Application of appropriateness criteria to stress single photon emission computed tomography sestamibi studies: a comparison of the 2009 revised appropriateness criteria to the 2005 original criteria.

BACKGROUND: The 2005 appropriate use criteria (AUC) for stress single-photon emission computed tomographic myocardial perfusion imaging (SPECT MPI) were revised in 2009 to reflect changes in published evidence, clinical practice and experience with application of the 2005 AUC. The purpose of this study was to compare the 2009 AUC for SPECT MPI with the original 2005 criteria. METHODS: Using the Mayo Rochester Nuclear Cardiology Laboratory database, we retrospectively examined 281 patients who underwent stress SPECT MPI at Mayo Clinic Rochester between May 1, 2005, and May 15, 2005, using the revised 2009 AUC and compared these findings to our previously published results in this same cohort using the 2005 AUC. RESULTS: Compared to the 2005 AUC, the 2009 AUC resulted in a highly significant overall change (P < .001) in the classification of appropriateness. The 2009 AUC eliminated unclassified patients, reduced appropriate studies (59.8% vs 63.7%, P = .02), increased studies of uncertain appropriateness (16.0% vs 10.7%, P = .01), and increased inappropriate studies (24.2% vs 14.6%, P < .001). CONCLUSIONS: In this cohort of patients undergoing SPECT MPI, compared to our previous study using the original 2005 AUC, the 2009 AUC had a significant impact on the classification of appropriateness. The 2009 AUC eliminated unclassified patients, increased inappropriate studies and increased studies of uncertain appropriateness.

A case of simultaneous pulmonary embolism and acute myocardial infarction secondary to a previously undiagnosed patent foramen ovale.

We describe a 79-year-old male with recurrent high-grade liposarcoma who developed postoperative chest pain, dyspnea, and hypoxia suspicious for acute pulmonary embolism (PE). However, electrocardiogram (ECG) was suggestive of an acute ST-elevation myocardial infarction (MI). Heparin was initiated and emergent coronary angiography was performed, which demonstrated a "cutoff sign" in the distal left anterior descending artery (LAD) consistent with coronary embolism. A patent foramen ovale (PFO) and bilateral pulmonary emboli were subsequently identified. It was concluded that the patient had suffered an acute PE, with a portion of clot traversing the PFO and entering the LAD, resulting in a simultaneous acute ST-elevation MI. While the case described is rare, the underlying anatomical variant is common and may have practical significance. We discuss the literature regarding PFO with acute PE and paradoxical emboli.