The prognostic value of heart rate response during vasodilator stress myocardial perfusion imaging in patients with end-stage renal disease undergoing renal transplantation
Wael AlJaroudiChiedozie AnokwuteIbtihaj FughhiTania CampagnoliMarwan WassoufAviral VijMichael KharoutaAndrew AppisAmjad AliRami Doukky
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Objective To study and compare the diagnostic value in severe coronary artery disease (CAD) of 99 Tc m methoxyisobutylisonitrile (MIBI) electrocardiogram (ECG) gated early post exercise myocardial perfusion imaging (G MPI) with that of non ECG gated myocardial perfusion imaging (NG MPI). Methods Two hundred and fifteen suspected CAD patients had undergone G MPI and coronary artery angiography (CAG) within one month were enrolled and distributed into three vessel and non three vessel CAD groups according to CAG results (≥70%); the diagnostic values in severe CAD of G MPI and NG MPI were gained and compared to determine which one of the two protocols would be superior in identification of severe three vessel CAD. Results When the ≥70% diameter stenosis CAG was the diagnostic standard of severe CAD, the sensitivity of G MPI and NG MPI in the diagnosis of severe CAD were 95.3% (143/150) and 90.7% (136/150, χ 2=2.509, P =0 113), but when the comparison specifically pinpointed to severe three vessel CAD, there was significant difference between G MPI [100%(51/51)] and NG MPI [92.2% (47/51), χ 2=4.163, P =0.041]. Diagnostic specificity of G MPI was 80.0% and that of NG MPI was 72.3% ( χ 2=1.059, P =0.303). Conclusions The incremental diagnostic sensitivity of G MPI adding to the NG MPI in the diagnosis of severe CAD was mainly from the three vessel subgroup patients.Exercise stress G MPI has better diagnostic value in severe three vessel CAD patients than NG MPI.
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Early detection of potential asymptomatic coronary artery disease is very important, as patients with sudden cardiac death often do not show symptoms such as chest pain or motor dyspnea. Coronary CT angiography (CCTA) has long been unjustified as a screening tool for asymptomatic patients because of the risks posed by radiation exposure. However, there are still various opinions regarding the usefulness of CCTA for screening for coronary artery disease (CAD) in asymptomatic healthy individuals or patients. This review investigated the usefulness of coronary artery calcium score and CCTA as screening tests for CAD in asymptomatic healthy individuals or patients through various literature reviews. With the development of CT technology, recent studies have been conducted in asymptomatic CAD patients with a reduced radiation dose of less than 1 mSv. A total of 2.6% of asymptomatic subjects on CCTA found significant CAD over 70%, and it was concluded that screening CCTA for CAD showed prognostic power in predicting the future occurrence of CAD in asymptomatic people. However, after the completion of the current NIH SCOT-HEART 2 study, it may be possible to determine whether CCTA is appropriate as a screening tool for CAD in asymptomatic healthy individuals.
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Objective To study the clinical value of adenosine triphosphate stress myocardial perfusion tomography imaging (ATP-MPI) in detection of coronary artery disease (CAD). Methods There were 278 patients underwent ATP-MPI, 51 patients of them also underwent coronary angiography (CAG). Seventy-three patients underwent stress-rest myocardial perfusion tomography imaging with multi-stage submaximal exercise test (ST-MPI) and CAG serving as control group. Results ①Side effects: there were 11 different symptoms and atrioventricular conduction block (10 patients), sinoatrial conduction block (2 patients) occurred during ATP stress. Allopathy or interruption of ATP stress did not happen. ②The sensitivity and specificity of ATP-MPI in detection of CAD were 97.1% and 82.4%, respectively, and those in detection of ≥50% narrowing coronary artery were 91.0% and 94.7%, respectively. ③In patients without myocardial infarction, the sensitivity and specificity of ATP-MPI in detection of myocardial ischemia were comparable to those of ST-MPI. Conclusion ATP-MPI is an accurate, safe modality and is comparable to ST-MPI in the detection of CAD.
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Intravascular Ultrasound
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Objective To explore diagnostic value of adenosine triphosphate stress myocardial perfusion imaging(ATP-MPI) to coronary artery disease(CAD).Methods ATP-MPI was made for 47 CAD patients and the contrast analysis was conducted among ATP-MPI,stress test myocardial perfusion imaging(STMPI) and coronary angiography(CAG).Results The detectable rate of ATP-MPI,ST-MPI and CAG were(78.7)%,(80.9)% and(85.1)%.There was no significant difference among them(χ~2=(0.638),P(0.05)).With CAG as the standard,the sensitivity and specificity of ATP-MPI and ST-MPI in CAD detection had no significance(P(0.05)).Conclusion Dignosis by ATP-MPI to CAD can replace ST-MPI as a routine examination.
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Appropriate Use Criteria
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Several studies have suggested that a combined approach of stress myocardial perfusion imaging (MPI) and coronary computed tomography angiography (CCTA) can provide diagnostic results with excellent accuracy. We aimed to explore whether the addition of CCTA to stress MPI provides incremental diagnostic value in intermediate-to-high cardiovascular risk patients.A total of 106 consecutive patients (93 male, 65 ± 10.4 years) underwent coronary artery calcium scoring (CACS), CCTA and (201)Thallium stress MPI before coronary angiography was reviewed. Thirty-seven patients (34.9%) had a history of proven coronary artery disease (CAD) or revascularization procedures, and four had documented non-significant CAD (3.8%). The remaining patients consisted of 17 (16.0%) classified as intermediate, and 48 (45.3%) as the high-risk groups.Obstructive CAD was diagnosed by invasive coronary angiography in 88 patients with 161 vessels. The sensitivity and specificity in a patient-based analysis for obstructive CAD were 99% and 17% for CCTA, 80% and 50% for MPI and 91% and 67% for the combined method, respectively. The per-vessel diagnostic sensitivity and specificity were 95% and 54% for CCTA, 59% and 75% for MPI and 84% and 76% for the combined method. There were significant differences (p < 0.05) when comparing the combined method with MPI or CCTA by areas under the curve in a patient- or vessel-based analysis. However, CACS of 400 or more could not further stratify the patients with obstructive CAD.CCTA, not CACS, provided additional diagnostic values to stress MPI in patients with intermediate-to-high cardiovascular risk.Coronary artery disease (CAD) • Coronary computed tomography angiography (CCTA) • Myocardial perfusion imaging (MPI) • Single-photon emission computed tomography (SPECT).
Computed Tomography Angiography
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Myocardial perfusion imaging (MPI) is commonly used to detect ischemia. Concerns about silent ischemia may encourage orders for MPI in asymptomatic patients. Factors contributing to this practice are poorly described and the clinical utility is questionable. We conducted a single center retrospective cohort investigation on Veterans who underwent MPI between December 2010 and July 2011. We gathered data on symptoms, baseline characteristics, results of MPI, and cardiovascular events within 1 year. MPI were categorized using 2009 appropriate use criteria (AUC). Of 592 patients, 127 (21.5%) had no symptoms at the time of MPI. Comparing symptomatic and asymptomatic patients, no differences were observed in baseline characteristics except abnormal ECG, more common in asymptomatic patients (n = 86, 67.7% vs. n = 232, 49.9% for symptomatic patients, P < 0.0001). Asymptomatic MPI were more commonly inappropriate (n = 26, 21.5% vs. n = 31, 6.7% for appropriate/uncertain, P < 0.0001). Detection of ischemia between patients with and without symptoms was not different (P = 0.86); however, among asymptomatic MPI that also demonstrated ischemia, none were inappropriate (n = 10 appropriate, n = 7 uncertain). In multivariate regression, 2 factors were associated with asymptomatic status, abnormal ECG (odds ratio [OR] 2.29, 95% confidence interval [CI] 1.5–3.49) and age over the median (OR 0.63, 95% CI: 0.41–0.95). A substantial portion of MPI tests are ordered for patients without symptoms. When compared to symptomatic patients, MPI for asymptomatic patient were more commonly inappropriate; however, the prevalence of ischemia was similar. MPI may be clinically relevant in some asymptomatic patients and decisions to test should be based on the AUC.
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