Nuclear cardiology practice and associated radiation doses in Europe: results of the IAEA Nuclear Cardiology Protocols Study (INCAPS) for the 27 European countries.

PURPOSE: Nuclear cardiology is widely used to diagnose coronary artery disease and to guide patient management, but data on current practices, radiation dose-related best practices, and radiation doses are scarce. To address these issues, the IAEA conducted a worldwide study of nuclear cardiology practice. We present the European subanalysis. METHODS: In March 2013, the IAEA invited laboratories across the world to document all SPECT and PET studies performed in one week. The data included age, gender, weight, radiopharmaceuticals, injected activities, camera type, positioning, hardware and software. Radiation effective dose was calculated for each patient. A quality score was defined for each laboratory as the number followed of eight predefined best practices with a bearing on radiation exposure (range of quality score 0 - 8). The participating European countries were assigned to regions (North, East, South, and West). Comparisons were performed between the four European regions and between Europe and the rest-of-the-world (RoW). RESULTS: Data on 2,381 European patients undergoing nuclear cardiology procedures in 102 laboratories in 27 countries were collected. A cardiac SPECT study was performed in 97.9 % of the patients, and a PET study in 2.1 %. The average effective dose of SPECT was 8.0 ± 3.4 mSv (RoW 11.4 ± 4.3 mSv; P < 0.001) and of PET was 2.6 ± 1.5 mSv (RoW 3.8 ± 2.5 mSv; P < 0.001). The mean effective doses of SPECT and PET differed between European regions (P < 0.001 and P = 0.002, respectively). The mean quality score was 6.2 ± 1.2, which was higher than the RoW score (5.0 ± 1.1; P < 0.001). Adherence to best practices did not differ significantly among the European regions (range 6 to 6.4; P = 0.73). Of the best practices, stress-only imaging and weight-adjusted dosing were the least commonly used. CONCLUSION: In Europe, the mean effective dose from nuclear cardiology is lower and the average quality score is higher than in the RoW. There is regional variation in effective dose in relation to the best practice quality score. A possible reason for the differences between Europe and the RoW could be the safety culture fostered by actions under the Euratom directives and the implementation of diagnostic reference levels. Stress-only imaging and weight-adjusted activity might be targets for optimization of European nuclear cardiology practice.

Streptococcal tonsillitis and acute streptococcal myocarditis: an unusual combination assessed by cardiac magnetic resonance imaging and endomyocardial biopsy.

OBJECTIVES: Acute streptococcal tonsillitis is occasionally combined with myocarditis. Our aim was to examine patients with tonsillitis in whom myocarditis was suspected by using cardiac magnetic resonance imaging (MRI) and endomyocardial biopsy. METHODS: After prospective evaluation of 200 patients with tonsillitis, 17 men (median age, 23 years; age range, 18 to 29 years) were recruited for cardiac MRI because of a suspicion of myocarditis. Chest pain 3 to 5 days after tonsillitis was the main complaint in 15 patients, and atypical chest discomfort in 2 patients. We performed cardiac MRI including short TI inversion recovery T2-weighted scanning and T1-weighted scanning with early gadolinium enhancement (EGE) and late gadolinium enhancement (LGE). The left ventricular ejection fraction and the presence of myocarditis were evaluated by the standard protocol. A T2 ratio of greater than 2 and an EGE value of greater than 4 were considered abnormal. Heart biopsy was suggested for patients with a reduced left ventricular ejection fraction. RESULTS: Cardiac enzyme levels were increased in 8 of the 17 patients. Increased T2 ratio values (median, 2.8; range, 2.5 to 4.0) were documented in 16 patients. The EGE values were increased (median, 12; range, 8 to 19) in 16 patients. Positive LGE was identified in 13 patients. Endomyocardial biopsy in 4 patients revealed acute myocarditis, and polymerase chain reaction analysis identified streptococcal genomes. Re-evaluation by cardiac MRI 3 months later showed normal results in 14 patients. CONCLUSIONS: Acute streptococcal tonsillitis can be occasionally complicated by myocarditis with either a typical or an atypical presentation. Cardiac MRI can facilitate the diagnosis in both forms and allow a noninvasive follow-up.

Cardiovascular disease in women: Executive summary of the expert panel statement of women in cardiology of the hellenic cardiological society.

The perception that women represent a low-risk population for cardiovascular (CV) disease (CVD) needs to be reconsidered. Starting from risk factors, women are more likely to be susceptible to unhealthy behaviors and risk factors that have different impact on CV morbidity and mortality as compared to men. Despite the large body of evidence as regards the effect of lifestyle factors on the CVD onset, the gender-specific effect of traditional and non-traditional risk factors on the prognosis of patients with already established CVD has not been well investigated and understood. Furthermore, CVD in women is often misdiagnosed, underestimated, and undertreated. Women also experience hormonal changes from adolescence till elder life that affect CV physiology. Unfortunately, in most of the clinical trials women are underrepresented, leading to the limited knowledge of CV and systemic impact effects of several treatment modalities on women's health. Thus, in this consensus, a group of female cardiologists from the Hellenic Society of Cardiology presents the special features of CVD in women: the different needs in primary and secondary prevention, as well as therapeutic strategies that may be implemented in daily clinical practice to eliminate underestimation and undertreatment of CVD in the female population.

Outcome of patients with acute myocardial infarction admitted in hospitals with or without catheterization laboratory: results from the HELIOS registry.

AIMS: To compare the treatment and outcomes of myocardial infarction patients in hospitals with and without catheterization laboratory. METHODS AND RESULTS: The Hellenic Infarction Observation Study was a countrywide registry of acute myocardial infarction, conducted during 2005-2006. The registry enrolled 1840 patients with myocardial infarction from 31 hospitals with a proportional representation of all types of hospitals and of all geographical areas. Out of these patients, 645 (35%) were admitted in 11 hospitals with and 1195 (65%) in 20 hospitals without catheterization laboratory. Patients admitted in hospitals with catheterization laboratory in comparison with patients admitted in hospitals without were younger (66+/-14 vs. 68+/-13, P<0.004) with less diabetes (27 vs. 33%, P<0.001), but without other baseline differences (female 27 vs. 25%, prior myocardial infarction 20 vs. 17%, Killip class>1 22 vs. 23%). Reperfusion rates for ST-segment elevation myocardial infarction were 67% (43% lytic, 24% primary percutaneous coronary interventions) versus 56% (55% lytic, 1% percutaneous coronary interventions; P<0.01). In-hospital outcomes in hospitals with versus in hospitals without laboratory were: mortality 6.5 versus 8.3% (NS), stroke 2.2 versus 1.1% (NS), major bleeding 1.1 versus 0.6% (NS), and heart failure 11 versus 16% (P<0.01). In multivariate regression analysis, being admitted in a hospital without catheterization laboratory was not an independent predictor of increased in-hospital mortality (odds ratio=1.18, 95% confidence interval: 0.72-1.93, P=0.505). CONCLUSION: Although the majority of acute myocardial infarction patients was admitted in hospitals without catheterization laboratory, these patients do not have a survival disadvantage, provided they are treated with lytic therapy, medical secondary prevention drugs, and eventual revascularization according to current guidelines.

Cardiovascular magnetic resonance imaging pattern at the time of diagnosis of treatment naïve patients with connective tissue diseases.

BACKGROUND-AIM: Cardiac involvement at diagnosis of connective tissue disease (CTD) has been described by echocardiography. We hypothesized that cardio-vascular magnetic resonance (CMR) detects occult lesions at CTD diagnosis. PATIENTS-METHODS: CMR was performed early after diagnosis in 78 treatment-naïve CTDs (aged 43±11, 59F/19M) without cardiac involvement [5 Takayasu arteritis (TA), 4 Churg Strauss syndrome (CSS), 5 Wegener granulomatosis (WG), 16 systemic lupus erythematosus (SLE), 12 rheumatoid arthritis (RA), 8 mixed connective tissue diseases (MCTD), 12 ankylosing spondylitis (AS), 3 polymyalgia rheumatica (PMR), 8 systemic sclerosis (SSc) and 5 dermatomyositis (DM)]. Acute and chronic lesions were assessed by T2>2 with positive LGE and T2<2 with positive LGE, respectively. RESULTS: In 3/5 TA, 3/4 CSS, 4/5 WG, 10/16 SLE, 9/12 RA, 6/8 MCTD, 4/12 AS, 1/3 PMR, 2/8 SSc and 2/5 DM, the T2 ratio was higher compared to normal (2.78±0.25 vs 1.5±0.2, p<0.01). Myocarditis was identified in 1 TA, 1 SLE, 1 RA, 1 SSc and 2 DM patients; diffuse, subendocardial fibrosis in 1 CSS and 1 RA patient, while subendocardial myocardial infarction in 3 SLE, 1 MCTD, 1 PMR and 2 RA patients. CMR re-evaluation after 6 and 12months of rheumatic and cardiac treatment, available in 28/52 CTDs with increased T2 ratio, showed significant improvement in T2 ratio (p<0.001), non-significant change in LGE extent and normalisation of those with impaired LV function. CONCLUSIONS: Occult CMR lesions, including oedema, myocarditis, diffuse subendocardial fibrosis and myocardial infarction are not unusual in treatment naïve CTDs and may be reversed with appropriate treatment.

Highlights of the 12th International Conference on Nuclear Cardiology and Cardiac CT.

The 12th International Conference on Nuclear Cardiology and Cardiac CT was held from 3 to 5 May 2015 in Madrid, Spain. In this article, the three Congress Program Committee Chairs summarize selected highlights of the presented abstracts.

Cardiac computed tomography core syllabus of the European Association of Cardiovascular Imaging (EACVI).

The European Association of Cardiovascular Imaging (EACVI) Core Syllabus for Cardiac Computed Tomography (CT) is now available online. The syllabus lists key elements of knowledge in Cardiac CT. It represents a framework for the development of training curricula and provides expected knowledge-based learning outcomes to the Cardiac CT trainees.

Nuclear cardiology core syllabus of the European Association of Cardiovascular Imaging (EACVI).

The European Association of Cardiovascular Imaging (EACVI) Core Syllabus for Nuclear Cardiology is now available online. The syllabus lists key elements of knowledge in nuclear cardiology. It represents a framework for the development of training curricula and provides expected knowledge-based learning outcomes to the nuclear cardiology trainees.

Appropriateness criteria for cardiovascular imaging use in heart failure: report of literature review.

The Imaging Task Force appointed by the European Society of Cardiology (ESC) and the European Association of Cardiovascular Imaging (EACVI) identified the need to develop appropriateness criteria for the use of cardiovascular imaging in heart failure as a result of continuously increasing demand for imaging in diagnosis, definition of aetiology, follow-up, and treatment planning. This article presents the report of literature review performed in order to inform the process of definition of clinical indications and to aid the decisions of the appropriateness criteria voting panel. The report is structured according to identified common heart failure clinical scenarios.

Cardiovascular imaging practice in Europe: a report from the European Association of Cardiovascular Imaging.

The need for cardiovascular imaging (CVI) is expected to increase over the coming years due to the changes in CV disease epidemiology and ageing of the population. However, reliable statistics on CVI practice in Europe are lacking. Establishing the current status of the use of CVI across Europe has become the first comprehensive project of the European Association of Cardiovascular Imaging and the European Society of Cardiology Taskforce on CVI. In 2013, a survey with relevant information regarding CVI was sent to all National Imaging/Echocardiography Societies and Working Groups. Representatives from 41 countries returned the questionnaire. The present report provides key results of the survey, relating to existing education, training, certification and national accreditation programmes, healthcare organizations, and reimbursement systems.

Reporting nuclear cardiology: a joint position paper by the European Association of Nuclear Medicine (EANM) and the European Association of Cardiovascular Imaging (EACVI).

The report of an imaging procedure is a critical component of an examination, being the final and often the only communication from the interpreting physician to the referring or treating physician. Very limited evidence and few recommendations or guidelines on reporting imaging studies are available; therefore, an European position statement on how to report nuclear cardiology might be useful. The current paper combines the limited existing evidence with expert consensus, previously published recommendations as well as current clinical practices. For all the applications discussed in this paper (myocardial perfusion, viability, innervation, and function as acquired by single photon emission computed tomography and positron emission tomography or hybrid imaging), headings cover laboratory and patient demographics, clinical indication, tracer administration and image acquisition, findings, and conclusion of the report. The statement also discusses recommended terminology in nuclear cardiology, image display, and preliminary reports. It is hoped that this statement may lead to more attention to create well-written and standardized nuclear cardiology reports and eventually lead to improved clinical outcome.

The multi-modality cardiac imaging approach to the Athlete's heart: an expert consensus of the European Association of Cardiovascular Imaging.

The term 'athlete's heart' refers to a clinical picture characterized by a slow heart rate and enlargement of the heart. A multi-modality imaging approach to the athlete's heart aims to differentiate physiological changes due to intensive training in the athlete's heart from serious cardiac diseases with similar morphological features. Imaging assessment of the athlete's heart should begin with a thorough echocardiographic examination.Left ventricular (LV) wall thickness by echocardiography can contribute to the distinction between athlete's LV hypertrophy and hypertrophic cardiomyopathy (HCM). LV end-diastolic diameter becomes larger (>55 mm) than the normal limits only in end-stage HCM patients when the LV ejection fraction is <50%. Patients with HCM also show early impairment of LV diastolic function, whereas athletes have normal diastolic function.When echocardiography cannot provide a clear differential diagnosis, cardiac magnetic resonance (CMR) imaging should be performed.With CMR, accurate morphological and functional assessment can be made. Tissue characterization by late gadolinium enhancement may show a distinctive, non-ischaemic pattern in HCM and a variety of other myocardial conditions such as idiopathic dilated cardiomyopathy or myocarditis. The work-up of athletes with suspected coronary artery disease should start with an exercise ECG. In athletes with inconclusive exercise ECG results, exercise stress echocardiography should be considered. Nuclear cardiology techniques, coronary cardiac tomography (CCT) and/or CMR may be performed in selected cases. Owing to radiation exposure and the young age of most athletes, the use of CCT and nuclear cardiology techniques should be restricted to athletes with unclear stress echocardiography or CMR.

Role of multimodality cardiac imaging in the management of patients with hypertrophic cardiomyopathy: an expert consensus of the European Association of Cardiovascular Imaging Endorsed by the Saudi Heart Association.

Taking into account the complexity and limitations of clinical assessment in hypertrophic cardiomyopathy (HCM), imaging techniques play an essential role in the evaluation of patients with this disease. Thus, in HCM patients, imaging provides solutions for most clinical needs, from diagnosis to prognosis and risk stratification, from anatomical and functional assessment to ischaemia detection, from metabolic evaluation to monitoring of treatment modalities, from staging and clinical profiles to follow-up, and from family screening and preclinical diagnosis to differential diagnosis. Accordingly, a multimodality imaging (MMI) approach (including echocardiography, cardiac magnetic resonance, cardiac computed tomography, and cardiac nuclear imaging) is encouraged in the assessment of these patients. The choice of which technique to use should be based on a broad perspective and expert knowledge of what each technique has to offer, including its specific advantages and disadvantages. Experts in different imaging techniques should collaborate and the different methods should be seen as complementary, not as competitors. Each test must be selected in an integrated and rational way in order to provide clear answers to specific clinical questions and problems, trying to avoid redundant and duplicated information, taking into account its availability, benefits, risks, and cost.

EuroEcho-Imaging 2013: highlights.

The annual meeting of the European Association of Echocardiography (EuroEcho-Imaging) was held in Istanbul, Turkey. In the present paper, we present a summary of the 'Highlights' session.

Appropriateness criteria for cardiovascular imaging use in clinical practice: a position statement of the ESC/EACVI taskforce.

There is a growing interest from the scientific community in the appropriate use of cardiovascular imaging techniques for diagnosis and decision making in Europe. To develop appropriateness criteria for cardiovascular imaging use in clinical practice in Europe, a dedicated taskforce has been appointed by the European Society of Cardiology (ESC) and the European Association of Cardiovascular Imaging (EACVI). The present paper describes the appropriateness criteria development process.