Cardiovascular magnetic resonance (CMR) has become the primary tool for noninvasive assessment of myocardial inflammation in patients with suspected myocarditis. The International Consensus Group on ...CMR Diagnosis of Myocarditis was founded in 2006 to achieve consensus among CMR experts and develop recommendations on the current state-of-the-art use of CMR for myocarditis. The recommendations include indications for CMR in patients with suspected myocarditis, CMR protocol standards, terminology for reporting CMR findings, and diagnostic CMR criteria for myocarditis (i.e., “Lake Louise Criteria”).
External validation of the CRAX2MACE model Hijazi, Waseem; Leslie, Willam; Filipchuk, Neil ...
Journal of nuclear cardiology,
04/2023, Volume:
30, Issue:
2
Journal Article
Peer reviewed
Open access
Single-photon emission computed tomography (SPECT) myocardial perfusion is frequently used to predict risk of major adverse cardiovascular events (MACE). We performed an external validation of the ...CRAX2MACE score, developed to estimate 2-year risk of MACE in patients with suspected coronary artery disease (CAD).
Patients who underwent clinically indicated SPECT with available follow-up for MACE were included (N = 2,985). The prediction performance for MACE (revascularization, myocardial infarction, or death) within 2 years for CRAX2MACE was compared with stress and ischemic total perfusion deficit (TPD) using area under the receiver operating characteristic curve (AUC). Calibration was assessed with calibration plots, Brier score, and the Hosmer-Lemeshow test.
MACE occurred within 2 years in 243 (8.1%) patients. The AUC for CRAX2MACE (0.710, 95% CI 0.677-0.743) was significantly higher compared to stress TPD (AUC 0.669, 95% CI 0.632-0.706, P = .010) and ischemic TPD (AUC 0.664, 95% CI 0.627-0.700, P < .001). The model had acceptable goodness-of-fit (P = .103) and was well-calibrated with Brier score of 0.071.
CRAX2MACE had higher predictive performance for 2-year MACE than quantitative perfusion in an external population. The current model is simple to use and could be implemented to assist physicians when estimating patient risk.
A Multinational Study to Establish the Value of Early Adenosine Technetium-99m Sestamibi Myocardial Perfusion Imaging in Identifying a Low-Risk Group for Early Hospital Discharge After Acute ...Myocardial Infarction
John J. Mahmarian, Leslee J. Shaw, Neil G. Filipchuk, Habib A. Dakik, Sherif S. Iskander, Terrence D. Ruddy, Milena J. Henzlova, Felix Keng, Adel Allam, Lemuel A. Moyé, Craig M. Pratt, for the INSPIRE Investigators
The INSPIRE (Adenosine Sestamibi Post-Infarction Evaluation) trial enrolled 728 clinically stable patients who had adenosine myocardial perfusion tomography early after acute myocardial infarction (AMI) and followed them for 1 year. Total cardiac events and death/reinfarction significantly increased within each INSPIRE risk group from low (5.4%, 1.8%), to intermediate (14%, 9.2%), to high (18.6%, 11.6%) (p < 0.01). Event rates at 1 year were lowest in patients with the smallest perfusion defects but increased when defect size exceeded 20% (p < 0.0001). Gated adenosine tomography performed early after AMI can accurately identify a sizeable low-risk group who have a <2% death and reinfarction rate at 1 year.
The purpose of this study was to determine whether gated adenosine Tc-99m sestamibi single-photon emission computed tomography (ADSPECT) could accurately define risk and thereby guide therapeutic decision making in stable survivors of acute myocardial infarction (AMI).
Controversy continues as to the role of noninvasive stress imaging in stratifying risk early after AMI.
The INSPIRE (Adenosine Sestamibi Post-Infarction Evaluation) trial is a prospective multicenter trial which enrolled 728 clinically stable survivors of AMI who had gated ADSPECT within 10 days of hospital admission and subsequent 1-year follow-up. Event rates were assessed within prospectively defined INSPIRE risk groups based on the adenosine-induced left ventricular perfusion defect size, extent of ischemia, and ejection fraction.
Total cardiac events/death and reinfarction significantly increased within each INSPIRE risk group from low (5.4%, 1.8%), to intermediate (14%, 9.2%), to high (18.6%, 11.6%) (p < 0.01). Event rates at 1 year were lowest in patients with the smallest perfusion defects but progressively increased when defect size exceeded 20% (p < 0.0001). The perfusion results significantly improved risk stratification beyond that provided by clinical and ejection fraction variables. The low-risk INSPIRE group, comprising one-third of all enrolled patients, had a shorter hospital stay with lower associated costs compared with the higher-risk groups (p < 0.001).
Gated ADSPECT performed early after AMI can accurately identify a sizeable low-risk group who have a <2% death and reinfarction rate at 1 year. Identifying these low-risk patients for early hospital discharge may improve utilization of health care resources at considerable cost savings.
Abstract Background CMR offers accurate assessment of structure and function with high resolution. Although the use of CMR has been well established in Europe, information is lacking for the extent ...of this emerging modality in North America. Objectives This study aimed to summarize indications, safety, image quality, extent of contrast use and extent of stress tests performed in a high-volume CMR centre. Methods Consecutive patients scanned from July 2005 to November 2010 were included, with duplicates and research subjects removed. Original clinical referrals were categorized into 10 main indications. Results Retrospective analysis was performed on 6463 patients (mean ± SD age = 50 ± 17). The most common clinical indications were non-ischemic cardiomyopathies (28%), including myocarditis (18%), coronary artery disease (17%), ARVD and/or other RV disease (12%), and congenital heart disease (11%). Gadolinium-based contrast was given to 89.5% of patients as part of their CMR protocol. Of 10.9% (703/6463) of patients that underwent stress CMR, adenosine was administered most commonly. Of 703 patients, 1 (0.14%) suffered ventricular tachycardia during adenosine stress, and transient, asymptomatic AV block was occasionally observed. Moderate to severe complications after contrast agent administration occurred in 9 (0.16%) of 5782 contrast-enhanced studies, characterized by nausea and vomiting in 6 (0.12%) and by symptoms of acute systemic allergic reaction in 2 (0.04%). Image quality was good (82.0%), moderate but diagnostic (16.6%) and poor in 1.4% of cases. Conclusion In the high-volume CMR centre, main clinical indications were for myocarditis/cardiomyopathies, coronary artery disease and RV-related queries. CMR showed an excellent safety profile and high image quality in 99% of cases.
An Initial Strategy of Intensive Medical Therapy Is Comparable to That of Coronary Revascularization for Suppression of Scintigraphic Ischemia in High-Risk But Stable Survivors of Acute Myocardial ...Infarction
John J. Mahmarian, Habib A. Dakik, Neil G. Filipchuk, Leslee J. Shaw, Sherif S. Iskander, Terrence D. Ruddy, Felix Keng, Milena J. Henzlova, Adel Allam, Lemuel A. Moyé, Craig M. Pratt, for the INSPIRE Investigators
We randomized 205 stable post-infarction patients with large total (≥20%) and ischemic (≥10%) adenosine-induced left ventricular (LV) perfusion defects and an LV ejection fraction ≥35% to a strategy of either intensive medical therapy or coronary revascularization. Images were repeated after optimizing therapy. Intensive medical therapy and coronary revascularization comparably reduced total (−16.2 ± 10% vs. −17.8 ± 12%) and ischemic (−15 ± 9% vs. −16.2 ± 9%) perfusion defect sizes (p = NS). A similar percentage in both groups had suppression of adenosine-induced ischemia (80% vs. 81%; p = NS). Sequential adenosine tomography can monitor changes in ischemia after either medical therapy or coronary revascularization, and both therapies comparably reduce scintigraphic ischemia.
The purpose of this study was to determine the relative benefit of intensive medical therapy compared with coronary revascularization for suppressing scintigraphic ischemia.
Although medical therapies can reduce myocardial ischemia and improve patient survival after acute myocardial infarction, the relative benefit of medical therapy versus coronary revascularization for reducing ischemia is unknown.
A prospective randomized trial in 205 stable survivors of acute myocardial infarction was made to define the relative efficacy of an intensive medical therapy strategy versus coronary revascularization for suppressing scintigraphic ischemia as assessed by serial gated adenosine Tc-99m sestamibi myocardial perfusion tomography. All patients at baseline had large total (≥20%) and ischemic (≥10%) adenosine-induced left ventricular perfusion defects and an ejection fraction ≥35%. Imaging was performed during 1 to 10 days of hospital admission and repeated in an identical fashion after optimization of therapy. Patients randomized to either strategy had similar baseline demographic and scintigraphic characteristics.
Both intensive medical therapy and coronary revascularization induced significant but comparable reductions in total (−16.2 ± 10% vs. −17.8 ± 12%; p = NS) and ischemic (−15 ± 9% vs. −16.2 ± 9%; p = NS) perfusion defect sizes. Likewise, a similar percentage of patients randomized to medical therapy versus coronary revascularization had suppression of adenosine-induced ischemia (80% vs. 81%; p = NS).
Sequential adenosine sestamibi myocardial perfusion tomography can effectively monitor changes in scintigraphic ischemia after anti-ischemic medical or coronary revascularization therapy. A strategy of intensive medical therapy is comparable to coronary revascularization for suppressing ischemia in stable patients after acute infarction who have preserved LV function.
OBJECTIVE:--The purpose of this study was to assess whether the prevalence of inducible myocardial ischemia increases over time in patients with type 2 diabetes. RESEARCH DESIGN AND ...METHODS--Participants enrolled in the Detection of Ischemia in Asymptomatic Diabetics (DIAD) study underwent repeat adenosine-stress myocardial perfusion imaging 3 years after initial evaluation. Patients with intervening cardiac events or revascularization and those who were unable or unwilling to repeat stress imaging were excluded. RESULTS:--Of the initial 522 DIAD patients, 358 had repeat stress imaging (DIAD-2), of whom 71 (20%) had ischemia at enrollment (DIAD-1). Of 287 patients with normal DIAD-1 studies, 259 (90%) remained normal in DIAD-2, whereas 28 (10%) developed new ischemia in DIAD-2. Of the 71 patients with abnormal DIAD-1 studies, 56 (79%) demonstrated resolution of ischemia, whereas 15 (21%) remained abnormal. During this 3-year interval, medical treatment was intensified, with more patients using statins, aspirin, and ACE inhibitors than at baseline. Patients with resolution of ischemia had significantly greater increases in these medications than patients who developed new ischemia (P = 0.04). CONCLUSIONS:--Thus, the majority of asymptomatic patients with type 2 diabetes demonstrated resolution of ischemia upon repeat stress imaging after 3 years. This resolution was associated with more intensive treatment of cardiovascular risk factors.
Coronary artery disease (CAD) is the major cause of mortality and morbidity in patients with type 2 diabetes. But the utility of screening patients with type 2 diabetes for asymptomatic CAD is ...controversial.
To assess whether routine screening for CAD identifies patients with type 2 diabetes as being at high cardiac risk and whether it affects their cardiac outcomes.
The Detection of Ischemia in Asymptomatic Diabetics (DIAD) study is a randomized controlled trial in which 1123 participants with type 2 diabetes and no symptoms of CAD were randomly assigned to be screened with adenosine-stress radionuclide myocardial perfusion imaging (MPI) or not to be screened. Participants were recruited from diabetes clinics and practices and prospectively followed up from August 2000 to September 2007.
Cardiac death or nonfatal myocardial infarction (MI).
The cumulative cardiac event rate was 2.9% over a mean (SD) follow-up of 4.8 (0.9) years for an average of 0.6% per year. Seven nonfatal MIs and 8 cardiac deaths (2.7%) occurred among the screened group and 10 nonfatal MIs and 7 cardiac deaths (3.0%) among the not-screened group (hazard ratio HR, 0.88; 95% confidence interval CI, 0.44-1.88; P = .73). Of those in the screened group, 409 participants with normal results and 50 with small MPI defects had lower event rates than the 33 with moderate or large MPI defects; 0.4% per year vs 2.4% per year (HR, 6.3; 95% CI, 1.9-20.1; P = .001). Nevertheless, the positive predictive value of having moderate or large MPI defects was only 12%. The overall rate of coronary revascularization was low in both groups: 31 (5.5%) in the screened group and 44 (7.8%) in the unscreened group (HR, 0.71; 95% CI, 0.45-1.1; P = .14). During the course of study there was a significant and equivalent increase in primary medical prevention in both groups.
In this contemporary study population of patients with diabetes, the cardiac event rates were low and were not significantly reduced by MPI screening for myocardial ischemia over 4.8 years.
clinicaltrials.gov Identifier: NCT00769275.
Single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) remains one of the most widely used imaging modalities for the diagnosis and prognostication of coronary artery ...disease (CAD). Despite the extensive prognostic information provided by MPI, little is known about how this influences the prescription of medical therapy for CAD. We evaluated the relationship between MPI with computed tomography (CT) attenuation correction and prescription of acetylsalicylic acid (ASA) and statins.
We performed a retrospective analysis of consecutive patients who underwent SPECT MPI at a single centre between 2015 and 2021. Myocardial perfusion abnormalities and coronary calcium burden were assessed, with attenuation correction imaging 77.8% of patients. Medication prescriptions before and within 180 days after the test were compared. Associations between abnormal perfusion and calcium burden with ASA and statin prescription were assessed using multivariable logistic regression. In total, 9908 patients were included, with a mean age 66.8 ± 11.7 years and 5337 (53.9%) males. The prescription of statins increased more in patients with abnormal perfusion (increase of 19.2 vs. 12.0%, P < 0.001). Similarly, the presence of extensive CAC led to a greater increase in statin prescription compared with no calcium (increase 12.1 vs. 7.8%, P < 0.001). In multivariable analyses, ischaemia and coronary artery calcium were independently associated with ASA and statin prescription.
Abnormal MPI testing was associated with significant changes in medical therapy. Both calcium burden and perfusion abnormalities were associated with increased prescriptions of medical therapy for CAD.
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