[Cardiac imaging in (asymptomatic) diabetic patients]. / Kardiale Bildgebung beim (asymptomatischen) Diabetiker.

Coronary artery disease (CAD) plays an important role in diabetic patients because they have a very high cardiovascular mortality risk. Therefore the question arises if all diabetic patients should be screened for CAD. In patients with (a)typical angina or anginal equivalents (e.g. shortness of breath) an extended CAD evaluation is indicated. Unselected screening in diabetic patients, however, does not seem to make sense as the only large prospective randomized study in this field did not demonstrate a survival benefit in the screened patient population. It is noteworthy that preoperative risk stratification deserves special consideration in diabetic patients. If screening is considered there is the anatomic approach (calcium score, non-invasive coronary angiography) or the functional approach (stress testing, ischemia evaluation). In diabetic patients who in general should already have all the medication with respect to coronary prevention, functional rather than anatomic testing makes sense because revascularization can be considered in patients with extensive ischemia. In contrast, anatomic testing if positive would only be confirming that a medical preventive strategy is necessary. On the other hand a normal anatomic test has a very high negative predictive value. Therefore, CAD evaluation should follow an individual patient tailored approach as long as evidence-based guidelines are lacking.

[Culture-negative, purulent pericarditis]. / 44-jähriger Patient mit kulturnegativer, purulenter Perikarditis.

We report about a patient with purulent pericarditis due to Neisseria meningitidis pretreated with antibiotics. Clinical signs were suggestive of pericardial tamponade. Cultures from blood and pericardial aspirate remained negative. Broad-range polymerase chain reaction from pericardial fluid detected Neisseria sp.. Latex agglutination assay from pleural fluid showed positive reaction with meningococcal antigen serogroup C. Meningococcal pericarditis without meningitis is a rare manifestation. Non-culture based diagnostic methods in patients with such severe infections and negative cultures play an important role.

Optimization of imaging before pulmonary vein isolation by radiofrequency ablation: breath-held ungated versus ECG/breath-gated MRA.

Isolation of the pulmonary veins has emerged as a new therapy for atrial fibrillation. Pre-procedural magnetic resonance (MR) imaging enhances safety and efficacy; moreover, it reduces radiation exposure of the patients and interventional team. The purpose of this study was to optimize the MR protocol with respect to image quality and acquisition time. In 31 patients (23-73 years), the anatomy of the pulmonary veins, left atrium and oesophagus was assessed on a 1.5-Tesla scanner with four different sequences: (1) ungated two-dimensional true fast imaging with steady precession (2D-TrueFISP), (2) ECG/breath-gated 3D-TrueFISP, (3) ungated breath-held contrast-enhanced three-dimensional turbo fast low-angle shot (CE-3D-tFLASH), and (4) ECG/breath-gated CE-3D-TrueFISP. Image quality was scored from 1 (structure not visible) to 5 (excellent visibility), and the acquisition time was monitored. The pulmonary veins and left atrium were best visualized with CE-3D-tFLASH (scores 4.50 +/- 0.52 and 4.59 +/- 0.43) and ECG/breath-gated CE-3D-TrueFISP (4.47 +/- 0.49 and 4.63 +/- 0.39). Conspicuity of the oesophagus was optimal with CE-3D-TrueFISP and 2D-TrueFISP (4.59 +/- 0.35 and 4.19 +/- 0.46) but poor with CE-3D-tFLASH (1.03 +/- 0.13) (p < 0.05). Acquisition times were shorter for 2D-TrueFISP (44 +/- 1 s) and CE-3D-tFLASH (345 +/- 113 s) compared with ECG/breath-gated 3D-TrueFISP (634 +/- 197 s) and ECG/breath-gated CE-3D-TrueFISP (636 +/- 230 s) (p < 0.05). In conclusion, an MR imaging protocol comprising CE-3D-tFLASH and 2D-TrueFISP allows assessment of the pulmonary veins, left atrium and oesophagus in less than 7 min and can be recommended for pre-procedural imaging before electric isolation of pulmonary veins.

Impact of contemporary emergency percutaneous coronary angioplasty for acute myocardial infarction on length of hospital stay.

QUESTIONS UNDER STUDY: Compared to thrombolysis, acute percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI) allows both immediate revascularisation and identification of additional relevant stenosis, so that subsequently no further risk stratification should be necessary and hospital stay shortened. Our aim was to evaluate the impact of PCI on outcome and length of hospital stay after MI compared to that in the thrombolysis era. METHODS: Retrospective evaluation in a Swiss tertiary referral centre of 105 patients with AMI undergoing emergency PCI, who initially were neither in cardiogenic shock nor transferred to another primary or secondary care hospital for further treatment. Main outcome measurement was length of overall hospital stay. Additional measurements included mortality, left ventricular function, and time point of the last major adverse cardiac event (MACE). RESULTS: Overall hospitalisation time was 11.1 +/- 6.8 days, thus being only 1.5 days shorter than in the thrombolysis era. Age above 70 or type of infarction did not influence hospitalisation time, but age below 60 years did. In-hospital mortality was 1%. Left-ventricular function was considerably impaired (<35%) in 6 patients. After the sixth hospital day, 97% of MACE had occurred. According to a validated risk score, 92% of patients belonged to a low risk group with a 30-day mortality risk of 1.4% or less and could have been discharged not later than day 6. CONCLUSIONS: Our data suggest that an early discharge strategy, although safe in low risk patients is not followed at the present time. This approach could further reduce costs without jeopardizing outcome.

Incremental prognostic value of post-stress left ventricular ejection fraction and volume by gated myocardial perfusion single photon emission computed tomography.

BACKGROUND: The incremental prognostic value of post-stress left ventricular ejection fraction (EF) and volume over perfusion has not been investigated. METHODS AND RESULTS: We identified 1680 consecutive patients who underwent rest Tl-201/stress Tc-99m sestamibi gated single photon emission computed tomography (SPECT) and who were followed-up for 569+/-106 days. Receiver-operator characteristics analysis defined an EF<45%, an end-systolic volume (ESV) >70 mL, and an end-diastolic volume >120 mL as optimal thresholds, yielding moderate sensitivity and high specificity in the prediction of cardiac death. Patients with an EF> or = 45% had mortality rates <1%/year, despite severe perfusion abnormalities, whereas patients with an EF<45% had high mortality rates, even with only mild/moderate perfusion abnormalities (9.2%/year; P<0.00001). Similarly, an ESV< or = 70 mL was related to a low cardiac death rate (<1.2%/year), even for patients with severe perfusion abnormalities, whereas patients with an ESV>70 mL and only mild/moderate perfusion abnormalities had high death rates (8.2%/year; P<0.00001). Patients with an EF<45% and an ESV< or = 70 mL had low cardiac death rates (1.7%/year); those with an EF<45% but an ESV>70 mL had high death rates (7.9%/year; P<0.02). Multivariate Cox proportional hazards regression showed that perfusion variables and ESV were independent predictors of overall coronary events, whereas EF and ESV demonstrated incremental prognostic values over prescan and perfusion information in predicting cardiac death and cardiac death or myocardial infarction. CONCLUSIONS: Post-stress EF and ESV by gated-SPECT have incremental prognostic values over prescan and perfusion information in predicting cardiac death, and they provide clinically useful risk stratification.

When to stress patients after coronary artery bypass surgery? Risk stratification in patients early and late post-CABG using stress myocardial perfusion SPECT: implications of appropriate clinical strategies.

OBJECTIVES: The study compared the prognostic significance of myocardial perfusion single-photon emission computed tomography (SPECT) (MPS) in patients early and late after coronary artery bypass graft surgery (CABG). BACKGROUND: The long-term effectiveness of CABG is limited by graft stenosis. The greatest incidence of graft occlusion occurs between five and eight years after surgery. However, little is known regarding the appropriate time to stress patients post-CABG with respect to risk stratification. METHODS: We identified 1,765 patients, who underwent MPS 7.1 +/- 5.0 years post-CABG. All patients underwent rest T1-201/stress Tc-99m sestamibi MPS and were followed up > or =1 year after testing. Patients with early CABG or PTCA (<60 days after MPS) were censored. The prognostic population consisted of 1,544 patients. A semiquantitative visual analysis employing a 20-segment model was used to define summed stress score (SSS), summed rest score (SRS), summed difference score (SDS), and the number of nonreversible segments (NRS). RESULTS: During follow-up, 53 cardiac deaths (CD) occurred. There was a significant increase in annual CD rates as a function of SSS. A multivariate analysis identified age, ischemia (SDS), and infarct size (NRS) as independent predictors of CD. Nuclear variables added incremental value to prescan information. The annual CD rate was relatively low (1.3%) in patients < or =5 years post-CABG. In this subgroup only age and infarct size (NRS) were predictive of CD. CONCLUSION: MPS is strongly predictive of subsequent CD in post-CABG patients and adds incremental value over clinical and treadmill test information. Our data suggest that symptomatic patients < or =5 years and all patients >5 years post-CABG may benefit from testing.

Value of routine holter monitoring for the detection of paroxysmal atrial fibrillation in patients with cerebral ischemic events.

BACKGROUND AND PURPOSE: Holter monitoring for the detection of paroxysmal atrial fibrillation (PAF) is a routine procedure after cerebral ischemic events, although its value is unknown. The aim of this study was to evaluate the incidence of PAF and its impact on drug treatment modifications in this population. METHODS: Retrospective evaluation of all Holter ECGs in patients with cerebral ischemic events was done. Chart analysis with regard to drug treatment modification and cardiovascular drug therapy was performed in all patients. RESULTS: Between January 2000 and December 2002, 425 hospitalized patients (median age, 68 years) had routine Holter ECG after a cerebral ischemic event. PAF was diagnosed in 9 patients (2.1%): in 2, oral anticoagulation was contraindicated; 1 had severe carotid stenosis as an additional risk factor; 1 had PAF but was on oral anticoagulation for basilar thrombosis; 2 had had PAF before and were on aspirin; and 3 had a new diagnosis of PAF. The last 5 patients were put on oral anticoagulation. Thus, routine Holter ECG resulted in drug treatment modification in only 5 of 425 patients (1.2%). CONCLUSIONS: PAF in cerebral ischemic event patients has a low incidence and, if diagnosed, rarely leads to drug modification. Therefore, routine Holter monitoring for PAF screening is not recommended in this patient population.

Silent coronary artery disease in patients with diabetes mellitus.

Coronary artery disease (CAD) represents the leading cause of death in diabetic patients. Silent myocardial ischaemia more often occurs in diabetics than in non-diabetics. It has been well recognised that silent myocardial ischaemia is not different from symptomatic ischaemia with respect to prognosis and adverse events. Asymptomatic high-risk diabetic patients therefore might benefit from routine screening for silent ischaemia and risk stratification; furthermore, silent ischaemia has to be treated accordingly.

Elevated troponin levels in absence of coronary artery disease after supraventricular tachycardia.

Generally speaking elevated troponin levels are consistent with the diagnosis of acute coronary syndrome and haemodynamically relevant coronary artery stenosis. However, they may also point to minor myocardial injury in other circumstances. Four patients with elevated troponin levels after supraventricular tachycardia without evidence of coronary artery disease and very low risk scores for acute coronary syndrome are described and discussed.

[Diagnosis of coronary artery disease--part 1: general approach]. / Diagnostik der koronaren Herzkrankheit - Teil 1: Generelles Testprinzip.

Tests for the diagnosis of coronary artery disease (CAD) rely on two main diagnostic principles, that is direct visualisation of coronary anatomy or detection of stress-induced myocardial ischaemia. Whether a given test is useful for the patient's management critically depends on the clinical context, that is pre-test probability for significant CAD. Not every test is suitable for every patient. Non-invasive tests have the highest diagnostic yield in patients with chest pain and intermediate pre-test probability. In these patients, tests typically confirm the presence of CAD or make it highly unlikely. In patients with low or high pre-test probability, non-invasive tests provide hardly any added diagnostic information. However, in patients with high pre-test probability of CAD, non-invasive tests are helpful for risk stratification. In asymptomatic patients, there is no established indication for any tests apart from calculation of a global cardiovascular risk based on traditional risk factors and initiation of primary preventive measures if appropriate.

[Diagnosis of coronary artery disease - part 2: Exercise electrocardiogram and myocardial perfusion scintigraphy]. / Diagnostik der koronaren Herzkrankheit - Teil 2: Belastungs-EKG und Myokardperfusionsszintigraphie.

The principle of exercise stress test and myocardial perfusions scintigraphy (MPS) is based on the detection of exercise-induced myocardial ischaemia by ECG and non-invasive assessment of myocardial perfusion respectively, MPS being the more sensitive method. The exercise stress test is the method of choice in patients with a normal resting ECG and good exercise tolerance, whereas MPS is a suitable test for patients with abnormal resting ECG and/or exercise intolerance. Stressors for MPS included exercise, pharmacological stress, or a combination. Both exercise stress test and MPS are suitable for the evaluation of patients with chest pain and intermediate pre-test probability of significant coronary artery disease. For patients with high pre-test probability, both tests are helpful for risk stratification. Neither test makes sense for the evaluation of patients with chest pain and low pre-test probability of significant coronary artery disease or unselected asymptomatic patients.

[Diagnosis of coronary artery disease - part 3: Stress echocardiography and cardiac magnetic resonance imaging]. / Diagnostik der koronaren Herzkrankheit - Teil 3: Stress-Echokardiographie und kardiale Magnetresonanztomographie.

The diagnostic principle of stress echocardiography and cardiac magnetic resonance imaging (CMR) for the diagnosis of coronary artery disease is based on the visualisation of ischaemia-induced wall motion abnormalities. From a logistic point of view, stress echocardiography is the easiest test given that it can be performed at bedside. Both stress echocardiography and stress CMR also permit direct visualisation of myocardial perfusion at rest and during pharmacological stress (typically adenosine) using contrast administration (microbubbles for stress echocardiography, gadolinium for stress CMR). These novel methods for the visualisation of myocardial perfusion seem to provide information similar to that obtained using myocardial perfusion imaging but these techniques (particularly myocardial perfusion echocardiography) are not broadly established in daily practice yet. Similar to other non-invasive tests stress echocardiography and stress CMR have the highest diagnostic yield in patients with intermediate probability of significant coronary artery disease.

[Diagnosis of coronary artery disease - part 4: Computed tomography and coronary angiography]. / Diagnostik der koronaren Herzkrankheit - Teil 4: Computertomographie und Koronarangiographie.

Invasive coronary angiography and computed tomography (CT) coronary angiography directly visualise coronary anatomy but do not provide information about the presence of inducible myocardial ischaemia. Due to its excellent negative predictive value CT coronary angiography is a suitable test to exclude significant coronary artery disease. However, given its high rate of false positive results particularly in the presence of significant coronary calcification CT coronary angiography only rarely is a real alternative to invasive coronary angiography in clinical practice. The coronary artery calcium score (CACS) is a surrogate for the extent of coronary atherosclerosis and a possible marker of biological age but does not provide any anatomical or pathophysiological information. In asymptomatic patients a CACS of zero is associated with a very low likelihood of a significant coronary stenosis and a good prognosis. However, this is not the case in symptomatic patients, and thus, CACS does not play a significant role in the diagnostic work-up in symptomatic patients in daily routine.

[Pain killers--killing the pain or the patient?]. / Nichtsteroidale Antirheumatika und Coxibe--die sanften Herzensbrecher?

Over the last years, the coxibes were widely used as potent and well tolerated pain killers. This was in part due to the better gastrointestinal tolerability of the coxibes. On the other hand the higher cox-2 selectivity is consistent with a higher cardio-vascular event rate in patients with coxibe therapy which has been demonstrated by several studies. Side effects are probably caused by the interaction of the following factors: impact on thrombocytes, coagulation, blood vessel physiology, and blood pressure. Of note, the reported cardio-vascular adverse event rates in trials evaluating coxibes and older non-steroidal anti-inflammatory drugs was very low. Furthermore, there were no difference in fatal event rates. This underscores the need to carefully deliberate about the beneficial and potentially harmful use of these drugs. In daily practice it therefore might be suitable to still use these drugs to alleviate pain in selected patients.

Stunning and left ventricular function--how long is the ventricle knocked out? Left ventricular function correlated with ischemic burden and recovery time after stress.

PURPOSE: Little is known about the relation between severity of ischemia and duration of myocardial stunning. The aim of this study was therefore to characterize the impact of ischemia on myocardial stunning and on its duration. METHODS: 310 patients (pts) who underwent myocardial perfusion SPECT (MPS) were evaluated. MPS acquired with a rest Thallium/stress Technetium-99m sestamibi protocol were scored with respect to % myocardium ischemic. Left ventricular post-stress ejection fraction (psEF) was evaluated by the widely used QGS algorithm. Resting LVEF (rEF) was assessed by invasive ventriculography. Patient groups were then compared with respect to different extents of ischemia and different time intervals between stress and imaging (< or = 60 min and > 60 min after stress). RESULTS: 21% of pts had a normal MPS, 8% had evidence of scar, 37% had evidence of ischemia, and 34% had evidence of scar plus ischemia. Pts with normal MPS had a significantly higher psEF than pts with ischemia, 61+/-8% and 56+/-8%, respectively (p=0.006), whereas rEF was not different. Overall, pts with < or = 10% myocardium ischemic had significantly higher psEF than pts with > 10% myocardium ischemic, 53+/-11% and 49+/-9%, respectively (p=0.006), whereas rEF was not different. In pts with evidence of ischemia who underwent imaging < or = 60 min after stress testing, pts with < or = 10% myocardium ischemic had higher psEF than pts with > 10% myocardium ischemic, 60+/-7% and 53+/-8%, respectively (p=0.037). In contrast, pts with evidence of ischemia who underwent imaging > 60 min after stress testing had similar psEF irrespective of extent of ischemia (53%+/-8 in pts with < or = 10% ischemia and 54%+/-8 in pts with > 10% myocardium ischemic, p=0.12). CONCLUSIONS: Ischemia had a significant impact on psEF in patients who underwent imaging less than 1 h after stress. More than one hour after stress testing stunning seems to be less relevant in the interpretation of psEF.

Use of pro-atrial natriuretic peptide in the detection of myocardial ischaemia.

BACKGROUND: Because of its unique storage and release mechanisms allowing a very rapid response to haemodynamic changes, pro-atrial natriuretic peptide (proANP) may be a helpful cardiac marker in the detection of myocardial ischaemia. MATERIALS AND METHODS: A total of 260 consecutive patients with suspected myocardial ischaemia referred for rest/ergometry myocardial perfusion single-photon emission computed tomography (SPECT) were enrolled. Levels of plasma proANP were determined before and 1 min after maximal exercise. RESULTS: Baseline proANP and peak exercise proANP were significantly higher in patients with myocardial ischaemia as compared to those without ischaemia (median, 82 [IQR, 57-112] vs. 67 [IQR, 50-106] pmol L(-1), P = 0.007; and 89 [IQR, 65-121] vs. 78 [IQR, 57-116] pmol L(-1), P = 0.033). The area under the ROC curve for baseline proANP was 0.597 (95% CI, 0.527-0.667), as compared to 0.577 (95% CI, 0.507-0.648) for peak exercise proANP. Exercise-induced changes in proANP were similar in patients with and without myocardial ischaemia, and showed no correlation with the extent of myocardial ischaemia. CONCLUSIONS: Baseline proANP and peak exercise proANP are significantly higher in patients with myocardial ischaemia. However, because of considerable overlap in proANP levels between patients with and without myocardial ischaemia, neither measurement seems helpful in the detection of myocardial ischaemia in clinical practice.

[Noninvasive cardiac diagnosis for quantifying scarring, ischemia and pump function within the scope of a study. 20 useful facets in routine cardiology nuclear medicine practice]. / Nicht-invasive kardiale Diagnostik zur Quantifizierung von Narbe, Ischämie und Pumpfunktion im Rahmen einer Untersuchung. 20 nützliche Facetten im Alltag der kardiologischen Nuklearmedizin.

Myocardial perfusion SPECT (MPS) commonly is interpreted qualitatively and not quantitatively. Most of the prognostic literature is based on a semi-quantitative visual analysis (SQA) of MPS. However, data about the comparison between the SQA and coronary angiography (cath) is lacking. We therefore evaluated 167 patients who underwent MPS and subsequent cath. SQA using a 20 segment model was used for MPS interpretation. Patients with a small to moderate amount of ischemia (SDS < or = 4; mean 1.2 +/- 1.5) and with extensive ischemia (SDS > 4; mean 9.6 +/- 4.7) were then compared with respect to clinical and cath variables. Patients with extensive ischemia had more advanced CAD as demonstrated by several cath variables (more often triple vessel and LAD-disease). SQA therefore is a useful tool for MPS interpretation and decision making in patients with (suspected) CAD.