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.

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.

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.

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.

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.

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.

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.

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.

Prognostic value of normal stress-only myocardial perfusion imaging: a comparison between conventional and CZT-based SPECT.

PURPOSE: Single photon emission computed tomography (SPECT) myocardial perfusion imaging has proven to have prognostic importance in patients with suspected stable coronary artery disease (CAD). The recently introduced ultrafast cadmium zinc telluride (CZT)-based gamma cameras have been associated with less equivocal findings and more normal interpretations, allowing stress-only imaging to be performed more often. However, it is yet unclear whether normal stress-only CZT SPECT has comparable prognostic value as normally interpreted stress-only conventional SPECT. METHODS: The study population consisted of 1,650 consecutive patients without known CAD with normal stress-only myocardial perfusion results with either conventional (n = 362) or CZT SPECT (n = 1,288). The incidence of major adverse cardiac events (MACE, all-cause death, non-fatal myocardial infarction and/or coronary revascularization) was compared between the conventional SPECT and CZT SPECT groups. Multivariable analyses using the Cox model were used to adjust for differences in baseline variables. RESULTS: Patients scanned with CZT were less often male (33 vs 39 %), had less often hypercholesterolaemia (41 vs 50 %) and had more often a family history of CAD (57 vs 49 %). At a median follow-up time of 37 months (interquartile range 28-45 months) MACE occurred in 68 patients. The incidence of MACE was 1.5 %/year in the CZT group, compared to 2.0 %/year in the conventional group (p = 0.08). After multivariate analyses, there was a trend to a lower incidence of MACE in the CZT SPECT group (hazard ratio 0.61, 95 % confidence interval 0.35-1.04, p = 0.07). CONCLUSION: The prognostic value of normal stress-only CZT SPECT is at least comparable and may be even better than that of normal conventional stress SPECT.

Early or late intervention in patients with transient ST-segment elevation acute coronary syndrome: Subgroup analysis of the ELISA-3 trial.

OBJECTIVES: To investigate incidence and patient characteristics of transient ST-segment elevation (TSTE) ACS and to compare outcome of early versus late invasive treatment. BACKGROUND: Optimal timing of treatment in TSTE-ACS patients is not outlined in current guidelines and no prospective randomized trials have been done so far. METHODS: Post hoc subgroup analysis of patients with TSTE randomized in the ELISA 3 trial. This study compared early (<12 h) versus late (>48 h) angiography and revascularization in 542 patients with high-risk NSTE-ACS. Primary endpoint was incidence of death, reinfarction, or recurrent ischemia at 30 days follow-up. RESULTS: TSTE was present in 129 patients (24.2%) and associated with male gender, smoking and younger age. The primary endpoint occurred in 8.9% of patients with and 13.0% of patients without TSTE (RR = 0.681, P = 0.214). Incidence of death or MI after 2 year follow-up was 5.7 and 14.6% respectively (RR = 0.384, P = 0.008). Within the group of patients with TSTE, incidence of the primary endpoint was 5.8% in the early and 12.7% in the late treatment group (RR = 0.455, P = 0.213), driven by reduction in recurrent ischemia. Enzymatic infarct size, bleeding and incidence of death or recurrent MI at 2 years follow-up was comparable between the treatment groups. CONCLUSIONS: In high-risk patients with NSTE-ACS, TSTE is frequently seen. Similar to findings in patients with high-risk NSTE-ACS, immediate angiography and revascularization in these patients is feasible but not superior to later treatment. Prospective randomized trials are needed to provide more evidence in the optimal timing of treatment in patients with TSTE-ACS. © 2016 Wiley Periodicals, Inc.

Myocardial perfusion imaging in stable symptomatic patients with extensive coronary atherosclerosis.

PURPOSE: High coronary artery calcium (CAC) scores are associated with a high likelihood of ischaemia and obstructive coronary disease. Myocardial perfusion imaging (MPI) is a key investigation to determine the need for revascularization. However, the value of MPI in presence of extensive CAC has so far only been demonstrated in asymptomatic patients, whereas its value in symptomatic patients remains largely unclear. Therefore, we studied the impact of MPI in symptomatic patients with a CAC score ≥ 1,000. METHODS: We included 282 patients (mean age 69 ± 9 years, 63% men) without a history of coronary disease with suspected stable angina referred for MPI and with a CAC score ≥ 1,000. On follow-up at 18 months invasive angiography, coronary revascularization, nonfatal myocardial infarction and death were recorded. RESULTS: MPI was normal in 54 %, equivocal in 10 % and abnormal in 37 % (fixed defect 9 % and ischaemia 28 %) of patients. More abnormal MPI findings were observed in men, smokers and those with even higher CAC scores. During follow-up, 1 patient (with nonischaemic MPI) died from a cardiac cause, 1 patient (with ischaemic MPI) suffered a myocardial infarction and 92 patients (33 %) underwent revascularization. Ischaemia on MPI was a strong predictor of coronary revascularization (odds ratio 13.1; 95 % CI 7.1-24.3; p < 0.001). CONCLUSION: Ischaemia on MPI is observed in approximately 30 % of patients with a CAC score ≥ 1,000, and is a strong predictor of coronary revascularization. However, nonischaemic MPI does not exclude revascularization, and patients with persisting complaints should be considered for invasive angiography.

Myocardial perfusion imaging with a cadmium zinc telluride-based gamma camera versus invasive fractional flow reserve.

PURPOSE: Recently introduced ultrafast cardiac SPECT cameras with cadmium zinc telluride-based (CZT) detectors may provide superior image quality allowing faster acquisition with reduced radiation doses. Although the level of concordance between conventional SPECT and invasive fractional flow reserve (FFR) measurement has been studied, that between FFR and CZT-based SPECT is not yet known. Therefore, we aimed to assess the level of concordance between CZT SPECT and FFR in a large patient group with stable coronary artery disease. METHODS: Both invasive FFR and myocardial perfusion imaging with a CZT-based SPECT camera, using Tc-tetrofosmin as tracer, were performed in 100 patients with stable angina and intermediate grade stenosis on invasive coronary angiography. A cut-off value of <0.75 was used to define abnormal FFR. RESULTS: The mean age of the patients was 64 ± 11 years, and 64 % were men. SPECT demonstrated ischaemia in 31 % of the patients, and 20 % had FFR <0.75. The concordance between CZT SPECT and FFR was 73 % on a per-patient basis and 79 % on a per-vessel basis. Discordant findings were more often seen in older patients and were mainly (19 %) the result of ischaemic SPECT findings in patients with FFR ≥ 0.75, whereas only 8 % had an abnormal FFR without ischaemia as demonstrated by CZT SPECT. CONCLUSION: Only 20 - 30 % of patients with intermediate coronary stenoses had significant ischaemia as assessed by CZT SPECT or invasive FFR. CZT SPECT showed a modest degree of concordance with FFR, which is comparable with previous results with conventional SPECT. Further investigations are particularly necessary in patients with normal SPECT and abnormal FFR, especially to determine whether these patients should undergo revascularization.

Prevalence, location, and extent of significant coronary artery disease in patients with normal myocardial perfusion imaging.

BACKGROUND: False-negative myocardial perfusion imaging (MPI) can by due to left main (LM) or three-vessel disease causing "balanced ischemia". However, so far prevalence of LM or three-vessel-disease in patients with normal MPI is unclear. We assessed prevalence, location, and extent of significant coronary artery disease (CAD) in patients with normal MPI. METHODS: Between 2006 and 2010, 256 patients with normal MPI who had invasive angiography because of persisting or worsening of the same initial symptoms were studied. Significant CAD was defined as stenosis > 70% or LM > 50%. RESULTS: A total of 93 patients (36%) had significant CAD. Significant CAD was observed more frequently in males, higher age and those with typical angina complaints. Significant LM disease was present in 7%, three-vessel disease in 10%, two-vessel disease in 22%, and single vessel disease (not left main) in 61%. In those with single vessel disease, the location was the LAD in 40%, the RCA in 30%, and the LCX in 30%. CONCLUSIONS: In selected patients with normal MPI, one-third had significant CAD. The majority of these patients had single vessel disease (not left main). LM or three vessel disease, causing "balanced ischemia", is a less common cause of false-negative MPI.

The influence of coronary calcium score on the interpretation of myocardial perfusion imaging.

PURPOSE: Coronary artery calcium (CAC) scores influence the pre-test likelihood of ischemia in patients undergoing myocardial perfusion imaging (MPI). We investigated the influence of CAC score knowledge on the visual interpretation of MPI in patients referred for the diagnostic work-up of suspected coronary artery disease. METHODS: We retrospectively analyzed symptomatic patients who were referred for MPI. For the current analysis, we selected 151 patients who underwent SPECT MPI with simultaneous CAC scoring. MPI was visually interpreted in two separate sessions, first without and then with knowledge of the CAC score. MPI results were classified into four groups: normal, fixed defects, ischemia, and equivocal. RESULTS: Mean age of the patients was 64 ± 11 years, 56% were male. Without knowledge of the CAC score MPI was evaluated as normal in 36%, compared to 40% with knowledge of the CAC score (P = 0.636). Overall, the addition of the CAC score changed the interpretation of MPI in 56 patients (37%). Importantly, the frequency of equivocal MPI interpretations decreased from 21% without knowledge of CAC score to 9% with knowledge of CAC score (P = 0.002). CONCLUSIONS: Knowledge of the CAC score has a major impact on the interpretation of MPI, increasing the interpretative certainty.

Coronary artery calcium scoring to exclude flow-limiting coronary artery disease in symptomatic stable patients at low or intermediate risk.

PURPOSE: To assess the capability of a zero coronary artery calcium (CAC) score to help exclude flow-limiting coronary artery disease (CAD) in a homogeneous population with stable anginal complaints and a low-to-intermediate pretest likelihood. MATERIALS AND METHODS: The study protocol had institutional ethics committee approval, with written informed consent from all patients. Between 2009 and 2011, a total of 3501 consecutive stable patients without known CAD underwent prospectively simultaneous myocardial perfusion imaging and CAC scoring on a hybrid, 64-section single photon emission computed tomography (SPECT)/computed tomography (CT) scanner. In 868 (25%) of 3501 patients, the CAC score was zero, and these patients constituted the current study population. When feasible, additional coronary CT angiography was performed in those with abnormal SPECT findings. Clinical follow-up was recorded with regard to invasive coronary angiography, coronary revascularization, nonfatal myocardial infarction, or death. Results were analyzed by using descriptive statistics. RESULTS: In 868 patients (mean age, 54 years ± 11 [standard deviation]; 610 [70%] female, 258 [30%] male), SPECT findings were normal in 766 (88%) and abnormal in 102 (12%), with equivocal results in 41 (5%), persistent defect in 35 (4%), and ischemia in 26 (3%). In the group with abnormal SPECT findings, additional coronary CT angiography was performed in 93 patients (91%), showing nonobstructive CAD in eight patients (9%) and normal coronary arteries in 85 patients (91%). In the other nine patients (9%), invasive angiography was used to exclude obstructive CAD. At a median follow-up of 17 months (25th percentile, 11; 75th percentile, 24 months), no coronary events were recorded. CONCLUSION: A CAC score of zero in stable patients at low or intermediate risk excludes flow-limiting CAD. These findings support the possibility of CAC scoring as a simple and safe tool to select patients for additional testing or discharge, as recommended in the literature.

Prognostic value of admission glycosylated hemoglobin and glucose in nondiabetic patients with ST-segment-elevation myocardial infarction treated with percutaneous coronary intervention.

BACKGROUND: In nondiabetic patients with ST-segment-elevation myocardial infarction, acute hyperglycemia is associated with adverse outcome. Whether this association is due merely to hyperglycemia as an acute stress response or whether longer-term glycometabolic derangements are also involved is uncertain. It was our aim to determine the association between both acute and chronic hyperglycemia (hemoglobin A(1c) [HbA(1c)]) and outcome in nondiabetic patients with ST-segment-elevation myocardial infarction. METHODS AND RESULTS: This observational study included consecutive patients (n=4176) without known diabetes mellitus admitted with ST-segment-elevation myocardial infarction. All patients were treated with primary percutaneous intervention. Both glucose and HbA(1c) were measured on admission. Main outcome measure was total long-term mortality; secondary outcome measures were 1-year mortality and enzymatic infarct size. One-year mortality was 4.7%, and mortality after total follow-up (3.3 ± 1.5 years) was 10%. Both elevated HbA(1c) levels (P<0.001) and elevated admission glucose (P<0.001) were associated with 1-year and long-term mortality. After exclusion of early mortality (within 30 days), HbA(1c) remained associated with long-term mortality (P<0.001), whereas glucose lost significance (P=0.09). Elevated glucose, but not elevated HbA(1c), was associated with larger infarct size. After multivariate analysis, HbA(1c) (hazard ratio, 1.2 per interquartile range; P<0.01), but not glucose, was independently associated with long-term mortality. CONCLUSIONS: In nondiabetic patients with ST-segment-elevation myocardial infarction, both elevated admission glucose and HbA(1c) levels were associated with adverse outcome. Both of these parameters reflect different patient populations, and their association with outcome is probably due to different mechanisms. Measurement of both parameters enables identification of these high-risk groups for aggressive secondary risk prevention.

Impact of a new ultrafast CZT SPECT camera for myocardial perfusion imaging: fewer equivocal results and lower radiation dose.

PURPOSE: The new ultrafast cardiac single photon emission computed tomography (SPECT) cameras with cadmium-zinc-telluride (CZT)-based detectors are faster and produce higher quality images as compared to conventional SPECT cameras. We assessed the need for additional imaging, total imaging time, tracer dose and 1-year outcome between patients scanned with the CZT camera and a conventional SPECT camera. METHODS: A total of 456 consecutive stable patients without known coronary artery disease underwent myocardial perfusion imaging on a hybrid SPECT/CT (64-slice) scanner using either conventional (n = 225) or CZT SPECT (n = 231). All patients started with low-dose stress imaging, combined with coronary calcium scoring. Rest imaging was only done when initial stress SPECT testing was equivocal or abnormal. Coronary CT angiography was subsequently performed in cases of ischaemic or equivocal SPECT findings. Furthermore, 1-year clinical follow-up was obtained with regard to coronary revascularization, nonfatal myocardial infarction or death. RESULTS: Baseline characteristics were comparable between the two groups. With the CZT camera, the need for rest imaging (35 vs 56%, p < 0.001) and additional coronary CT angiography (20 vs 28%, p = 0.025) was significantly lower as compared with the conventional camera. This resulted in a lower mean total administered isotope dose per patient (658 ± 390 vs 840 ± 421 MBq, p < 0.001) and shorter imaging time (6.39 ± 1.91 vs 20.40 ± 7.46 min, p < 0.001) with the CZT camera. After 1 year, clinical outcome was comparable between the two groups. CONCLUSION: As compared to images on a conventional SPECT camera, stress myocardial perfusion images acquired on a CZT camera are more frequently interpreted as normal with identical clinical outcome after 1-year follow-up. This lowers the need for additional testing, results in lower mean radiation dose and shortens imaging time.