Routine transthoracic echocardiography in ischaemic stroke or transient ischaemic attack of undetermined cause: a prospective multicentre study.

BACKGROUND: Guidelines recommend routine transthoracic echocardiography (TTE) after ischaemic stroke or transient ischaemic attack of undetermined cause; yet, only limited scientific evidence exists. Therefore, we aimed to determine in these patients the prevalence of TTE-detected major cardiac sources of embolism (CSE), which are abnormalities leading to therapeutic changes. METHODS: Six Dutch hospitals conducted a prospective observational study that enrolled patients with ischaemic stroke or transient ischaemic attack of undetermined cause. Patients underwent TTE after comprehensive diagnostic evaluation on stroke units, including blood chemistry, 12-lead electrocardiogram (ECG), ≥ 24 h continuous ECG monitoring, brain imaging and cervical artery imaging. Primary outcome measure was the proportion of patients with TTE-detected major CSE. RESULTS: From March 2018 to October 2020, 1084 patients, aged 66.6 ± 12.5 years, were enrolled; 456 (42.1%) patients were female and 869 (80.2%) had ischaemic stroke. TTE detected major CSE in only 11 (1.0%) patients. Ten (90.9%) of these patients also had major ECG abnormalities (previous infarction, major repolarisation abnormalities, or previously unknown left bundle branch block) that would have warranted TTE assessment regardless of stroke evaluation. Such ECG abnormalities were present in 11.1% of the total study population. A single patient (0.1%) showed a major CSE despite having no ECG abnormality. CONCLUSIONS: This multicentre cross-sectional study in patients who-after workup on contemporary stroke units-were diagnosed with ischaemic stroke or transient ischaemic attack of undetermined cause found TTE-detected major CSE in only 1% of all patients. Most of these patients also had major ECG abnormalities. These findings question the value of routine TTE assessment in this clinical setting.

The incremental value of coronary artery calcium score in predicting long-term prognosis and defining the warranty period of normal adenosine stress-only myocardial perfusion imaging using CZT SPECT.

BACKGROUND: Normal stress-only (SO) myocardial perfusion imaging (MPI) using SPECT reduces imaging time and radiation dose with a good prognosis. However, the long-term prognostic value of combining coronary artery calcium score (CACS) with SO MPI to determine the warranty period remains unknown. Hence, we assessed the incremental prognostic value of CACS and its impact on the warranty period of normal SO MPI using SPECT. METHODS: We retrospectively included 1375 symptomatic patients without a history of coronary artery disease (CAD) and a normal SO MPI using adenosine who underwent simultaneous CAC scoring. Annual major adverse cardiac events (MACE) rates were calculated for CACS categories: 0, 1-399, 400-999, and ≥1000. RESULTS: The mean age was 60.0 ± 11.8 years (66.9% female) with a median follow-up of 10.3 [IQR 9.6-10.9] years. The warranty period for annual MACE rate for normal SO SPECT extended the total follow-up time in years. MACE rate categorized by CAC categories demonstrated an increase in MACE rates with increasing CACS; CACS 0 and CACS 1-399 were associated with a 10-year warranty period, CACS 400-999 had a warranty period of 4 years and no warranty period could be given for CACS≥1000 (5.9 % at 1 year). CONCLUSIONS: CACS as an adjunct to normal pharmacological SO MPI provides additional prognostic information and aids in determining a warranty period.

Transient ST-elevation myocardial infarction versus persistent ST-elevation myocardial infarction. An appraisal of patient characteristics and functional outcome.

BACKGROUND: Up to 24% of patients presenting with ST-elevation myocardial infarction (STEMI) show resolution of ST-elevation and symptoms before revascularization. The mechanisms of spontaneous reperfusion are unclear. Given the more favorable outcome of transient STEMI, it is important to obtain further insights in differential aspects. METHODS: We compared 251 patients who presented with transient STEMI (n = 141) or persistent STEMI (n = 110). Clinical angiographic and laboratory data were collected at admission and in subset of patients additional index hemostatic data and at steady-state follow-up. Cardiac magnetic resonance imaging (CMR) was performed at 2-8 days to assess myocardial injury. RESULTS: Transient STEMI patients had more cardiovascular risk factors than STEMI patients, including more arterial disease and higher cholesterol values. Transient STEMI patients showed angiographically more often no intracoronary thrombus (41.1% vs. 2.7%, P < 0.001) and less often a high thrombus burden (9.2% vs. 40.0%, P < 0.001). CMR revealed microvascular obstruction less frequently (4.2% vs. 34.6%, P < 0.001) and smaller infarct size [1.4%; interquartile range (IQR), 0.0-3.7% vs. 8.8%; IQR, 3.9-17.1% of the left ventricle, P < 0.001] with a better preserved left ventricular ejection fraction (57.8 ± 6.7% vs. 52.5 ± 7.6%, P < 0.001). At steady state, fibrinolysis was higher in transient STEMI, as demonstrated with a reduced clot lysis time (89 ± 20% vs. 99 ± 25%, P = 0.03). CONCLUSIONS: Transient STEMI is a syndrome with less angiographic thrombus burden and spontaneous infarct artery reperfusion, resulting in less myocardial injury than STEMI. The presence of a more effective fibrinolysis in transient STEMI patients may explain these differences and might provide clues for future treatment of STEMI.

Does fractional flow reserve overestimate severity of LAD lesions?

BACKGROUND: Fractional Flow Reserve (FFR) is increasingly used to estimate the severity of coronary stenoses, prior to coronary revascularization. However, it has been suggested that FFR overestimates the severity of Left Anterior Descending (LAD) lesions. Our aim was to verify whether in patients without ischemia on Myocardial Perfusion Imaging, FFR of the LAD is more often abnormal in comparison to FFR of other coronary arteries. METHODS: Prospective cohort study of consecutive patients who underwent FFR measurement because of persistent or worsening of angina complaints, within 6 months after normal Myocardial Perfusion Imaging. FFR measurements of a graft or diagonal branch were excluded. A FFR ≤ 0.80 denoted a functionally relevant stenosis. RESULTS: In 133 patients, 167 FFR measurements were performed, of which 85 in the LAD. Mean age of the patients was 64.8 ± 10.5 years, 40% were women. There were no differences in baseline characteristics between patients undergoing LAD and non-LAD measurements. An abnormal FFR was observed in 35.3% of the LAD measurements, compared to 9.8% in the non-LAD measurements (P = 0.001). Also after adjusting for age and gender, the FFR remained more frequently abnormal in the LAD with OR 5.2 (95% CI 2.2 to 12.3). Of the abnormal FFR LAD measurements, 70% were visually considered non-obstructive on invasive angiography. CONCLUSIONS: In selected patients without ischemia on MPI, FFR measurement of the LAD is significantly more often abnormal. The majority of these patients has no obstructive lesions on invasive angiography. Possibly, FFR overestimates severity of LAD lesions, with risk of unnecessary revascularization.

Impact of elevated HbA1c on long-term mortality in patients presenting with acute myocardial infarction in daily clinical practice: insights from a 'real world' prospective registry of the Zwolle Myocardial Infarction Study Group.

BACKGROUND: Long-term clinical outcome is less well known in up to presentation persons unknown with diabetes mellitus who present with acute myocardial infarction and elevated glycosylated haemoglobin (HbA1c) levels on admission. We aimed to study the prognostic impact of deranged HbA1c at presentation on long-term mortality in patients not known with diabetes, presenting with acute myocardial infarction. METHODS: A single-centre, large, prospective observational study in patients with and without known diabetes admitted to our hospital for ST-segment elevation myocardial infarction (STEMI) and non-STEMI. Newly diagnosed diabetes mellitus was defined as HbA1c of 48 mmol/l or greater and pre-diabetes mellitus was defined as HbA1c between 39 and 47 mmol/l. The primary endpoint was all-cause mortality at short (30 days) and long-term (median 52 months) follow-up. RESULTS: Out of 7900 acute myocardial infarction patients studied, 1314 patients (17%) were known diabetes patients. Of the 6586 patients without known diabetes, 3977 (60%) had no diabetes, 2259 (34%) had pre-diabetes and 350 (5%) had newly diagnosed diabetes based on HbA1c on admission. Both short-term (3.9% vs. 7.4% vs. 6.0%, p<0.001) and long-term mortality (19% vs. 26% vs. 35%, p<0.001) for both pre-diabetes patients as well as newly diagnosed diabetes patients was poor and comparable to known diabetes patients. After multivariate analysis, newly diagnosed diabetes was independently associated with long-term mortality (hazard ratio 1.72, 95% confidence interval 1.27-2.34, P=0.001). CONCLUSIONS: In the largest study to date, newly diagnosed or pre-diabetes was present in 33% of acute myocardial infarction patients and was associated with poor long-term clinical outcome. Newly diagnosed diabetes (HbA1c ⩾48 mmol/mol) is an independent predictor of long-term mortality. More attention to early detection of diabetic status and initiation of blood glucose-lowering treatment is necessary.

Design of the ZWOT-CASE study: an observational study on the effectiveness of an integrated programme for cardiovascular risk management compared to usual care in general practice.

BACKGROUND: Cardiovascular diseases (CVD) contribute considerably to mortality and morbidity. Prevention of CVD by lifestyle change and medication is important and needs full attention. In the Netherlands an integrated programme for cardiovascular risk management (CVRM), based on the Chronic Care Model (CCM), has been introduced in primary care in many regions in recent years, but its effects are unknown. In the ZWOT-CASE study we will assess the effect of integrated care for CVRM in the region of Zwolle on two major cardiovascular risk factors: systolic blood pressure (SBP) and low-density lipoprotein cholesterol (LDL-cholesterol) in patients with or at high risk of CVD. METHODS: This study is a pragmatic observational study comparing integrated care for CVRM with usual care among patients aged 40-80 years with CVD (n = 370) or with a high CVD risk (n = 370) within 26 general practices. After 1 yr follow-up, primary outcomes (SBP and LDL-cholesterol level) are measured. Secondary outcomes include lifestyle habits (smoking, dietary habits, alcohol use, physical activity), risk factor awareness, 10-year risk of cardiovascular morbidity or mortality, health care consumption, patient satisfaction and quality of life. CONCLUSION: The ZWOT-CASE study will provide insight in the effects of integrated care for CVRM in general practice in patients with CVD or at high CVD risk. TRIAL REGISTRATION: The ZWOlle Transmural Integrated Care for CArdiovaScular Risk Management Study; ClinicalTrials.gov ; Identifier: NCT03428061; date of registration: 09-02-2018; This study has been retrospectively registered.

1-Year Outcomes of Delayed Versus Immediate Intervention in Patients With Transient ST-Segment Elevation Myocardial Infarction.

OBJECTIVES: The aim of the present study was to determine the effect of a delayed versus an immediate invasive approach on final infarct size and clinical outcome up to 1 year. BACKGROUND: Up to 24% of patients with acute coronary syndromes present with ST-segment elevation myocardial infarction (STEMI) but show complete resolution of ST-segment elevation and symptoms before revascularization. Current guidelines do not clearly state whether these patients with transient STEMI should be treated with a STEMI-like or non-ST-segment elevation acute coronary syndrome-like intervention strategy. METHODS: In this multicenter trial, 142 patients with transient STEMI were randomized 1:1 to either delayed or immediate coronary intervention. Cardiac magnetic resonance imaging was performed at 4 days and at 4-month follow-up to assess infarct size and myocardial function. Clinical follow-up was performed at 4 and 12 months. RESULTS: In the delayed (22.7 h) and the immediate (0.4 h) invasive groups, final infarct size as a percentage of the left ventricle was very small (0.4% [interquartile range: 0.0% to 2.5%] vs. 0.4% [interquartile range: 0.0% to 3.5%]; p = 0.79), and left ventricular function was good (mean ejection fraction 59.3 ± 6.5% vs. 59.9 ± 5.4%; p = 0.63). In addition, the overall occurrence of major adverse cardiac events, consisting of death, recurrent infarction, and target lesion revascularization, up to 1 year was low and not different between both groups (5.7% vs. 4.4%, respectively; p = 1.00). CONCLUSIONS: At follow-up, patients with transient STEMI have limited infarction and well-preserved myocardial function in general, and delayed or immediate revascularization has no effect on functional outcome and clinical events up to 1 year.

Influence of coronary calcification on hyperemic response during fractional flow reserve measurements.

AIM: During invasive fractional flow reserve (FFR) adenosine and nitrates are used to obtain maximal hyperemia. Severe coronary artery calcification (CAC) is associated with impaired vasodilation. We investigated the hyperemic response during FFR in vessels with severe versus mild CAC. METHODS AND RESULTS: We retrospectively selected 236 patients who underwent both CAC scoring and invasive FFR. FFR was performed in 304 vessels with intermediate stenoses. Delta (Δ) FFR, the pressure gradient before the administration of adenosine minus FFR after the administration of adenosine, was used to investigate the hyperemic response. Mean age of the total population was 65 ±â€¯10 years, 65% was male. Median CAC score was 510 (range 0 to 6141). Mean pressure gradient before the administration of adenosine was comparable in vessels with severe versus mild CAC. FFR was more often ≤0.80 in vessels with severe CAC (p = 0.045). Patients with a large Δ FFR were younger (p = 0.05). There was no association between Δ FFR and severity of calcifications. Regression analysis did not demonstrate an association between CAC score and the hyperemic response (p = 0.49). CONCLUSION: We did not find an association between the severity of CAC and the hyperemic response during invasive FFR.

Coronary calcium score influences referral for invasive coronary angiography after normal myocardial perfusion SPECT.

BACKGROUND: In patients with normal SPECT but persistent complaints, invasive angiography may exclude obstructive coronary disease. We assessed whether high coronary artery calcium (CAC) scores are associated with increased referral for invasive angiography following normal SPECT. METHODS AND RESULTS: 2286 consecutive patients (mean age 60 ± 12, 39% male) with normal SPECT were assessed. All patients underwent simultaneous CAC scoring. Patients were categorized into four groups based on their CAC score: CAC = 0 (n = 694), CAC 1 to 100 (n = 891), CAC 101 to 400 (n = 368), and CAC >400 (n = 333). The decision to perform angiography was left to the discretion of treating physician. Follow-up angiography was confined to the first 60 days after SPECT. Occurrence of MACE (late revascularization, myocardial infarction or death) was recorded. Overall, 100 patients (4.4%) underwent early angiography with increasing rates in higher CAC score groups (1.0%, 2.6%, 8.4%, and 11.7%), respectively, P < .001). A CAC score >400 (OR 3.56, 95% CI 2.19 to 5.77, P < .001) was independently associated with referral to angiography. Similarly, CAC score >400 was an independent predictor for MACE (HR 9.26, 95% CI 5.06 to 16.93). Early angiography did not influence prognosis (HR 1.57, 95% CI 0.91 to 2.73). CONCLUSIONS: CAC scoring impacts clinical decision-making and increases referral rates for invasive angiography after normal SPECT.

Timing of revascularization in patients with transient ST-segment elevation myocardial infarction: a randomized clinical trial.

Aims: Patients with acute coronary syndrome who present initially with ST-elevation on the electrocardiogram but, subsequently, show complete normalization of the ST-segment and relief of symptoms before reperfusion therapy are referred to as transient ST-segment elevation myocardial infarction (STEMI) and pose a therapeutic challenge. It is unclear what the optimal timing of revascularization is for these patients and whether they should be treated with a STEMI-like or a non-ST-segment elevation myocardial infarction (NSTEMI)-like invasive approach. The aim of the study is to determine the effect of an immediate vs. a delayed invasive strategy on infarct size measured by cardiac magnetic resonance imaging (CMR). Methods and results: In a randomized clinical trial, 142 patients with transient STEMI with symptoms of any duration were randomized to an immediate (STEMI-like) [0.3 h; interquartile range (IQR) 0.2-0.7 h] or a delayed (NSTEMI-like) invasive strategy (22.7 h; IQR 18.2-27.3 h). Infarct size as percentage of the left ventricular myocardial mass measured by CMR at day four was generally small and not different between the immediate and the delayed invasive group (1.3%; IQR 0.0-3.5% vs. 1.5% IQR 0.0-4.1%, P = 0.48). By intention to treat, there was no difference in major adverse cardiac events (MACE), defined as death, reinfarction, or target vessel revascularization at 30 days (2.9% vs. 2.8%, P = 1.00). However, four additional patients (5.6%) in the delayed invasive strategy required urgent intervention due to signs and symptoms of reinfarction while awaiting angiography. Conclusion: Overall, infarct size in transient STEMI is small and is not influenced by an immediate or delayed invasive strategy. In addition, short-term MACE was low and not different between the treatment groups.

Anatomically and functionally relevant coronary stenoses in patients with normal single-photon emission computed tomography but persistent stable angina.

Aims: Single-photon emission computed tomography (SPECT) is widely used for the assessment of coronary artery disease and for decision making regarding revascularization. Concerns about possible false negative findings exist. Our aim was to assess the prevalence of stenoses which are both functionally and anatomically significant in patients referred for invasive fractional flow reserve (FFR) measurements following a normal SPECT, because of persistent complaints. Methods and results: One hundred and thirty-three consecutive patients with normal SPECT were included, with a total of 180 FFR measurements. Luminal narrowing of ≥70% (≥50% for left main) together with a FFR ≤0.80 denoted an anatomically and functionally significant coronary artery stenosis. Separate analyses were performed for FFR <0.75. Mean age of the patients was 65, 40% were women. Sixteen percent of the study population had both anatomically and functionally significant stenoses. Besides the use of nitrate, no differences in baseline characteristics, symptoms, coronary history, or pre-test likelihood could be identified for the prediction of functionally relevant obstructive coronary disease. If FFR <0.75 was used, only 7.5% of the patients had both anatomically and functionally significant stenoses. Conclusion: In patients with normal SPECT who undergo FFR measurements because of persistent complaints, the prevalence of stenoses which are both anatomically and functionally significant is low. This suggests that the prevalence of false-negative SPECT is (very) low.

Minimal starting time of data reconstruction for qualitative myocardial perfusion rubidium-82 positron emission tomography imaging.

OBJECTIVE: Qualitative positron emission tomography (PET) myocardial perfusion imaging (MPI) scans are reconstructed with a delay after an injection of rubidium-82 (Rb) to ensure blood pool clearance and sufficient left ventricle to myocardium contrast. Our aim was to derive the minimal starting time of data reconstruction (STDR) after an injection of Rb for which the diagnostic value and image quality remained unaffected. MATERIALS AND METHODS: We retrospectively included 23 patients who underwent rest-stress Rb PET MPI using 740 MBq. Patients fulfilling one of the two criteria indicating a slow blood pool clearance (ejection fraction <50% and/or cardiac output <3 l/min) were included in a consecutive manner. PET images using five different STDRs (1:15-2:15 min) were reconstructed and compared with reference images (STDR of 2:30 min). Differences in the summed rest score greater than or equal to 3 and total perfusion deficit greater than 3% were considered to significantly influence the diagnostic value. In addition, image quality was scored by two experts as not interpretable, inferior, adequate, or excellent. RESULTS: The summed rest score differed greater than or equal to 3 from the reference in seven or more patients (≥30%) using STDR less than or equal to 2:00 min (P<0.02). STDR less than or equal to 1:30 min resulted in six or more patients (≥26%) with a total perfusion deficit difference greater than 3% (P<0.03).In addition, STDR less than or equal to 2:00 min resulted in a lower image quality (P<0.002) and STDR less than or equal to 2:15 min resulted in greater than or equal to two scans with noninterpretable image quality. CONCLUSION: STDR less than or equal to 2:15 min resulted in lower diagnostic value or insufficient image quality for qualitative PET MPI using 740 MBq Rb. An STDR of 2:30 min can be considered for clinical adoption.

Minimizing rubidium-82 tracer activity for relative PET myocardial perfusion imaging.

OBJECTIVES: Recommended rubidium-82 activities for relative myocardial perfusion imaging (MPI) using present-generation PET scanners may be unnecessarily high. Our aim was to derive the minimum activity for a reliable relative PET MPI assessment. MATERIALS AND METHODS: We analyzed 140 scans from 28 consecutive patients who underwent rest-stress MPI-PET (Ingenuity TF). Scans of 852, 682, 511, and 341 MBq were simulated from list-mode data and compared with a reference scan using 1023 MBq. Differences in the summed rest score, total perfusion deficit, and image quality were obtained between the reference and each of the simulated rest scans. Combined stress-rest scans obtained at a selected activity of 682 MBq were diagnostically interpreted by experts and outcome was compared with the reference scan interpretation. RESULTS: Differences in summed rest score more than or equal to 3 were found using 682, 511, and 341 MBq in two (7%), four (14%), and five (18%) patients, respectively. Differences in total perfusion deficit more than 7% were only found at 341 MBq in one patient. Image quality deteriorated significantly only for the 341 MBq scans (P<0.001). Interpretation of stress-rest scans did not differ between 682 and 1023 MBq scans. CONCLUSION: A significant reduction in administered Rb-82 activity is feasible in relative MPI. An activity of 682 MBq resulted in reliable diagnostic outcomes and image quality, and can therefore be considered for clinical adoption.

Changes in cardiovascular medication after coronary artery calcium scanning and normal single photon emission computed tomography myocardial perfusion imaging in symptomatic patients.

The impact of coronary artery calcium (CAC) scoring on subsequent changes in cardiovascular medication use in symptomatic patients with normal myocardial perfusion imaging (MPI) findings is not well established. The aim of the current study was to evaluate changes in aspirin and statin use in patients suspected for coronary artery disease after CAC scoring and normal single photon emission computed tomography (SPECT) MPI. METHODS: In the current study, 1,033 stable symptomatic patients without a known history of coronary artery disease with normal SPECT MPI who underwent concomitant CAC scoring were included. All patients had a clinical indication for imaging, mainly atypical chest pain and dyspnea, and were referred from the outpatient clinic of our hospital. Data regarding posttest medication change (either starting or discontinuation of aspirin and statin therapy at the subsequent outpatient visit) were retrospectively collected. Patients were categorized into 4 groups based on their CAC score. RESULTS: Mean age of the patients was 61±11 years and 39% were male. At baseline, 35% of the patients used aspirin and 39% used statin. In patients with CAC scores 0, 1-99, 100-399, and ≥400, aspirin was started in 1%, 4%, 9%, and 9%, respectively, and statin was started in 0%, 7%, 18%, and 24% of the patients, respectively (P<.001). Aspirin was discontinued in 19%, 11%, 7%, and 1% and statin was discontinued in 8%, 6%, 2%, and 0% (P<.001) of the patients in these respective CAC score categories. After correction for differences in risk factors and baseline medication use, increased CAC was independently associated with posttest aspirin (odds ratio 4.6, 11.2, and 27.1 for CAC scores 1-99, 100-399, and ≥400, respectively; P<.001) and statin use (odds ratio 4.4, 19.4, and 60.9 for CAC scores 1-99, 100-399, and ≥400, respectively; P<.001). CONCLUSIONS: Higher CAC scores are associated with the initiation of aspirin and statin therapy in patients with normal SPECT MPI. In patients with lower CAC scores, discontinuation of cardioprotective medication is more likely. CAC score is independently associated with posttest statin and aspirin use.

Prognostic Value of Myocardial Perfusion Imaging with a Cadmium-Zinc-Telluride SPECT Camera in Patients Suspected of Having Coronary Artery Disease.

The prognostic value of myocardial perfusion imaging (MPI) with the cadmium-zinc-telluride (CZT) SPECT camera is not well established. Therefore, the aim of the current study was to evaluate the prognostic value of MPI performed with a CZT SPECT camera in a large cohort of patients suspected of having coronary artery disease. Methods: Consecutive symptomatic stable patients (n = 4,057) without a history of coronary artery disease underwent CZT SPECT MPI. During a median follow-up of 2.4 y (25th-75th percentile, 1.7-3.4), patients were monitored for primary (nonfatal myocardial infarction and cardiac mortality) and secondary outcomes (late revascularization [>90 d after scanning] and primary outcome). Results: Patients with normal perfusion demonstrated low annual event rates (primary outcome, 0.2%; secondary outcome, 0.6%). Annual event rates increased with the extent of abnormality of myocardial perfusion. In patients with small ischemic perfusion defects, annual event rates were 0.7% and 2.8% for the primary and secondary outcome, respectively. In patients with moderate or large ischemic perfusion defects, these event rates were 1.2% and 4.3%, respectively. After multivariate analysis, the risk for events was significantly associated with the extent of ischemia (hazard ratio for small ischemic defects: 2.2, 95% confidence interval [CI], 0.9-5.9 and 4.6, 95% CI, 2.8-7.6, for primary and secondary outcomes, respectively; hazard ratio for moderate or large ischemic defects: 4.0, 95% CI, 1.5-10.5 and 12.1, 95% CI, 7.2-20.2, for primary and secondary outcomes, respectively). Conclusion: Our findings show that MPI acquired with a CZT SPECT camera provides excellent prognostic information, with low event rates in patients with normal myocardial perfusion. In patients with abnormal SPECT MPI, the extent of abnormality is independently associated with an increased risk of events.

Two-year outcome after early or late Intervention in non-ST elevation acute coronary syndrome.

OBJECTIVE: To compare long-term outcome of an early to a delayed invasive strategy in high-risk patients with non-ST elevation acute coronary syndrome (NSTE-ACS). METHODS: This prospective, multicentre trial included patients with NSTE-ACS and at least two out of three of the following high-risk criteria: (1) evidence of extensive myocardial ischaemia on ECG, (2) elevated biomarkers for myocardial necrosis and (3) age above 65 years. Patients were randomised to either an early (angiography and revascularisation if appropriate <12 hours) or a delayed invasive strategy (>48 hours after randomisation). Endpoint for this prespecified long-term follow-up was the composite incidence of death or reinfarction after 2 years. Data collection was performed by telephone contact with the patients, their relatives or general practitioner and by review of hospital records. RESULTS: Endpoint status after 2-year follow-up was collected in 521 of 542 initially enrolled patients. Incidence of death or reinfarction was 11.8% in the early and 13.1% in the delayed treatment group (relative risk (RR)=0.90, 95% CI 0.57 to 1.42). No significant differences were found in occurrence of the individual components of the primary endpoint: death 6.1% vs 8.9%, RR 0.69 (95% CI 0.37 to 1.27), reinfarction 6.5% vs 5.4%, RR 1.20 (95% CI 0.60 to 2.38). Post-hoc subgroup analysis showed statistical significant interaction between age and treatment strategy on outcome (p=0.02). CONCLUSIONS: After 2 years follow-up, no difference in incidence of death or reinfarction was seen between early to late invasive strategy. These findings are in line with results of other studies with longer follow-up. Older patients seem to benefit more from early invasive treatment.

Sequential SPECT/CT imaging for detection of coronary artery disease in a large cohort: evaluation of the need for additional imaging and radiation exposure.

BACKGROUND: Performing both single photon emission computerized tomography (SPECT) and coronary computed tomography angiography (CCTA) in patients suspected for coronary artery disease (CAD) leads to increased radiation exposure. We evaluated the need for additional imaging and following implications for radiation exposure of a sequential SPECT/computed tomography (CT) algorithm. METHODS AND RESULTS: 5018 consecutive patients without history of CAD were referred for stress-first SPECT and coronary artery calcium (CAC) scoring. If stress SPECT was abnormal, additional rest SPECT and, if feasible, CCTA were acquired. Stress SPECT was normal in 2617 patients (52%). CCTA was not performed in 1289 of the 2401 patients referred for additional imaging (54%), mainly because of severe CAC (47%) or fast/irregular heart rate (22%). 642 patients with abnormal SPECT underwent CCTA, which excluded significant CAD in 378 patients (59%). Mean radiation dose was 4.5 ± 0.3 mSv for stress-only imaging and 13.2 ± 3.3 mSv for additional imaging (P < 0.001). CONCLUSIONS: Half of the patients do not require additional imaging in our sequential SPECT/CT algorithm, which is accompanied with low radiation exposure. CCTA cannot be performed in half of the patients who undergo additional imaging because of (relative) contra-indications. CCTA is able to correct for false-positive SPECT findings in our algorithm.

Sequential SPECT/CT imaging starting with stress SPECT in patients with left bundle branch block suspected for coronary artery disease.

OBJECTIVES: To investigate the impact of left bundle branch block (LBBB) on sequential single photon emission computed tomography (SPECT)/ CT imaging starting with stress-first SPECT. METHODS: Consecutive symptomatic low- to intermediate-risk patients without a history of coronary artery disease (CAD) referred for SPECT/CT were included from an observational registry. If stress SPECT was abnormal, additional rest SPECT and, if feasible, coronary CT angiography (CCTA) were acquired. RESULTS: Of the 5,018 patients, 218 (4.3 %) demonstrated LBBB. Patients with LBBB were slightly older than patients without LBBB (65±12 vs. 61±11 years, p<0.001). Stress SPECT was more frequently abnormal in patients with LBBB (82 % vs. 46 %, p<0.001). After reviewing stress and rest images, SPECT was normal in 43 % of the patients with LBBB, compared to 77 % of the patients without LBBB (p<0.001). Sixty-four of the 124 patients with LBBB and abnormal stress-rest SPECT underwent CCTA (52 %), which could exclude obstructive CAD in 46 of the patients (72 %). CONCLUSIONS: Sequential SPECT/CT imaging starting with stress SPECT is not the optimal imaging protocol in patients with LBBB, as the majority of these patients have potentially false-positive stress SPECT. First-line testing using CCTA may be more appropriate in low- to intermediate-risk patients with LBBB. KEY POINTS: • Stress-first SPECT imaging is attractive if many patients demonstrate normal stress perfusion. • The majority of left bundle branch block patients have abnormal stress-first SPECT. • Coronary CT excluded obstructive CAD in many LBBB patients with abnormal SPECT. • Stress-first SPECT imaging is not the optimal imaging protocol in LBBB patients. • In LBBB patients imaging with initial coronary CT may be more appropriate.