Search

Background: Guidelines for evaluating patients with suspected coronary artery disease (CAD) recommend pretest probability (PTP) estimation but provide no clear recommendations regarding diagnostic testing in patients with >5% to 15% risk of obstructive CAD. The diagnostic and prognostic value of PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) minimal risk score (PMRS) calculation in this patient group is unknown., Objectives: This work aims to improve the evaluation of stable patients with suspected CAD by using the PMRS, which identifies patients at minimal risk of CAD and events in patients with >5% to 15% PTP of obstructive CAD., Methods: Greater than 5% to 15% PTP patients from 2 large clinical trials were used for subcohort derivation: PROMISE (N = 10,003) and Dan-NICAD (Danish study of Non-Invasive Testing in Coronary Artery Disease) (N = 3,252). First, the PMRS cutoff associated with a prevalence of obstructive CAD ≤5% was determined in the >5% to 15% PTP PROMISE core lab computed tomographic angiography patients (discovery cohort: n = 2,191). This cutoff was validated for obstructive CAD in >5% to 15% PTP Dan-NICAD patients (CAD validation cohort: n = 1,386) and for prognostic impact on death and myocardial infarction in >5% to 15% PTP PROMISE non-core lab computed tomographic angiography patients (prognosis validation cohort: n = 2,753)., Results: In the discovery cohort, a CAD prevalence of ≤5% was found at a PMRS of ≥34%. In the CAD validation cohort, this cutoff down-classified 442 (31.9%) of >5% to 15% PTP patients into the low PTP group (CAD ≤5%); the prevalence of obstructive CAD in down-classified patients was 3.2% compared to 7.1% in non-down-classified patients. A PMRS ≥34% was nonsignificantly associated with a lower risk of myocardial infarction and death in the prognosis validation cohort (HR: 0.58 [95% CI: 0.29-1.18]; P = 0.13)., Conclusions: For evaluating patients with suspected CAD, a combined use of traditional PTP and the PMRS correctly down-classified one-third of >5% to 15% PTP patients into a group with very low prevalence of obstructive CAD and adverse events. The proposed strategy may improve risk stratification and help reduce unneeded diagnostic testing., Competing Interests: Funding Support and Author Disclosures The study was supported by The Danish Heart Foundation (Grant No. 15-R99-A5837-22920), the Health Research Fund of Central Denmark Region, and Aarhus University Research foundation. The PROMISE trial was supported by grants from the National Heart, Lung, and Blood Institute (R01HL098237, R01HL098236, R01HL098305 and R01HL098235). Dr Fordyce has received consulting fees from Bayer, Novo Nordisk, Boehringer Ingelheim, Sanofi, Pfizer, and Amgen; and has received research grants from Bayer outside of this work. Dr Bøttcher has been a member of the advisory board and has had research collaboration with Novo Nordisk, AstraZeneca, Bayer, Sanofi, Boehringer Ingelheim, Novartis, BMS-Pfizer, and Acarix outside of this work. Dr Douglas has received research funding from HeartFlow outside of this work. Dr Winther has received support from the Novo Nordisk Foundation Clinical Emerging Investigator grant (NNF21OC0066981). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

The ACR and the American College of Cardiology Foundation (ACCF) developed a joint process for determining the appropriate utilization (AU) of cardiovascular imaging modalities in heart failure (HF). This report represents an executive summary of the AU document which was aimed at critically and systematically creating, reviewing, and categorizing clinical situations where physicians order or use imaging tests for patients with suspected, incompletely characterized, or known HF., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Cardiac sympathetic imaging with meta-iodobenzylguanidine (mIBG) is a noninvasive tool to risk stratify patients with heart failure (HF). In patients with ischemic and nonischemic cardiomyopathy, cardiac mIBG activity is a very powerful predictor of survival. Cardiac sympathetic imaging can help in understanding how sympathetic overactivity exerts its deleterious actions, which may result in better therapy and outcome for patients with HF., (Copyright (c) 2010 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

In July of 2008, the National Heart, Lung, and Blood Institute convened experts in noninvasive cardiovascular imaging, outcomes research, statistics, and clinical trials to develop recommendations for future randomized controlled trials of the use of imaging in: 1) screening the asymptomatic patient for coronary artery disease; 2) assessment of patients with stable angina; 3) identification of acute coronary syndromes in the emergency room; and 4) assessment of heart failure patients with chronic coronary artery disease with reduced left ventricular ejection fraction. This study highlights several possible trial designs for each clinical situation.

Purpose: The approach to cardiac risk stratification of patients undergoing vascular surgery continues to be controversial. The success of algorithms that use clinical risk factors to determine cardiac risk have been inconsistent. Dipyridamole myocardial scintigraphy (DMS) has been accepted as a sensitive, noninvasive approach to risk stratification with excellent negative predictive value. Low positive predictive value (PPV) of abnormal DMS scans is a shortcoming that contributes to extensive preoperative cardiac evaluation and intervention with associated morbidity, mortality, and cost in most patients who undergo uncomplicated vascular procedures, regardless of DMS results., Methods: Over 6 years, 237 patients underwent DMS before surgical management of infrarenal aortic aneurysm, aortoiliac, or infrainguinal occlusive disease. The value of multiple clinical factors and DMS were assessed retrospectively for the prediction of perioperative myocardial infarction (MI), heart-related death, or preoperative selection for myocardial revascularization. Only congestive heart failure and two or more reversible defects on DMS were statistically significant on logistic regression analysis., Results: The PPV of DMS was 19% for all patients with reversible defects, 12% for patients with one reversible defect, and 36.7% for patients with two or more reversible defects. The rates of cardiac death and MI were 1.3% and 5.9%, respectively. Perioperative echocardiography revealed unchanged postinfarction ejection fraction in most patients who experienced MI. Cost-effectiveness of DMS screening was evaluated., Conclusions: The costs per MI and cardiac death averted suggest a decline in cost-effectiveness of screening with DMS over time, assuming improving cardioprotective strategies of patient care. Clinical risk factors were minimally useful in the prediction of perioperative MI, heart-related death, or need for myocardial revascularization. The PPV of DMS is low, and the majority of MIs may be clinically insignificant. The cost-effectiveness of cardiac screening with DMS may not be justifiable given current trends of health care reform.