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Cardiovascular risk stratification is often performed in patients considered for renal transplantation. In a single center, we sought to examine the association between abnormal stress testing with imaging and post-renal transplant major adverse cardiovascular events (MACE) using multivariable logistic regression. From January 2006 to May 2016 232 patients underwent renal transplantation and 59 (25%) had an abnormal stress test result. Compared to patients with a normal stress test, patients with an abnormal stress test had a higher prevalence of dyslipidemia, diabetes mellitus, obesity, coronary artery disease (CAD), and heart failure. Among those with an abnormal result, 45 (76%) had mild, 10 (17%) moderate, and 4 (7%) severe ischemia. In our cohort, 9 patients (3.9%) had MACE at 30-days post-transplant, 5 of whom had an abnormal stress test. The long-term MACE rate, at a median of 5 years, was 32%. After adjustment, diabetes (OR 2.37, 95% CI 1.12–5.00, p = 0.02), CAD (OR: 3.05, 95% CI 1.30–7.14, p = 0.01) and atrial fibrillation (OR: 5.86, 95% CI 1.86–18.44, p = 0.002) were independently associated with long-term MACE, but an abnormal stress test was not (OR: 0.83, 95% CI 0.37–1.92, p = 0.68). In conclusion, cardiac stress testing was not an independent predictor of long-term MACE among patients undergoing renal transplant.

The coronavirus disease-2019 (COVID-19) pandemic has dramatically disrupted cardiovascular disease fellowship training. Significant reductions in cardiac volumes and simultaneous reassignment of physicians, including to COVID-19–centric services, have led to educational challenges in fellowship

Academic medical centers (AMCs) are presently facing enormous challenges arising from a prospective decline in government funding for research and education, shifting payment models emphasizing efficiency and value, and increasing competition. Left unabated, these challenges will drive many AMCs to de-emphasize or forsake their core missions in an effort to survive. Stemming from a symposium held at the 2015 Scientific Sessions of the American College of Cardiology titled, "The Academic Medical Center of the Future," we propose a series of changes, including internal restructuring, system-wide partnership, and novel approaches to support research and education, that are designed to better position AMCs to compete and face their growing challenges in a manner that preserves their essential missions. In aggregate, these changes will facilitate establishing the academic medical system of the future.

James A. Arrighi, MD, FACC, Chair Lisa A. Mendes, MD, FACC, Co-Chair Jesse E. Adams III, MD, FACC John E. Brush Jr, MD, FACC[#][1] G. William Dec Jr, MD, FACC Ali Denktas, MD, FACC Susan Fernandes, LPD, PA-C Rosario Freeman, MD, MS, FACC[#][1] Rebecca T. Hahn, MD, FACC Jonathan L.

There has been rapid advancement within the field of cardiovascular disease (CVD) with increasing disease complexity and rapidly evolving technologies. These changes present new challenges in training the next generation of cardiologists. In parallel, there has been an evolution in graduate medical

Eric S. Williams, MD, MACC, Chair Jonathan L. Halperin, MD, FACC, Co-Chair James A. Arrighi, MD, FACC Eric H. Awtry, MD, FACC Eric R. Bates, MD, FACC John E. Brush, Jr, MD, FACC Salvatore Costa, MD, FACC Lori Daniels, MD, MAS, FACC Susan Fernandes, LPD, PA-C Rosario Freeman, MD, MS, FACC

1.1 Document Development Process #### 1.1.1 Writing Committee Organization The Writing Committee was selected to represent the American College of Cardiology (ACC) and the American Society of Nuclear Cardiology (ASNC) and included a cardiovascular training program director; a nuclear

Since the 1995 publication of its Core Cardiovascular Training Statement (COCATS),1 the American College of Cardiology (ACC) has played a central role in defining the knowledge, experiences, skills, and behaviors expected of all clinical cardiologists upon completion of training. Subsequent updates have incorporated major advances and revisions—both in content and structure—including, most recently, …

Continued engagement in valued life activities is a protective factor for depression and has been linked to readiness to quit smoking in medical populations but has never been examined among acute coronary syndrome (ACS) patients.The purpose of this study is to investigate relationships among valued life activities, mood, and smoking post-ACS.Participants were 54 post-ACS patients who were smoking before ACS hospitalization. Data on mood, smoking status, engagement in valued activities, restriction of valued activities, and satisfactory replacement of restricted activities was collected 1-12 months post-ACS.Depressive symptoms were associated with both less valued activity engagement and greater valued activity restriction. Positive affect was associated with greater valued activity engagement and negative affect was associated with greater valued activity restriction. Satisfactory replacement of restricted activities was associated with greater positive affect, fewer depressive symptoms, and quitting smoking post-ACS. The majority of these relationships remained significant after controlling for relevant covariates, including physical functioning.Valued activity restriction and engagement may contribute to depressed mood and failure to quit smoking in ACS patients. Psychotherapies that target greater engagement in valued life activities deserve further investigation in ACS patients.

Eric S. Williams, MD, MACC, Chair Jonathan L. Halperin, MD, FACC, Co-Chair James A. Arrighi, MD, FACC Eric H. Awtry, MD, FACC Eric R. Bates, MD, FACC Salvatore Costa, MD, FACC Lori Daniels, MD, FACC Akshay Desai, MD, FACC Douglas E. Drachman, MD, FACC Susan Fernandes, LPD, PA-C Rosario

Academic medical centers (AMCs) are presently facing enormous challenges arising from a prospective decline in government funding for research and education, shifting payment models emphasizing efficiency and value, and increasing competition. Left unabated, these challenges will drive many AMCs to de-emphasize or forsake their core missions in an effort to survive. Stemming from a symposium held at the 2015 Scientific Sessions of the American College of Cardiology titled, "The Academic Medical Center of the Future," we propose a series of changes, including internal restructuring, system-wide partnership, and novel approaches to support research and education, that are designed to better position AMCs to compete and face their growing challenges in a manner that preserves their essential missions. In aggregate, these changes will facilitate establishing the academic medical system of the future.

The assessment of myocardial viability may be an important component of the evaluation of patients with coronary artery disease and left ventricular dysfunction. The primary goal of viability assessment in such patients is to guide therapeutic decisions by determining which patients would most likely benefit from revascularization. In patients with chronic coronary artery disease, left ventricular dysfunction may be a consequence of prior myocardium infarction, which is an irreversible condition, or reversible ischemic states such as stunning and hibernation. Imaging techniques utilize several methods to assess myocardial viability: left ventricular function, morphology, perfusion, and metabolism. Each technique (echocardiography, nuclear imaging, magnetic resonance imaging, and x-ray computed tomography) has the ability to assess one or more of these parameters. This article describes how each of these imaging modalities can be used to assess myocardial viability, and reviews the relative strengths and limitations of each technique.

Objectives This study examined short-term cardiac catheterization rates and medication changes after cardiac imaging. Background Noninvasive cardiac imaging is widely used in coronary artery disease, but its effects on subsequent patient management are unclear. Methods We assessed the 90-day post-test rates of catheterization and medication changes in a prospective registry of 1,703 patients without a documented history of coronary artery disease and an intermediate to high likelihood of coronary artery disease undergoing cardiac single-photon emission computed tomography, positron emission tomography, or 64-slice coronary computed tomography angiography. Results Baseline medication use was relatively infrequent. At 90 days, 9.6% of patients underwent catheterization. The rates of catheterization and medication changes increased in proportion to test abnormality findings. Among patients with the most severe test result findings, 38% to 61% were not referred to catheterization, 20% to 30% were not receiving aspirin, 35% to 44% were not receiving a beta-blocker, and 20% to 25% were not receiving a lipid-lowering agent at 90 days after the index test. Risk-adjusted analyses revealed that compared with stress single-photon emission computed tomography or positron emission tomography, changes in aspirin and lipid-lowering agent use was greater after computed tomography angiography, as was the 90-day catheterization referral rate in the setting of normal/nonobstructive and mildly abnormal test results. Conclusions Overall, noninvasive testing had only a modest impact on clinical management of patients referred for clinical testing. Although post-imaging use of cardiac catheterization and medical therapy increased in proportion to the degree of abnormality findings, the frequency of catheterization and medication change suggests possible undertreatment of higher risk patients. Patients were more likely to undergo cardiac catheterization after computed tomography angiography than after single-photon emission computed tomography or positron emission tomography after normal/nonobstructive and mildly abnormal study findings. (Study of Perfusion and Anatomy9s Role in Coronary Artery [CAD] [SPARC]; NCT00321399)

Introduction. Cardiac involvement occurs in a significant minority (5%-30%) of patients with sarcoidosis and can have a benign or life-threatening course. Clinical manifestations include conduction abnormalities, ventricular and supraventricular arrhythmias, valvular dysfunction, and heart failure. 1 The diagnosis of cardiac sarcoidosis is often difficult to make, and is suggested by relatively nonspecific findings such as electrocardiographic abnormalities (particularly heart block) or abnormalities in left ventricular function. Endomyocardial biopsy, while providing improved specificity, is invasive and has poor sensitivity. Initial strategies using nuclear imaging techniques such as gallium or myocardial perfusion imaging (MPI) demonstrated relatively poor sensitivity and specificity for cardiac sarcoidosis. Recently, FDG (F-18 fluorodeoxyglucose) positron emission tomography (PET), performed under fasting conditions, has been shown to have improved sensitivity and specificity for the diagnosis of cardiac sarcoidosis compared to other modalities. A case of a 73-year-old man with known pulmonary sarcoidosis and multiple coronary risk factors who presented with a new cardiomyopathy is presented in this study. Initial evaluation with single photon emission computed tomography (SPECT) technetium 99m (Tc-99m) tetrofosmin MPI strongly suggested an ischemic etiology. Subsequent coronary angiography and FDG PET, however, was consistent with cardiac sarcoidosis, highlighting the potential value of PET imaging in the evaluation of suspected cardiac sarcoidosis. Case report. A 73-year-old man with a history of biopsy-proven stage I pulmonary sarcoidosis presented with acute respiratory failure. His past medical history included sarcoidosis, diabetes mellitus, end-stage renal disease on hemodialysis, and atrial fibrillation. The patient was diagnosed with pulmonary sarcoidosis approximately 30 years ago by routine chest x-ray. He underwent a lung biopsy at that time that was positive for granulomatous inflammation consistent with sarcoidosis. He was asymptomatic until approximately 1 month prior to admission at which time developed worsening dyspnea on exertion. This progressed to shortness of breath at rest which prompted him to seek medical attention.

Danon disease is a rare, codominant X-linked genetic disorder characterized by the triad of left ventricular hypertrophy, mental retardation, and peripheral myopathy. This disease is caused by mutations in the gene that encodes lysosomal associated membrane protein 2 (LAMP2), a deficiency of which results in the accumulation of autophagic granular débris within the vacuoles of muscle cells. This is a report of an asymptomatic 19-year-old man with Danon disease in the absence of mental retardation or clinically significant skeletal myopathy. This case underscores the importance of accurate diagnosis of unexplained left ventricular hypertrophy, in order to establish an appropriate treatment plan and to advise genetic counseling.

Cardiologists, radiologists, and nuclear medicine physicians receive training and may be allowed to perform cardiovascular imaging by using echocardiography, nuclear cardiology, or cardiovascular computed tomography. Given the tremendous variability in training and expertise, physician certification in each of these areas has been developed as a measure of providing quality studies for accurate patient diagnosis and management. In this paper, the history, the process of examination development and administration, eligibility requirements, the results of physician testing, and board recognition will be presented for each of the 3 boards. Payers and government regulators have recognized these boards as a measure of physician quality, and they are often required for physician reimbursement and licensure. Because many physicians provide service in more than 1 specialty, discussions are ongoing to simplify the application, testing and recertification processes.

Background— Disturbances of autonomic function after infarction are associated with both total mortality and sudden death. Although many imaging techniques for assessing the cardiac autonomic nervous system have been studied, the clinical usefulness of these techniques remains uncertain. This exploratory pilot study examined the relationship between abnormalities of ventricular sympathetic innervation delineated by scintigraphic imaging with 123 I- m IBG and inducible ventricular tachyarrhythmias in patients with left ventricular dysfunction and previous myocardial infarction. Methods and Results— Fifty patients underwent electrophysiological (EP) testing and 15-minute and 4-hour planar and single photon emission computed tomography (SPECT) imaging with 123 I- m IBG and SPECT imaging with 99m Tc-tetrofosmin. The primary efficacy variables were the 4-hour heart:mediastinum ratio (H/M) and the 123 I- m IBG/ 99m Tc-tetrofosmin SPECT mismatch score. EP studies were categorized as positive (EP + ) or negative (EP − ) for inducibility of sustained (>30 seconds) ventricular tachyarrhythmias. Thirty patients were EP + , and 20 were EP − . There were no significant differences in the 4-hour H/M ratios or 123 I- m IBG/ 99m Tc-tetrofosmin SPECT mismatch scores between the two groups. In a multivariable analysis using all 123 I- m IBG and 99m Tc-tetrofosmin SPECT measurements, the only variable that showed a significant difference between EP + and EP − patients was the 4-hour 123 I- m IBG SPECT defect score. A 4-hour 123 I- m IBG SPECT defect score of ≥37 yielded a sensitivity of 77% and specificity of 75% for predicting EP results. Conclusions— The standard indices of 123 I- m IBG imaging (H/M and innervation-perfusion mismatch score) are not predictive of EP test results. The association of 123 I- m IBG SPECT defect severity with EP test inducibility in this exploratory study will require confirmation in a larger cohort of patients.

The 12th annual Scientific Sessions of the American Society of Nuclear Cardiology (ASNC) (chaired by Dr. Brian Abbott) were held in San Diego, California, from September 6 through 9, 2007. The meeting, entitled “Cardiac Imaging: Imagine the Future,” attracted over 1,700 attendees. The scientific

BACKGROUND Experimental data have shown that glucose utilization increases during acute myocardial ischaemia, and may persist for up to 24 h. Whether fluorodeoxyglucose (FDG) uptake can be imaged as a memory marker of ischaemia in humans is unknown. METHODS Patients with mild-to-moderate ischaemia on exercise single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) underwent repeat exercise testing within 1-2 weeks. Positron emission tomography (PET) was performed after injection of FDG 60 min post-exercise. SPECT and PET images were assessed visually, aided by circumferential profile-based analysis modified for 'hot-spot' imaging. RESULTS Twelve men with stress SPECT ischaemia (mean age, 69 years; nine with known coronary artery disease) were studied. The mean rate-pressure products for the first (SPECT) and second (FDG PET) exercise tests were similar (22,841+/-7321 vs. 22,680+/-7393 mmHg x bpm, P=NS). Overall, six of 12 patients studied had evidence of FDG uptake. The extent of ischaemia on SPECT was similar in FDG positive and FDG negative patients (summed difference score 10.6+/-6.9 vs. 8.0+/-1.6, P=NS). All patients with a positive FDG scan had uptake in either an ischaemic SPECT region or in a territory with known CAD by angiography. CONCLUSION Regional myocardial uptake of FDG is enhanced even when injected 1 h post-exercise stress in a subset of patients with ischaemia on exercise SPECT MPI. The ability to image FDG uptake injected 1 h after an ischaemic episode suggests the potential utility of FDG as a memory marker of transient ischaemia.

Preamble 1523 1. Introduction 1524 2. General Standards 1526 3. Training Components 1526 4. Training Requirements 1528 5. Evaluation of Proficiency 1542 6. Maintenance of Competency 1543 References 1543 Appendix 1. Author Relationships with Industry and Other Entities (Relevant) 1545 Appendix 2. Reviewer Relationships with Industry and Other Entities (Relevant) 1548 Appendix 3. Abbreviations 1551 Since the 1995 publication of its Core Cardiovascular Training Statement (COCATS), the American College of Cardiology (ACC) has played a central role in defining …

Purpose of review The assessment of myocardial viability provides important information that may guide therapeutic decisions in patients with coronary artery disease and left ventricular dysfunction. This review describes methods for assessing myocardial viability using single-photon emission computed tomography, with an emphasis on how to optimize the detection of viable myocardium using current techniques. Relevant comparisons of radionuclide techniques with echocardiographic methods are also discussed. Recent findings The basis for the assessment of myocardial viability using radionuclides is reviewed briefly. Radionuclide techniques provide important prognostic information that may affect the decision on if patients with coronary artery disease should be revascularized or treated medically. Data suggest that dobutamine stress echocardiography may underestimate viability in certain patients. Radionuclide techniques that assess both radiotracer uptake and ventricular function can provide a comprehensive approach to detect viable myocardium in most patients. Summary The methods for assessing myocardial viability using single-photon emission computed tomography are accurate, reproducible, and widely available. Viability testing should be considered in patients with known coronary artery disease and left ventricular dysfunction. Further studies are warranted to assess the affect of viability assessment on clinical outcomes.

Noninvasive imaging has become a cornerstone of the practice of cardiovascular medicine. When properly applied, the information obtained from cardiac imaging studies, integrated with overall clinical assessment, can be used to diagnose disease, determine its functional and physiological impact, assess prognosis, and guide therapeutic decisions. The last 2 decades have seen enormous growth in all medical imaging procedures.1 A major component of this increased utilization was in stress nuclear myocardial perfusion imaging (MPI) single-photon emission-computed tomography (SPECT), which has become one of the most commonly used and effective methods to assess patients with known or suspected coronary artery disease. The reasons for this growth have been, and will continue to be, debated for some time. On the more “positive” side, this growth may have been stimulated by a substantial body of research demonstrating the utility of MPI in a wide variety of clinical scenarios. Moreover, advancements in imaging technology and improved access to care may have been contributory. On the “negative” side, some argue that the growth in imaging has been fueled by misguided financial incentives and the practice of “defensive” medicine. One fact, however, is indisputable: Imaging accounts for a large amount of overall healthcare expenditures, and despite the potential for imaging to reduce downstream costs, control of this escalating cost has become central to public healthcare policy. Accordingly, constraint of this growth of cardiac imaging has become a major effort of the government, medical insurers, and professional societies. What is the best method for controlling the proliferation of cardiac imaging, and how should these methods be used to effect change in physician behavior? Article see p 499 In this issue of Circulation , Gibbons and colleagues2 report on their experience in the implementation of one such methodology, the appropriate use criteria (AUC) for SPECT MPI, in …

The accuracy of technetium-99m (Tc-99m) sestamibi single-photon emission computed tomography (SPECT) for the assessment of myocardial viability in patients with coronary artery disease and left ventricular (LV) dysfunction is not defined completely. This study determines whether the performance of Tc-99m sestamibi SPECT for viability detection differs between patients with mild-tomoderate coronary artery disease. Patients with regional and/or global LV dysfunction were separated into 2 groups on the basis of LV ejection fraction (EF) at rest: group 1 (LVEF >25%, mean 36 ± 6%, n = 9), and group 2 (LVEF ≤25%, mean 17 ± 5%, n = 11). All patients underwent semiquantitative Tc-99m sestamibi SPECT and positron emission tomography (PET) at rest with N-13 ammonia and F-18 fluorodeoxyglucose. The overall regional concordance of SPECT and PET for viability detection was 89% in group 1 and 78% in group 2 (p = 0.002). Discordance in group 2 was almost exclusively due to PET viable and/or SPECT nonviable regions. In regions with hypoperfusion at rest by PET, concordance was 78% in group 1 and only 64% in group 2 (p = 0.0015). In regions with reduced perfusion and relatively increased metabolic activity (“flow: metabolism mismatch”), Tc-99m sestamibi SPECT identified 88% of regions in group 1 as viable, but only 42% of regions in group 2 (p = 0.002). Thus, while Tc-99m sestamibi semiquantitative SPECT at rest shows a good concordance with PET for the detection of myocardial viability in patients with coronary artery disease with mild-to-moderate LV dysfunction, it may underestimate myocardial viability in patients with severe LV dysfunction, particularly in those patients with hypoperfusion at rest as assessed by PET.

Diastole, that portion of the cardiac cycle that begins with isovolumic relaxation and ends with mitral valve closure, results in ventricular filling and involves both active (energy-dependent) and passive processes. The interactions between active processes (myocardial relaxation) that primarily influence early ventricular filling and passive processes, such as loading conditions, myocardial compliance, and valvular disease, are complex. Clinical methods to assess ventricular filling include cardiac catheterization, radionuclide angiography, and echocardiography. Any measurements of diastolic function must be made with an understanding of the determinants of ventricular filling and the limitations of the diagnostic test. Many cardiac disorders are characterized by elevated pulmonary venous pressures in the face of normal systolic ventricular function, which suggests a primary abnormality of diastolic function. Abnormalities in diastolic function have been observed in coronary artery disease, congestive heart failure (with and without systolic dysfunction), hypertrophic cardiomyopathy, hypertension, and in healthy elderly subjects. Identification of these abnormalities may be useful clinically, particularly in patients with symptoms of heart failure and normal systolic function. Data are not available to determine the optimal therapy for such patients, although evidence suggests that calcium channel blockers, beta blockers, and agents that reverse myocardial hypertrophy may be useful. This review briefly summarizes the physiology of diastole, the methods of clinical assessment of diastolic function, and the role of diastolic function in cardiovascular disease.

Introduction: Chest pain unit (CPU) observation with defined stress utilization protocols is a common management option for low-risk emergency department patients. We sought to evaluate the safety of a joint emergency medicine and cardiology staffed CPU. Methods: Prospective observational trial of consecutive patients admitted to an emergency department CPU was conducted. A standard 6-hour observation protocol was followed by cardiology consultation and stress utilization largely at their discretion. Included patients were at low/intermediate risk by the American Heart Association, had nondiagnostic electrocardiograms, and a normal initial troponin. Excluded patients were those with an acute comorbidity, age 75, and a history of coronary artery disease, or had a coexistent problem restricting 24-hour observation. Primary outcome was 30-day major adverse cardiovascular events—defined as death, nonfatal acute myocardial infarction, revascularization, or out-of-hospital cardiac arrest. Results: A total of 1063 patients were enrolled over 8 months. The mean age of the patients was 52.8 11.8 years, and 51% (95% confidence interval CI, 48‐54) were female. The mean thrombolysis in myocardial infarction and Diamond & Forrester scores were 0.6% (95% CI, 0.51‐0.62) and 33% (95% CI, 31‐35), respectively. In all, 51% (95% CI, 48‐54) received stress testing (52% nuclear stress, 39% stress echocardiogram, 5% exercise, 4% other). In all, 0.9% patients (n 10, 95% CI, 0.4‐1.5) were diagnosed with a non-ST elevation myocardial infarction and 2.2% (n 23, 95% CI, 1.3‐3) with acute coronary syndrome. There was 1 (95% CI, 0%‐0.3%) case of a 30-day major adverse cardiovascular events. The 51% stress test utilization rate was less than the range reported in previous CPU studies (P 0.05). Conclusions: Joint emergency medicine and cardiology management of patients within a CPU protocol is safe, efficacious, and may safely reduce stress testing rates.