Comparison of high efficiency CZT SPECT MPI to coronary angiography.

BACKGROUND: The recently introduced cadmium zinc telluride (CZT) SPECT cameras have the potential to reduce radiation exposure to patients and shorten imaging time. So far, there has been only one small study comparing the results of high efficiency CZT SPECT myocardial perfusion imaging (MPI) to invasive coronary angiography. METHODS: All patients who had either a Tc-99m sestamibi or Tl-201 SPECT MPI study using a CZT camera (GE Discovery NM 530c) over a 1-year period followed by a coronary angiogram within 2 months were included. Only patients with a history of CABG surgery were excluded. Standard stress protocols were employed. Rest images were acquired for 5 min and stress supine and prone images for 3 min each. Both MPI studies and coronary angiograms were interpreted by blinded readers. A standard 17-segment model was employed for MPI interpretation, and coronary angiograms were interpreted for the presence of obstructive epicardial coronary artery disease (CAD) defined as ≥70% luminal narrowing. Correlation was based on the ability to diagnose obstructive epicardial CAD. RESULTS: Of the 3,111 patients who underwent SPECT imaging using the CZT camera during this time period, 230 patients qualified for the correlation study (mean age 64.2 ± 11.0 years old, 69% male, and 49% had a history of intracoronary stenting). Tc-99m was used in 76% vs Tl-201 in 24% of the studies. Exercise stress was performed in 60% of patients and vasodilator pharmacologic stress in 40%. Sensitivity was 95%, normalcy rate was 97%, and accuracy was 69% for detecting obstructive CAD. CONCLUSIONS: In this so far largest correlation study between coronary angiography and high efficiency CZT SPECT imaging, a high sensitivity and accuracy for detecting obstructive epicardial CAD was found for this new SPECT camera technology.

Early use of remote dielectric sensing after hospitalization to reduce heart failure readmissions.

AIMS: Readmission after hospitalization for acute decompensated heart failure (HF) remains a major public health problem. Use of remote dielectric sensing (ReDS) to measure lung water volume allows for an objective assessment of volume status and may guide medical optimization for HF. We hypothesized that the use of ReDS would lower 30 day readmission in patients referred to rapid follow-up (RFU) clinic after HF discharge. METHODS AND RESULTS: We conducted a retrospective analysis of the use of ReDS for patients scheduled for RFU within 10 days post-discharge for HF at Mount Sinai Hospital between 1 July 2017 and 31 July 2018. Diuretics were adjusted using a pre-specified algorithm. The association between use of ReDS and 30 day readmission was evaluated. A total of 220 patients were included. Mean age was 62.9 ± 14.7 years, and 36.4% were female. ReDS was performed in 80 (36.4%) and led to medication adjustment in 52 (65%). Use of ReDS was associated with a lower rate of 30 day cardiovascular readmission [2.6% vs. 11.8%, hazard ratio (HR): 0.21; 95% confidence interval (CI): 0.05-0.89; P = 0.04] and a trend towards lower all-cause readmission (6.5% vs. 14.1%, HR: 0.43; 95% CI: 0.16-1.15; P = 0.09) as compared with patients without a ReDS assessment. CONCLUSIONS: ReDS-guided HF therapy during RFU after HF hospitalization may be associated with lower risk of 30 day readmission.

Heart Retransplantation: Candidacy, Outcomes, and Management.

PURPOSE OF REVIEW: To describe the incidence and epidemiology of heart retransplantation in adults and children and to review the risk factors associated with adverse outcome following retransplantation to help guide recipient selection. RECENT FINDINGS: Heart retransplantation is associated with inferior short-term and long-term survival when compared with primary heart transplantation and its use remains controversial although less so in the pediatric heart transplant population. SUMMARY: In the most recent era of heart transplantation, patients retransplanted for CAV, greater than 1 year from their primary transplant, and who are not in critical condition have improved survival compared with other retransplant recipients. Survival with retransplantation can approach that of primary transplantation when patients are appropriately selected. More research is needed regarding the optimal timing for retransplantation and the optimal management for patients after retransplantation.

Contemporary Treatment of Heart Failure.

Heart failure (HF) affects 2.4% of the adult population in the United States and is associated with high health care costs. Medical and device therapy delay disease progression and improve survival in HF with reduced ejection fraction. Stage D HF is characterized by significant functional limitation, frequent HF hospitalization for decompensation, intolerance of medical therapy, use of inotropes, and high diuretic requirement. Advanced therapies with left ventricular assist devices and cardiac transplantation reduce mortality and improve quality of life, and early referral to specialized centers is imperative for patient selection and success with these therapies.

Management of refractory cardiogenic shock.

Cardiogenic shock is a life-threatening condition that occurs in response to reduced cardiac output in the presence of adequate intravascular volume and results in tissue hypoxia. Cardiogenic shock has several underlying aetiologies, with the most common being acute myocardial infarction (AMI). Refractory cardiogenic shock presents as persistent tissue hypoperfusion despite administration of adequate doses of two vasoactive medications and treatment of the underlying aetiology. Investigators of the SHOCK trial reported a long-term mortality benefit of emergency revascularization for shock complicating AMI. Since the publication of the SHOCK trial and subsequent guideline recommendations, the increase in community-based use of percutaneous coronary intervention for this condition has resulted in a significant decline in mortality. Despite these successes in the past 15 years, mortality still remains exceptionally high, particularly in patients with refractory cardiogenic shock. In this Review, we discuss the aetiology and pathophysiology of cardiogenic shock and summarize the data on the available therapeutics and their limitations. Although new mechanical circulatory support devices have been shown to improve haemodynamic variables in patients with shock complicating AMI, they did not improve clinical outcomes and are associated with high costs and complications.

Point-of-Care Ultrasound and the Rapid Response System.

Over the years, the use of ultrasound has moved solely from the domain of the radiologist to that of the intensivist and emergentologist for use in acute care settings. By virtue of its ease of use and rapid learning curve to proficiency, we are now seeing an increased desire by internists to learn the modality and apply it at the patient's bedside. The rapid response system represents a rational starting point for the introduction of point-of-care ultrasound to the inpatient ward setting.