less expensive than other stress imaging tests. For U.K. women, the optimal strategy was stress echocardiography followed by catheter-based coronary angiography if echocardiography induced mild or moderate ischemia. RESULTS OF SENSITIVITY ANALYSIS Results were sensitive to changes in the probability of CAD and assumptions about false-positive results. LIMITATIONS All cardiac stress imaging tests were assumed to be available. Exercise electrocardiography was included only in a sensitivity analysis. Differences in QALYs among strategies were small. CONCLUSION Coronary CT angiography is a cost-effective triage test for 60-year-old patients who have nonacute chest pain and a low to intermediate probability of CAD. PRIMARY FUNDING SOURCE Erasmus University Medical Center.
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Affiliation(s)
- Tessa S.S. Genders
- From Erasmus University Medical Center, Rotterdam, the Netherlands; University of London, London, United Kingdom; UCSF Medical Center, San Francisco, California; and Harvard University, Boston, Massachusetts
| | - Steffen E. Petersen
- From Erasmus University Medical Center, Rotterdam, the Netherlands; University of London, London, United Kingdom; UCSF Medical Center, San Francisco, California; and Harvard University, Boston, Massachusetts
| | - Francesca Pugliese
- From Erasmus University Medical Center, Rotterdam, the Netherlands; University of London, London, United Kingdom; UCSF Medical Center, San Francisco, California; and Harvard University, Boston, Massachusetts
| | - Amardeep G. Dastidar
- From Erasmus University Medical Center, Rotterdam, the Netherlands; University of London, London, United Kingdom; UCSF Medical Center, San Francisco, California; and Harvard University, Boston, Massachusetts
| | - Kirsten E. Fleischmann
- From Erasmus University Medical Center, Rotterdam, the Netherlands; University of London, London, United Kingdom; UCSF Medical Center, San Francisco, California; and Harvard University, Boston, Massachusetts
| | - Koen Nieman
- From Erasmus University Medical Center, Rotterdam, the Netherlands; University of London, London, United Kingdom; UCSF Medical Center, San Francisco, California; and Harvard University, Boston, Massachusetts
| | - M.G. Myriam Hunink
- From Erasmus University Medical Center, Rotterdam, the Netherlands; University of London, London, United Kingdom; UCSF Medical Center, San Francisco, California; and Harvard University, Boston, Massachusetts
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Renker M, Baumann S, Rier J, Ebersberger U, Fuller SR, Batalis NI, Schoepf UJ, Chiaramida SA. Imaging coronary artery disease and the myocardial ischemic cascade: clinical principles and scope. Radiol Clin North Am 2015; 53:261-9. [PMID: 25726992 DOI: 10.1016/j.rcl.2014.11.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
On a subcellular level, atherogenesis is characterized by the translocation of proatherogenic lipoproteins into the arterial wall. An inflammatory response involving complex repair mechanisms subsequently causes maladaptive vascular changes resulting in coronary stenosis or occlusion. The chronology of the underlying processes occurring from atherosclerosis to myocardial ischemia affect the selection and interpretation of diagnostic testing. An understanding of the ischemic cascade, atherosclerosis, coronary remodeling, plaque morphology, and their relationship to clinical syndromes is essential in determining which diagnostic modalities are useful in clinical practice.
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Affiliation(s)
- Matthias Renker
- Heart and Vascular Center, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Drive, Charleston, SC 29425-2260, USA; Department of Medicine I, Cardiology and Angiology, Giessen University Hospital, Klinistrasse 33, Giessen 35392, Germany
| | - Stefan Baumann
- Heart and Vascular Center, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Drive, Charleston, SC 29425-2260, USA; 1st Department of Medicine University Medical Centre Mannheim (UMM), Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany
| | - Jeremy Rier
- Heart and Vascular Center, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Drive, Charleston, SC 29425-2260, USA
| | - Ullrich Ebersberger
- Heart and Vascular Center, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Drive, Charleston, SC 29425-2260, USA; Department of Cardiology, Heart Centre Munich-Bogenhausen, Munich Municipal Hospital Group, Englschalkinger Strasse 77, Munich 81925, Germany
| | - Stephen R Fuller
- Heart and Vascular Center, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Drive, Charleston, SC 29425-2260, USA
| | - Nicholas I Batalis
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, HD281, 165 Ashley Avenue, Charleston, SC 29425, USA
| | - U Joseph Schoepf
- Heart and Vascular Center, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Drive, Charleston, SC 29425-2260, USA.
| | - Salvatore A Chiaramida
- Heart and Vascular Center, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Drive, Charleston, SC 29425, USA
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Pennell DJ, Baksi AJ, Kilner PJ, Mohiaddin RH, Prasad SK, Alpendurada F, Babu-Narayan SV, Neubauer S, Firmin DN. Review of Journal of Cardiovascular Magnetic Resonance 2013. J Cardiovasc Magn Reson 2014; 16:100. [PMID: 25475898 PMCID: PMC4256918 DOI: 10.1186/s12968-014-0100-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 11/21/2014] [Indexed: 01/19/2023] Open
Abstract
There were 109 articles published in the Journal of Cardiovascular Magnetic Resonance (JCMR) in 2013, which is a 21% increase on the 90 articles published in 2012. The quality of the submissions continues to increase. The editors are delighted to report that the 2012 JCMR Impact Factor (which is published in June 2013) has risen to 5.11, up from 4.44 for 2011 (as published in June 2012), a 15% increase and taking us through the 5 threshold for the first time. The 2012 impact factor means that the JCMR papers that were published in 2010 and 2011 were cited on average 5.11 times in 2012. The impact factor undergoes natural variation according to citation rates of papers in the 2 years following publication, and is significantly influenced by highly cited papers such as official reports. However, the progress of the journal's impact over the last 5 years has been impressive. Our acceptance rate is <25% and has been falling because the number of articles being submitted has been increasing. In accordance with Open-Access publishing, the JCMR articles go on-line as they are accepted with no collating of the articles into sections or special thematic issues. For this reason, the Editors have felt that it is useful once per calendar year to summarize the papers for the readership into broad areas of interest or theme, so that areas of interest can be reviewed in a single article in relation to each other and other recent JCMR articles. The papers are presented in broad themes and set in context with related literature and previously published JCMR papers to guide continuity of thought in the journal. We hope that you find the open-access system increases wider reading and citation of your papers, and that you will continue to send your quality manuscripts to JCMR for publication.
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Affiliation(s)
- Dudley John Pennell
- />Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP UK
- />Imperial College, London, UK
| | - Arun John Baksi
- />Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP UK
- />Imperial College, London, UK
| | - Philip John Kilner
- />Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP UK
- />Imperial College, London, UK
| | - Raad Hashem Mohiaddin
- />Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP UK
- />Imperial College, London, UK
| | - Sanjay Kumar Prasad
- />Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP UK
- />Imperial College, London, UK
| | - Francisco Alpendurada
- />Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP UK
- />Imperial College, London, UK
| | - Sonya Vidya Babu-Narayan
- />Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP UK
- />Imperial College, London, UK
| | | | - David Nigel Firmin
- />Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP UK
- />Imperial College, London, UK
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Petrov G, Kelle S, Fleck E, Wellnhofer E. Incremental cost-effectiveness of dobutamine stress cardiac magnetic resonance imaging in patients at intermediate risk for coronary artery disease. Clin Res Cardiol 2014; 104:401-9. [PMID: 25395355 PMCID: PMC4544498 DOI: 10.1007/s00392-014-0793-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 11/10/2014] [Indexed: 01/12/2023]
Abstract
Aims The effectiveness of stress cardiac magnetic resonance (CMR) as a gatekeeper for coronary angiography (CA) has been established. Level five HTA studies according to the hierarchical model of diagnostic test evaluation are not available. Methods This cohort study included 1,158 consecutive patients (mean age 63 ± 11 years, 42 % women) presenting at our institution between January 1, 2003 and December 31, 2004 with suspected coronary artery disease (CAD) for an elective CA. The patients were assessed for eligibility and propensity score matching was applied to address selection bias regarding the patients’ allocation to CMR or direct CA. Median patient follow-up was 7.9 years (95 % CI 7.8–8.0 years). The primary effect was calculated as relative survival difference. The cost unit calculation (per patient) at our institute was the source of costs. Results Survival was similar in CMR and CA (p = 0.139). Catheterizations ruling out CAD were significantly reduced by the CMR gate-keeper strategy. Patients with prior CMR had significantly lower costs at the initial hospital stay and at follow-up (CMR vs. CA, initial: 2,904€ vs. 3,421€, p = 0.018; follow-up: 2,045€ vs. 3,318€, p = 0.037). CMR was cost-effective in terms of a contribution of 12,466€ per life year to cover a part of the CMR costs. Conclusion Stress CMR prior to CA was saving 12,466€ of hospital costs per life year. Lower costs at follow-up suggest sustained cost-effectiveness of the CMR-guided strategy. Electronic supplementary material The online version of this article (doi:10.1007/s00392-014-0793-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- George Petrov
- Department of Internal Medicine/Cardiology, German Heart Institute Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Sebastian Kelle
- Department of Internal Medicine/Cardiology, German Heart Institute Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Eckart Fleck
- Department of Internal Medicine/Cardiology, German Heart Institute Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Ernst Wellnhofer
- Department of Internal Medicine/Cardiology, German Heart Institute Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
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Ripley DP, Motwani M, Plein S, Greenwood JP. Established and emerging cardiovascular magnetic resonance techniques for the assessment of stable coronary heart disease and acute coronary syndromes. Quant Imaging Med Surg 2014; 4:330-44. [PMID: 25392820 DOI: 10.3978/j.issn.2223-4292.2014.07.16] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 04/23/2014] [Indexed: 12/30/2022]
Abstract
Coronary heart disease (CHD) is a leading cause of death and disability worldwide. International guidelines recommend cardiovascular magnetic resonance (CMR) as an investigative option in those presenting with chest pain to inform diagnosis, risk stratify and determine the need for revascularization. CMR offers a unique method to assess global and regional cardiac function, myocardial perfusion, myocardial viability, tissue characterisation and proximal coronary anatomy all within a single study. This results in high diagnostic accuracy for the detection of significant coronary stenoses and an established role in the management of both stable CHD and acute coronary syndromes (ACS). The growing evidence base for the prognostic value of CMR, emerging advances in acquisition techniques, improvements in hardware and the completion of current major multi-centre clinical CMR trials will further raise its prominence in international guidelines and routine cardiological practice. This article will focus on the rapidly evolving role of the multi-parametric CMR examination in the assessment of patients with stable and unstable CHD.
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Affiliation(s)
- David P Ripley
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Manish Motwani
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Sven Plein
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - John P Greenwood
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
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Cardiac magnetic resonance imaging for ischemic heart disease: update on diagnosis and prognosis. Top Magn Reson Imaging 2014; 23:21-31. [PMID: 24509621 DOI: 10.1097/rmr.0000000000000014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Despite significant advancements in the treatment of ischemic heart disease (IHD), IHD remains a leading cause of mortality and morbidity. In addition, there remains clinical equipoise regarding a number of important management issues across the spectrum of IHD, from evaluating patients with chest pain in the emergency department, to deciding whether patients with chronic stable angina or severe ischemic cardiomyopathies should undergo invasive revascularization procedures. Recent data over the past 2 decades has demonstrated that cardiac magnetic resonance imaging is highly accurate and carries robust prognostic value in the evaluation of patients with both acute and chronic IHD. The combination of cine imaging for cardiac structure and function, late gadolinium enhancement imaging of myocardial scar, qualitative and quantitative measures of myocardial fibrosis, and stress perfusion imaging for the presence and extent of ischemia provides a comprehensive and detailed characterization of cardiac anatomy and physiology that guides critical treatment decisions for patients. This review aims to cover both the diagnostic and prognostic utility of cardiac magnetic resonance imaging for the spectrum of IHD.
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Bernard M, Jacquier A, Kober F. Cardiovascular magnetic resonance in ischemic heart disease. Future Cardiol 2014; 10:487-96. [PMID: 25301312 DOI: 10.2217/fca.14.39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Ischemic heart disease is the major cause of death in developed countries. Recently, cardiovascular magnetic resonance (CMR) has appeared as a powerful technique for diagnosis and prognosis of ischemia, as well as for postischemic therapy follow-up. The objective of this chapter is to provide an overview of the role of CMR in assessing ischemic myocardium. It reviews the most recent studies in this field and includes CMR parameters that are already well established in the clinical setting as well as promising or emerging parameters in clinical use.
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Affiliation(s)
- Monique Bernard
- Aix-Marseille Université, CNRS, Centre de Résonance Magnétique Biologique et Médicale (CRMBM), UMR 7339, Faculté de Médecine, 27 Bd Jean Moulin 13385 Marseille, Cedex 5, France
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Buss SJ, Breuninger K, Lehrke S, Voss A, Galuschky C, Lossnitzer D, Andre F, Ehlermann P, Franke J, Taeger T, Frankenstein L, Steen H, Meder B, Giannitsis E, Katus HA, Korosoglou G. Assessment of myocardial deformation with cardiac magnetic resonance strain imaging improves risk stratification in patients with dilated cardiomyopathy. Eur Heart J Cardiovasc Imaging 2014; 16:307-15. [PMID: 25246506 DOI: 10.1093/ehjci/jeu181] [Citation(s) in RCA: 198] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
AIMS To investigate the prognostic impact of left-ventricular (LV) cardiac magnetic resonance (CMR) deformation imaging in patients with non-ischaemic dilated cardiomyopathy (DCM) compared with late-gadolinium enhancement (LGE) quantification and LV ejection fraction (EF). METHODS AND RESULTS A total of 210 subjects with DCM were examined prospectively with standard CMR including measurement of LGE for quantification of myocardial fibrosis and feature tracking strain imaging for assessment of LV deformation. The predefined primary endpoint, a combination of cardiac death, heart transplantation, and aborted sudden cardiac death, occurred in 26 subjects during the median follow-up period of 5.3 years. LV radial, circumferential, and longitudinal strains were significantly associated with outcome. Using separate multivariate analysis models, global longitudinal strain (average of peak negative strain values) and mean longitudinal strain (negative peak of the mean curve of all segments) were independent prognostic parameters surpassing the value of global and mean LV radial and circumferential strain, as well as NT-proBNP, EF, and LGE mass. A global longitudinal strain greater than -12.5% predicted outcome even in patients with EF < 35% (P < 0.01) and in those with presence of LGE (P < 0.001). Mean longitudinal strain was further investigated using a clinical model with predefined cut-offs (EF < 35%, presence of LGE, NYHA class, mean longitudinal strain greater than -10%). Mean longitudinal strain exhibited an independent prognostic value surpassing that provided by NYHA, EF, and LGE (HR = 5.4, P < 0.01). CONCLUSION LV longitudinal strain assessed with CMR is an independent predictor of survival in DCM and offers incremental information for risk stratification beyond clinical parameters, biomarker, and standard CMR.
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Affiliation(s)
- Sebastian J Buss
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, INF 410, Heidelberg 69120, Germany
| | - Kristin Breuninger
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, INF 410, Heidelberg 69120, Germany
| | - Stephanie Lehrke
- Department of Radiology, Ev.-Luth. Diakonissenanstalt, Knuthstraße 1, Flensburg 24939, Germany
| | - Andreas Voss
- Department of Psychology, University of Heidelberg, Hauptstrasse 47-51, Heidelberg 69117, Germany
| | | | - Dirk Lossnitzer
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, INF 410, Heidelberg 69120, Germany
| | - Florian Andre
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, INF 410, Heidelberg 69120, Germany
| | - Philipp Ehlermann
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, INF 410, Heidelberg 69120, Germany
| | - Jennifer Franke
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, INF 410, Heidelberg 69120, Germany
| | - Tobias Taeger
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, INF 410, Heidelberg 69120, Germany
| | - Lutz Frankenstein
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, INF 410, Heidelberg 69120, Germany
| | - Henning Steen
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, INF 410, Heidelberg 69120, Germany
| | - Benjamin Meder
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, INF 410, Heidelberg 69120, Germany
| | - Evangelos Giannitsis
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, INF 410, Heidelberg 69120, Germany
| | - Hugo A Katus
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, INF 410, Heidelberg 69120, Germany
| | - Grigorios Korosoglou
- Department of Cardiology, Angiology and Pneumology, University of Heidelberg, INF 410, Heidelberg 69120, Germany
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Moschetti K, Favre D, Pinget C, Pilz G, Petersen SE, Wagner A, Wasserfallen JB, Schwitter J. Comparative cost-effectiveness analyses of cardiovascular magnetic resonance and coronary angiography combined with fractional flow reserve for the diagnosis of coronary artery disease. J Cardiovasc Magn Reson 2014; 16:13. [PMID: 24461028 PMCID: PMC4015639 DOI: 10.1186/1532-429x-16-13] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Accepted: 12/17/2013] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND According to recent guidelines, patients with coronary artery disease (CAD) should undergo revascularization if significant myocardial ischemia is present. Both, cardiovascular magnetic resonance (CMR) and fractional flow reserve (FFR) allow for a reliable ischemia assessment and in combination with anatomical information provided by invasive coronary angiography (CXA), such a work-up sets the basis for a decision to revascularize or not. The cost-effectiveness ratio of these two strategies is compared. METHODS Strategy 1) CMR to assess ischemia followed by CXA in ischemia-positive patients (CMR + CXA), Strategy 2) CXA followed by FFR in angiographically positive stenoses (CXA + FFR). The costs, evaluated from the third party payer perspective in Switzerland, Germany, the United Kingdom (UK), and the United States (US), included public prices of the different outpatient procedures and costs induced by procedural complications and by diagnostic errors. The effectiveness criterion was the correct identification of hemodynamically significant coronary lesion(s) (= significant CAD) complemented by full anatomical information. Test performances were derived from the published literature. Cost-effectiveness ratios for both strategies were compared for hypothetical cohorts with different pretest likelihood of significant CAD. RESULTS CMR + CXA and CXA + FFR were equally cost-effective at a pretest likelihood of CAD of 62% in Switzerland, 65% in Germany, 83% in the UK, and 82% in the US with costs of CHF 5'794, € 1'517, £ 2'680, and $ 2'179 per patient correctly diagnosed. Below these thresholds, CMR + CXA showed lower costs per patient correctly diagnosed than CXA + FFR. CONCLUSIONS The CMR + CXA strategy is more cost-effective than CXA + FFR below a CAD prevalence of 62%, 65%, 83%, and 82% for the Swiss, the German, the UK, and the US health care systems, respectively. These findings may help to optimize resource utilization in the diagnosis of CAD.
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Affiliation(s)
- Karine Moschetti
- Institute of Health Economics and Management (IEMS), University of Lausanne, Route de Chavannes 31, VIDY, 1015 Lausanne, Switzerland
- Technology Assessment Unit (UET), University Hospital (CHUV), Lausanne, Switzerland
| | - David Favre
- Institute of Health Economics and Management (IEMS), University of Lausanne, Route de Chavannes 31, VIDY, 1015 Lausanne, Switzerland
| | - Christophe Pinget
- Institute of Health Economics and Management (IEMS), University of Lausanne, Route de Chavannes 31, VIDY, 1015 Lausanne, Switzerland
- Technology Assessment Unit (UET), University Hospital (CHUV), Lausanne, Switzerland
| | - Guenter Pilz
- Klinik Agatharied, Akademisches Lehrkrankenhaus der LMU Munich, Hausham, Germany
| | - Steffen E Petersen
- National Institute for Health Research Cardiovascular Biomedical Research Unit at Barts, Queen Mary University of London, London, UK
| | - Anja Wagner
- Comprehensive Cardiology of Stamford and Greenwich, Stamford, CT 06902, USA
| | - Jean-Blaise Wasserfallen
- Institute of Health Economics and Management (IEMS), University of Lausanne, Route de Chavannes 31, VIDY, 1015 Lausanne, Switzerland
- Technology Assessment Unit (UET), University Hospital (CHUV), Lausanne, Switzerland
| | - Juerg Schwitter
- Cardiac MR Center, University Hospital (CHUV), Lausanne, Switzerland
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Yeh DD, Foster E. Is MRI the Preferred Method for Evaluating Right Ventricular Size and Function in Patients With Congenital Heart Disease? Circ Cardiovasc Imaging 2014; 7:198-205. [DOI: 10.1161/circimaging.113.000395] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Doreen DeFaria Yeh
- From the Massachusetts General Hospital, Division of Cardiology, Adult Congenital Heart Disease Program, Echocardiography Section, Boston, MA (D.D.F.Y.); and University of California San Francisco, Director Non-Invasive Cardiology (E.F.)
| | - Elyse Foster
- From the Massachusetts General Hospital, Division of Cardiology, Adult Congenital Heart Disease Program, Echocardiography Section, Boston, MA (D.D.F.Y.); and University of California San Francisco, Director Non-Invasive Cardiology (E.F.)
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Pennell DJ, Baksi AJ, Carpenter JP, Firmin DN, Kilner PJ, Mohiaddin RH, Prasad SK. Review of Journal of Cardiovascular Magnetic Resonance 2012. J Cardiovasc Magn Reson 2013; 15:76. [PMID: 24006874 PMCID: PMC3847143 DOI: 10.1186/1532-429x-15-76] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 08/22/2013] [Indexed: 02/07/2023] Open
Abstract
There were 90 articles published in the Journal of Cardiovascular Magnetic Resonance (JCMR) in 2012, which is an 8% increase in the number of articles since 2011. The quality of the submissions continues to increase. The editors are delighted to report that the 2011 JCMR Impact Factor (which is published in June 2012) has risen to 4.44, up from 3.72 for 2010 (as published in June 2011), a 20% increase. The 2011 impact factor means that the JCMR papers that were published in 2009 and 2010 were cited on average 4.44 times in 2011. The impact factor undergoes natural variation according to citation rates of papers in the 2 years following publication, and is significantly influenced by highly cited papers such as official reports. However, the progress of the journal's impact over the last 5 years has been impressive. Our acceptance rate is approximately 25%, and has been falling as the number of articles being submitted has been increasing. In accordance with Open-Access publishing, the JCMR articles go on-line as they are accepted with no collating of the articles into sections or special thematic issues. For this reason, the Editors have felt that it is useful once per calendar year to summarize the papers for the readership into broad areas of interest or theme, so that areas of interest can be reviewed in a single article in relation to each other and other recent JCMR articles. The papers are presented in broad themes and set in context with related literature and previously published JCMR papers to guide continuity of thought in the journal. We hope that you find the open-access system increases wider reading and citation of your papers, and that you will continue to send your quality manuscripts to JCMR for publication.
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Affiliation(s)
- Dudley J Pennell
- Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
- Imperial College, London, UK
| | - A John Baksi
- Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
- Imperial College, London, UK
| | - John Paul Carpenter
- Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
- Imperial College, London, UK
| | - David N Firmin
- Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
- Imperial College, London, UK
| | - Philip J Kilner
- Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
- Imperial College, London, UK
| | - Raad H Mohiaddin
- Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
- Imperial College, London, UK
| | - Sanjay K Prasad
- Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
- Imperial College, London, UK
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Klinke V, Muzzarelli S, Lauriers N, Locca D, Vincenti G, Monney P, Lu C, Nothnagel D, Pilz G, Lombardi M, van Rossum AC, Wagner A, Bruder O, Mahrholdt H, Schwitter J. Quality assessment of cardiovascular magnetic resonance in the setting of the European CMR registry: description and validation of standardized criteria. J Cardiovasc Magn Reson 2013; 15:55. [PMID: 23787094 PMCID: PMC3707748 DOI: 10.1186/1532-429x-15-55] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 05/16/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiovascular magnetic resonance (CMR) has become an important diagnostic imaging modality in cardiovascular medicine. However, insufficient image quality may compromise its diagnostic accuracy. We aimed to describe and validate standardized criteria to evaluate a) cine steady-state free precession (SSFP), b) late gadolinium enhancement (LGE), and c) stress first-pass perfusion images. These criteria will serve for quality assessment in the setting of the Euro-CMR registry. METHODS Thirty-five qualitative criteria were defined (scores 0-3) with lower scores indicating better image quality. In addition, quantitative parameters were measured yielding 2 additional quality criteria, i.e. signal-to-noise ratio (SNR) of non-infarcted myocardium (as a measure of correct signal nulling of healthy myocardium) for LGE and % signal increase during contrast medium first-pass for perfusion images. These qualitative and quantitative criteria were assessed in a total of 90 patients (60 patients scanned at our own institution at 1.5T (n=30) and 3T (n=30) and in 30 patients randomly chosen from the Euro-CMR registry examined at 1.5T). Analyses were performed by 2 SCMR level-3 experts, 1 trained study nurse, and 1 trained medical student. RESULTS The global quality score was 6.7±4.6 (n=90, mean of 4 observers, maximum possible score 64), range 6.4-6.9 (p=0.76 between observers). It ranged from 4.0-4.3 for 1.5T (p=0.96 between observers), from 5.9-6.9 for 3T (p=0.33 between observers), and from 8.6-10.3 for the Euro-CMR cases (p=0.40 between observers). The inter- (n=4) and intra-observer (n=2) agreement for the global quality score, i.e. the percentage of assignments to the same quality tertile ranged from 80% to 88% and from 90% to 98%, respectively. The agreement for the quantitative assessment for LGE images (scores 0-2 for SNR <2, 2-5, >5, respectively) ranged from 78-84% for the entire population, and 70-93% at 1.5T, 64-88% at 3T, and 72-90% for the Euro-CMR cases. The agreement for perfusion images (scores 0-2 for %SI increase >200%, 100%-200%,<100%, respectively) ranged from 81-91% for the entire population, and 76-100% at 1.5T, 67-96% at 3T, and 62-90% for the Euro-CMR registry cases. The intra-class correlation coefficient for the global quality score was 0.83. CONCLUSIONS The described criteria for the assessment of CMR image quality are robust with a good inter- and intra-observer agreement. Further research is needed to define the impact of image quality on the diagnostic and prognostic yield of CMR studies.
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Affiliation(s)
- Vincenzo Klinke
- Department of Cardiology, Center of Cardiac Magnetic Resonance (CRMC), University Hospital Lausanne, Lausanne, Switzerland
| | - Stefano Muzzarelli
- Department of Cardiology, Center of Cardiac Magnetic Resonance (CRMC), University Hospital Lausanne, Lausanne, Switzerland
- Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Nathalie Lauriers
- Department of Cardiology, Center of Cardiac Magnetic Resonance (CRMC), University Hospital Lausanne, Lausanne, Switzerland
| | - Didier Locca
- Department of Cardiology, Center of Cardiac Magnetic Resonance (CRMC), University Hospital Lausanne, Lausanne, Switzerland
| | - Gabriella Vincenti
- Department of Cardiology, Center of Cardiac Magnetic Resonance (CRMC), University Hospital Lausanne, Lausanne, Switzerland
| | - Pierre Monney
- Department of Cardiology, Center of Cardiac Magnetic Resonance (CRMC), University Hospital Lausanne, Lausanne, Switzerland
| | - Christian Lu
- Department of Radiology, University Hospital Lausanne, Lausanne, Switzerland
| | - Detlev Nothnagel
- Department of Cardiology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Guenter Pilz
- Department of Cardiology, Clinic Agatharied, Academic Teaching Hospital, University of Munich, Munich, Germany
| | - Massimo Lombardi
- Clinical Physiology Institute / G. Monasterio Foundation, Pisa, Italy
| | | | - Anja Wagner
- Department of Cardiology, Hahnemann University Hospital, Drexel University, College of Medicine, Philadelphia, USA
| | - Oliver Bruder
- Department of Cardiology, Elisabeth Hospital Essen, Essen, Germany
- Department of Angiology, Elisabeth Hospital Essen, Essen, Germany
| | - Heiko Mahrholdt
- Department of Cardiology, Robert Bosch Hospital Stuttgart, Stuttgart, Germany
| | - Juerg Schwitter
- Department of Cardiology, Center of Cardiac Magnetic Resonance (CRMC), University Hospital Lausanne, Lausanne, Switzerland
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Francis SA, Daly C, Heydari B, Abbasi S, Shah RV, Kwong RY. Cost-effectiveness analysis for imaging techniques with a focus on cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2013; 15:52. [PMID: 23767423 PMCID: PMC3707775 DOI: 10.1186/1532-429x-15-52] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 06/03/2013] [Indexed: 12/19/2022] Open
Abstract
With the need for healthcare cost-containment, increased scrutiny will be placed on new medical therapeutic or diagnostic technologies. Several challenges exist for a new diagnostic test to demonstrate cost-effectiveness. New diagnostic tests differ from therapeutic procedures due to the fact that diagnostic tests do not generally directly affect long-term patient outcomes. Instead, the results of diagnostic tests can influence management decisions for patients and by this route, diagnostic tests indirectly affect long-term outcomes. The benefits from a specific diagnostic technology depend therefore not only on its performance characteristics, but also on other factors such as prevalence of disease, and effectiveness of existing treatments for the disease of interest. We review the concepts and theories of cost-effectiveness analyses (CEA) as they apply to diagnostic tests in general. The limitations of CEA across different study designs and geographic regions are discussed, and we also examine the strengths and weakness of the existing publications where CMR was the focus of CEA compared to other diagnostic options.
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Affiliation(s)
- Sanjeev A Francis
- Cardiology Division, Department of Medicine, Massuchusetts General Hospital, Boston, MA, USA
| | - Caroline Daly
- Cardiology Division, St. James’ Hospital, Dublin, Ireland
| | - Bobak Heydari
- Department of Medicine, Brigham and Women's Hospital, Cardiovascular Division, Boston, MA, USA
| | - Siddique Abbasi
- Department of Medicine, Brigham and Women's Hospital, Cardiovascular Division, Boston, MA, USA
| | - Ravi V Shah
- Department of Medicine, Brigham and Women's Hospital, Cardiovascular Division, Boston, MA, USA
| | - Raymond Y Kwong
- Department of Medicine, Brigham and Women's Hospital, Cardiovascular Division, Boston, MA, USA
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Boldt J, Leber AW, Bonaventura K, Sohns C, Stula M, Huppertz A, Haverkamp W, Dorenkamp M. Cost-effectiveness of cardiovascular magnetic resonance and single-photon emission computed tomography for diagnosis of coronary artery disease in Germany. J Cardiovasc Magn Reson 2013; 15:30. [PMID: 23574690 PMCID: PMC3688498 DOI: 10.1186/1532-429x-15-30] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2012] [Accepted: 03/22/2013] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Recent studies have demonstrated a superior diagnostic accuracy of cardiovascular magnetic resonance (CMR) for the detection of coronary artery disease (CAD). We aimed to determine the comparative cost-effectiveness of CMR versus single-photon emission computed tomography (SPECT). METHODS Based on Bayes' theorem, a mathematical model was developed to compare the cost-effectiveness and utility of CMR with SPECT in patients with suspected CAD. Invasive coronary angiography served as the standard of reference. Effectiveness was defined as the accurate detection of CAD, and utility as the number of quality-adjusted life-years (QALYs) gained. Model input parameters were derived from the literature, and the cost analysis was conducted from a German health care payer's perspective. Extensive sensitivity analyses were performed. RESULTS Reimbursement fees represented only a minor fraction of the total costs incurred by a diagnostic strategy. Increases in the prevalence of CAD were generally associated with improved cost-effectiveness and decreased costs per utility unit (ΔQALY). By comparison, CMR was consistently more cost-effective than SPECT, and showed lower costs per QALY gained. Given a CAD prevalence of 0.50, CMR was associated with total costs of €6,120 for one patient correctly diagnosed as having CAD and with €2,246 per ΔQALY gained versus €7,065 and €2,931 for SPECT, respectively. Above a threshold value of CAD prevalence of 0.60, proceeding directly to invasive angiography was the most cost-effective approach. CONCLUSIONS In patients with low to intermediate CAD probabilities, CMR is more cost-effective than SPECT. Moreover, lower costs per utility unit indicate a superior clinical utility of CMR.
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Affiliation(s)
- Julia Boldt
- Department of Cardiology, Charité – Universitätsmedizin Berlin, Campus Virchow-Klinikum Augustenburger Platz 1, Berlin 13353, Germany
| | - Alexander W Leber
- Department of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Klaus Bonaventura
- Department of Cardiology, Angiology, and Conservative Intensive Care, Klinikum Ernst von Bergmann, Potsdam, Germany
- University Outpatient Clinic Potsdam, Sports Medicine and Sports Orthopaedics, University of Potsdam, Potsdam, Germany
| | - Christian Sohns
- Department of Cardiology and Pneumology, Heart Center, Georg-August-Universität Göttingen, Göttingen, Germany
| | - Martin Stula
- HELIOS Medical Care Center Weimar, Cardiologist and Center Director, Weimar, Germany
| | - Alexander Huppertz
- Imaging Science Institute Charité, Berlin, Germany
- Department of Radiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Wilhelm Haverkamp
- Department of Cardiology, Charité – Universitätsmedizin Berlin, Campus Virchow-Klinikum Augustenburger Platz 1, Berlin 13353, Germany
| | - Marc Dorenkamp
- Department of Cardiology, Charité – Universitätsmedizin Berlin, Campus Virchow-Klinikum Augustenburger Platz 1, Berlin 13353, Germany
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Bruder O, Wagner A, Lombardi M, Schwitter J, van Rossum A, Pilz G, Nothnagel D, Steen H, Petersen S, Nagel E, Prasad S, Schumm J, Greulich S, Cagnolo A, Monney P, Deluigi CC, Dill T, Frank H, Sabin G, Schneider S, Mahrholdt H. European Cardiovascular Magnetic Resonance (EuroCMR) registry--multi national results from 57 centers in 15 countries. J Cardiovasc Magn Reson 2013; 15:9. [PMID: 23331632 PMCID: PMC3564740 DOI: 10.1186/1532-429x-15-9] [Citation(s) in RCA: 170] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 12/20/2012] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The EuroCMR registry sought to evaluate indications, image quality, safety and impact on patient management of clinical routine CMR in a multi-national European setting. Furthermore, interim analysis of the specific protocols should underscore the prognostic potential of CMR. METHODS Multi-center registry with consecutive enrolment of patients in 57 centers in 15 countries. More than 27000 consecutive patients were enrolled. RESULTS The most important indications were risk stratification in suspected CAD/Ischemia (34.2%), workup of myocarditis/cardiomyopathies (32.2%), as well as assessment of viability (14.6%). Image quality was diagnostic in more than 98% of cases. Severe complications occurred in 0.026%, always associated with stress testing. No patient died during or due to CMR. In 61.8% CMR findings impacted on patient management. Importantly, in nearly 8.7% the final diagnosis based on CMR was different to the diagnosis before CMR, leading to a complete change in management. Interim analysis of suspected CAD and risk stratification in HCM specific protocols revealed a low rate of adverse events for suspected CAD patients with normal stress CMR (1.0% per year), and for HCM patients without LGE (2.7% per year). CONCLUSION The most important indications in Europe are risk stratification in suspected CAD/Ischemia, work-up of myocarditis and cardiomyopathies, as well as assessment of viability. CMR imaging is a safe procedure, has diagnostic image quality in more than 98% of cases, and its results have strong impact on patient management. Interim analyses of the specific protocols underscore the prognostic value of clinical routine CMR in CAD and HCM.
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Affiliation(s)
- Oliver Bruder
- Department of Cardiology and Angiology, Contilia Heart and Vascular Center, Essen, Germany
| | - Anja Wagner
- Comprehensive Cardiology of Stamford and Greenwich, Stamford, CT, USA
| | | | - Jürg Schwitter
- Cardiac MR Centre, University Hospital (CHUV), Lausanne, Switzerland
| | - Albert van Rossum
- Department of Cardiology, VU Medical Centre, Amsterdam, The Netherlands
| | - Günter Pilz
- Department of Cardiology, Hospital Agatharied, Hausham, Germany
| | | | - Henning Steen
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Steffen Petersen
- Barts and The London NIHR Biomedical Research Unit, The London Chest Hospital, London, UK
| | - Eike Nagel
- King’s College London BHF Centre of Excellence, Division of Imaging Sciences, NIHR Biomedical Research Centre at Guy’s and St.Thomas’ NHS Trust Foundation, The Rayne Institute, St. Thomas’ Hospital, London, UK
| | - Sanjay Prasad
- CMR Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
| | - Julia Schumm
- Department of Cardiology, Robert Bosch Medical Center, Auerbachstrasse 110, 70376, Stuttgart, Germany
| | - Simon Greulich
- Department of Cardiology, Robert Bosch Medical Center, Auerbachstrasse 110, 70376, Stuttgart, Germany
| | | | - Pierre Monney
- Cardiac MR Centre, University Hospital (CHUV), Lausanne, Switzerland
| | - Christina C Deluigi
- Department of Cardiology and Angiology, Contilia Heart and Vascular Center, Essen, Germany
| | - Thorsten Dill
- Department of Internal Medicine, Krankenhaus Benrath, Düsseldorf, Germany
| | - Herbert Frank
- Department of Internal Medicine and Cardiology, Donauklinikum Tulln, Austria
| | - Georg Sabin
- Department of Cardiology and Angiology, Contilia Heart and Vascular Center, Essen, Germany
| | | | - Heiko Mahrholdt
- Department of Cardiology, Robert Bosch Medical Center, Auerbachstrasse 110, 70376, Stuttgart, Germany
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Shaw LJ. Cost-effectiveness and future implications for cardiovascular imaging. Can J Cardiol 2013; 29:350-7. [PMID: 23332968 DOI: 10.1016/j.cjca.2012.10.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 10/19/2012] [Accepted: 10/19/2012] [Indexed: 10/27/2022] Open
Abstract
This review highlights the current economic climate for health care and the evidentiary standards that are increasingly applied to appropriate use of cardiovascular imaging. Additionally, the evidence on cost efficiency and effectiveness is explored in this review. Ongoing multicentre registries and clinical trials will further enrich this evidence base with regard to value-based imaging strategies that provide enhanced effectiveness and efficiency resulting in improved patient outcomes.
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Affiliation(s)
- Leslee J Shaw
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia 30324, USA.
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Schwitter J, Wacker CM, Wilke N, Al-Saadi N, Sauer E, Huettle K, Schönberg SO, Debl K, Strohm O, Ahlstrom H, Dill T, Hoebel N, Simor T. Superior diagnostic performance of perfusion-cardiovascular magnetic resonance versus SPECT to detect coronary artery disease: The secondary endpoints of the multicenter multivendor MR-IMPACT II (Magnetic Resonance Imaging for Myocardial Perfusion Assessment in Coronary Artery Disease Trial). J Cardiovasc Magn Reson 2012; 14:61. [PMID: 22938651 PMCID: PMC3443449 DOI: 10.1186/1532-429x-14-61] [Citation(s) in RCA: 112] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 08/09/2012] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Perfusion-cardiovascular magnetic resonance (CMR) is generally accepted as an alternative to SPECT to assess myocardial ischemia non-invasively. However its performance vs gated-SPECT and in sub-populations is not fully established. The goal was to compare in a multicenter setting the diagnostic performance of perfusion-CMR and gated-SPECT for the detection of CAD in various populations using conventional x-ray coronary angiography (CXA) as the standard of reference. METHODS In 33 centers (in US and Europe) 533 patients, eligible for CXA or SPECT, were enrolled in this multivendor trial. SPECT and CXA were performed within 4 weeks before or after CMR in all patients. Prevalence of CAD in the sample was 49% and 515 patients received MR contrast medium. Drop-out rates for CMR and SPECT were 5.6% and 3.7%, respectively (ns). The study was powered for the primary endpoint of non-inferiority of CMR vs SPECT for both, sensitivity and specificity for the detection of CAD (using a single-threshold reading), the results for the primary endpoint were reported elsewhere. In this article secondary endpoints are presented, i.e. the diagnostic performance of CMR versus SPECT in subpopulations such as multi-vessel disease (MVD), in men, in women, and in patients without prior myocardial infarction (MI). For diagnostic performance assessment the area under the receiver-operator-characteristics-curve (AUC) was calculated. Readers were blinded versus clinical data, CXA, and imaging results. RESULTS The diagnostic performance (= area under ROC = AUC) of CMR was superior to SPECT (p = 0.0004, n = 425) and to gated-SPECT (p = 0.018, n = 253). CMR performed better than SPECT in MVD (p = 0.003 vs all SPECT, p = 0.04 vs gated-SPECT), in men (p = 0.004, n = 313) and in women (p = 0.03, n = 112) as well as in the non-infarct patients (p = 0.005, n = 186 in 1-3 vessel disease and p = 0.015, n = 140 in MVD). CONCLUSION In this large multicenter, multivendor study the diagnostic performance of perfusion-CMR to detect CAD was superior to perfusion SPECT in the entire population and in sub-groups. Perfusion-CMR can be recommended as an alternative for SPECT imaging. TRIAL REGISTRATION ClinicalTrials.gov, Identifier: NCT00977093.
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Affiliation(s)
- Juerg Schwitter
- Cardiology, University Hospital Lausanne, Rue de Bugnon 46, CH-1011, Lausanne, Switzerland
| | | | - Norbert Wilke
- University of Florida Health Science Center, Gainesville/Jacksonville, USA
| | - Nidal Al-Saadi
- Franz-Volhard Clinic-Humboldt University, Berlin, Germany
| | | | | | - Stefan O Schönberg
- LMU Munich, Grosshadern, Germany
- current affiliation - University Medical Center Mannheim, Mannheim, Germany
| | - Kurt Debl
- University Hospital Regensburg, Regensburg, Germany
| | | | | | - Thorsten Dill
- Kerckhoff Clinics Bad Nauheim, Nauheim, Germany
- Current affiliation - Sana Kliniken Duesseldorf, Duesseldorf, Germany
| | - Nadja Hoebel
- GE Healthcare Buchler GmbH & Co.KG, Munich, Germany
| | - Tamas Simor
- Medical University of Science, Pecs, Hungary
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