RESUMEN
This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I2) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multi-societal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multi-focal or diffuse heterogenous intense 18F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more.
RESUMEN
This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I2) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multi-societal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multi-focal or diffuse heterogenous intense 18F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more.
Asunto(s)
Infecciones Cardiovasculares , Endocarditis , Humanos , Tomografía Computarizada por Tomografía de Emisión de Positrones , Fluorodesoxiglucosa F18 , Consenso , Tomografía Computarizada por Rayos X , Imagen Multimodal , Endocarditis/diagnóstico por imagen , Tomografía Computarizada de Emisión de Fotón ÚnicoRESUMEN
BACKGROUND: Appropriate use criteria (AUC) enhance application of cardiovascular imaging techniques but have been applied in limited settings, primarily in common cardiovascular disease processes. There are several complex systemic diseases with cardiovascular implications and special populations with unique cardiovascular considerations that could benefit from appropriateness analysis. Moreover, the high medical complexity of these topics indicate they would benefit from high-yield expert consensus recommendations of the available imaging options. The ASNC Imaging Indications (ASNC-I2) Series will provide a concise overview of relevant disease processes and their multimodality evaluation and will provide consensus clinical indications, diagnostic criteria, and clinical algorithms with representative clinical cases. METHODS: For each ASNC-I2 document, a diverse writing group and rating panel will be composed of experts from societies pertinent to the topic, including relevant imaging societies and clinical societies that manage the disease under evaluation. The rating panel will follow robust modified Delphi methodology and commonly-accepted appropriateness methods to create consensus diagnostic criteria, clinical algorithms, and clinical indications that they will then rate with level of agreement recorded. The clinical and imaging experts will provide concise, high-yield clinical summaries of the disease process, the non-imaging evaluation, and multimodality imaging. Relevant cases will be provided highlighting application of the diagnostic criteria and clinical algorithms. CONCLUSION: The ASNC Imaging Indications (ASNC-I2) Series will complement the diverse portfolio of documents from ASNC. It will use a multisocietal approach with robust appropriateness methodology to guide use of radionuclide imaging in the multimodality imaging context for the cardiovascular care of patients.
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Imagen Multimodal , Humanos , CintigrafíaRESUMEN
BACKGROUND: Positron emission tomography (PET) myocardial perfusion imaging (MPI) with the novel radiopharmaceutical Fluorine-18 Flurpiridaz has been shown in Phase 1, 2, and first Phase 3 clinical studies to be safe and effective in diagnosing coronary artery disease (CAD). We describe the methodology of the second FDA-mandated phase 3 prospective, open-label, international, multi-center trial of F-18 Flurpiridaz PET MPI. METHODS: The primary study end point is to assess the diagnostic efficacy of F-18 Flurpiridaz PET MPI in the detection of significant CAD [≥ 50% by quantitative invasive coronary angiography (ICA)] in patients with suspected CAD. The secondary endpoints are to evaluate the diagnostic efficacy of F-18 Flurpiridaz PET MPI compared to Tc-99 m-labeled SPECT MPI in the detection of CAD in all patients and in the following subgroups: (1) females; (2) patients with body mass index ≥ 30 kg/m2; and (3) diabetic patients. This trial's design differs from the first phase 3 trial in that (1) comparison to SPECT is now a secondary end point; (2) patients with known CAD are excluded; and (3) both SPECT and PET MPI are performed before ICA. CONCLUSIONS: This second phase 3 study will provide additional evidence on the diagnostic efficacy of F-18 Flurpiridaz PET MPI in the detection of significant CAD. TRIAL REGISTRATION NUMBER: NCT03354273.
Asunto(s)
Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Imagen de Perfusión Miocárdica , Tomografía de Emisión de Positrones , Piridazinas , Ensayos Clínicos Fase III como Asunto , Humanos , Estudios Multicéntricos como Asunto , Proyectos de InvestigaciónRESUMEN
BACKGROUND: Patients who achieve ≥ 10 METS during exercise SPECT myocardial perfusion imaging (MPI) have very low rates of significant ischemia and major adverse cardiac events (MACE). It is unknown how many older adults can achieve ≥ 10 METS, and if low risk extends to this subgroup. METHODS AND RESULTS: We examined the workload achieved, prevalence and predictors of ischemia, and MACE (cardiac death, non-fatal MI, late revascularization) in a cohort of 382 patients ≥ 65 years of age who underwent exercise 99mTc SPECT MPI. The cohort was 64.4% male and 36.9% had known coronary artery disease (CAD). All achieved ≥ 85% of maximum age-predicted heart rate. A workload of ≥ 10 METS was achieved in 25.4%; 50.3% attained 7-9 METS, and 24.4% reached < 7 METS. There was a stepwise decrease in prevalence of any ischemia and significant ischemia (≥ 10% of the left ventricle (LV)) as workload increased (P = 0.037). Patients achieving ≥ 10 METS had a 3.1% prevalence of ≥ 10% LV ischemia (1.2% in those without ST depression). Cardiac death and MACE rates in the ≥ 10 METS subgroup were 0.6%/year and 2.6%/year over a median 7.0 years of follow-up. CONCLUSIONS: A substantial proportion of older adults who undergo exercise SPECT MPI can achieve ≥ 10 METS. This subgroup has low rates of significant LV ischemia and MACE. The favorable diagnostic and prognostic implications of achieving a high workload in an older adult population suggest it is feasible, with certain exceptions, to include this subgroup in workload-based strategies of provisional imaging.
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Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/fisiopatología , Tolerancia al Ejercicio/fisiología , Isquemia Miocárdica/epidemiología , Anciano , Estudios de Cohortes , Enfermedad de la Arteria Coronaria/complicaciones , Prueba de Esfuerzo , Femenino , Humanos , Masculino , Imagen de Perfusión Miocárdica , Valor Predictivo de las Pruebas , Prevalencia , Tomografía Computarizada de Emisión de Fotón Único , Carga de TrabajoRESUMEN
Cardio-oncology is a growing field focused on the prevention and treatment of cardiovascular disease in oncologic patients. While a major focus of chemotherapy-related cardiac dysfunction has been on left ventricular ejection fraction, oncologic treatment can lead to cardiovascular pathology in a variety of ways. The use of multimodality imaging is essential to the care of these patients, with nuclear cardiology playing an important role. We will review nuclear cardiology's history, its current role, and its promising future in cardio-oncology and the management of these patients.
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Cardiología/tendencias , Oncología Médica/tendencias , Medicina Nuclear/tendencias , Función Ventricular Izquierda , Antineoplásicos/uso terapéutico , Cardiología/métodos , Cardiotoxicidad/prevención & control , Enfermedades Cardiovasculares/terapia , Corazón , Cardiopatías , Humanos , Isquemia , Microcirculación , Imagen de Perfusión Miocárdica , Miocardio , Neoplasias/tratamiento farmacológico , Volumen Sistólico , Tomografía Computarizada de Emisión de Fotón Único/métodosRESUMEN
BACKGROUND: Exercise stress electrocardiography (ECG) alone is underutilized in part due to poor diagnostic accuracy. High-frequency QRS analysis (HF-QRS) is a novel tool to supplement ST evaluation during stress ECG. We compared the diagnostic accuracy and net reclassification of HF-QRS analysis compared with ST evaluation for substantial myocardial ischemia by exercise SPECT myocardial perfusion imaging (MPI). METHODS AND RESULTS: Exercise SPECT MPI was performed in 257 consecutive eligible patients (mean age 59 ± 12, 67% male). An ischemic HF-QRS pattern was defined as a ≥ 1 µV absolute reduction and a ≥ 50% relative reduction of the root-mean-square of the 150-250 Hz band signal in ≥ 3 leads. Left ventricular ischemia of ≥ 10% on SPECT MPI was the diagnostic standard for substantial myocardial ischemia. HF-QRS analysis demonstrated incremental diagnostic value to ST evaluation plus clinical risk factors (AUC 0.804 vs 0.749, P < .0001). A HF-QRS + ST -analysis strategy identified 92.3% of subjects with substantial ischemia and no abnormality in 59.9% of the cohort. No cardiac events occurred in patients without substantial ischemia identified by HF-QRS analysis. CONCLUSIONS: In this prospective analysis, exercise stress ECG with HF-QRS analysis identified any and substantial ischemia with high diagnostic accuracy and may allow more than half of referred patients to safely avoid imaging.
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Diagnóstico por Computador/métodos , Electrocardiografía/métodos , Prueba de Esfuerzo/métodos , Isquemia Miocárdica/diagnóstico por imagen , Isquemia Miocárdica/patología , Imagen de Perfusión Miocárdica/métodos , Anciano , Área Bajo la Curva , Enfermedad de la Arteria Coronaria , Ejercicio Físico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Análisis de Regresión , Reproducibilidad de los Resultados , Factores de Riesgo , Tomografía Computarizada de Emisión de Fotón ÚnicoRESUMEN
Cardiac amyloidosis is emerging as an underdiagnosed cause of heart failure and mortality. Growing literature suggests that a noninvasive diagnosis of cardiac amyloidosis is now feasible. However, the diagnostic criteria and utilization of imaging in cardiac amyloidosis are not standardized. In this paper, Part 2 of a series, a panel of international experts from multiple societies define the diagnostic criteria for cardiac amyloidosis and appropriate utilization of echocardiography, cardiovascular magnetic resonance imaging, and radionuclide imaging in the evaluation of patients with known or suspected cardiac amyloidosis.
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Amiloidosis/diagnóstico por imagen , Cardiología/organización & administración , Cardiología/normas , Corazón/diagnóstico por imagen , Biopsia , Técnicas de Imagen Cardíaca/normas , Consenso , Técnica Delphi , Ecocardiografía , Insuficiencia Cardíaca , Ventrículos Cardíacos , Humanos , Imagen Multimodal , Prealbúmina/genética , Sociedades Médicas , Estados UnidosRESUMEN
Cardiac amyloidosis is emerging as an underdiagnosed cause of heart failure and mortality. Growing literature suggests that a noninvasive diagnosis of cardiac amyloidosis is now feasible. However, the diagnostic criteria and utilization of imaging in cardiac amyloidosis are not standardized. In this paper, Part 2 of a series, a panel of international experts from multiple societies define the diagnostic criteria for cardiac amyloidosis and appropriate utilization of echocardiography, cardiovascular magnetic resonance imaging, and radionuclide imaging in the evaluation of patients with known or suspected cardiac amyloidosis.
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American Heart Association , Amiloidosis/diagnóstico por imagen , Cardiología/normas , Cardiomiopatías/diagnóstico por imagen , Imagen Multimodal/normas , Sociedades Médicas/normas , Amiloidosis/epidemiología , Amiloidosis/terapia , Cardiología/métodos , Cardiomiopatías/epidemiología , Cardiomiopatías/terapia , Consenso , Ecocardiografía/métodos , Ecocardiografía/normas , Insuficiencia Cardíaca/diagnóstico por imagen , Insuficiencia Cardíaca/epidemiología , Insuficiencia Cardíaca/terapia , Humanos , Imagen por Resonancia Cinemagnética/métodos , Imagen por Resonancia Cinemagnética/normas , Imagen Molecular/métodos , Imagen Molecular/normas , Imagen Multimodal/métodos , Medicina Nuclear/métodos , Medicina Nuclear/normas , Tomografía Computarizada por Rayos X/métodos , Tomografía Computarizada por Rayos X/normas , Estados Unidos/epidemiologíaRESUMEN
PURPOSE OF REVIEW: This review is aimed at summarizing recent advances in functional, anatomical, and hybrid imaging techniques used in the assessment of ischemic complaints in patients with known coronary artery disease (CAD). RECENT FINDINGS: Cardiovascular imaging has seen significant growth over the last decade in the fields of coronary computed tomography angiography (CCTA), FFR derived from CCTA, cardiac magnetic resonance, radionuclide myocardial perfusion imaging, and hybrid imaging for the purposes of evaluating symptoms concerning for ischemia. This growth stems from refinement of imaging techniques and hardware and software advances that have made current techniques more accurate with less acquisition time. However, every anatomic and functional imaging modality has important technical and patient-specific limitations. This review assesses these issues, guides a patient-centered imaging approach, and identifies important research questions to resolve. Recent advances in non-invasive cardiovascular imaging can provide important information in patients with known CAD beyond traditional imaging techniques; the use of these novel tools refines the clinical management of complex patients with ischemic symptoms and known CAD.