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Funding Acknowledgements Type of funding sources: Other. Main funding source(s): Astellas Pharma US Background Coronary calcium is an important non-perfusion finding on SPECT CT attenuation correction (AC) and has been shown to help decrease equivocal interpretation and identifying atherosclerosis despite normal perfusion. Although correlations with measured calcium score have been good, an easy visual calcium score (VCS) for CT AC calcium and its prognostic value has not been well established. Purpose We aimed to evaluate the role of VCS calculated from low-dose CT for AC in predicting outcomes stratified by SPECT (normal versus abnormal). Methods A retrospective data review of patients who underwent cardiac SPECT CT at our center from January 2009 -August 2012 with a mean follow up of 4.5 years. Baseline characteristics and outcomes were collected. VCS scoring was established as follows and was completed on all scans by three senior cardiology fellows. When not congruent, consensus with third reader was established. Presence of visual calcium in any of the following arteries was recorded as a score of 1 with VCS range 0-6: left main, left anterior descending, left circumflex, right coronary, ascending aorta, and descending thoracic aorta. Subjects were divided into 3 groups based on the VCS of 4. Normal versus abnormal SPECT was defined as summed stress score/summed difference score of =4/> =2 respectively. Major adverse cardiac events (MACE) defined as presence of heart failure, myocardial infarction, and/or cardiac death. Results 538 consecutive patients with SPECT CT were evaluated. Mean age was 63.3 years with 54% females. There were 463 (86%) normal SPECT and 75 (14%) abnormal SPECT. Using VCS, there was a statistically significant increase in the percentage of MACE over the period of follow-up with step wise increase in VCS severity in normal SPECT group (p-value = 0.001), although not significant in the abnormal MPI group (Figure 1). There was a higher mortality with increasing VCS in both normal and abnormal SPECT (p= Conclusion This study highlights the importance of factoring CT AC calcium in risk assessment of SPECT. CT AC calcium represents an easily available and important adjunctive risk marker during SPECT interpretation. A simple VCS as derived in this study can help with the additive risk stratification in both normal and abnormal SPECT and is of an incremental prognostic value for MACE. Clinicians interpreting SPECT should include coronary calcification on AC CT routinely in reports to help management and prognostication decisions. Our study shows that VCS can be a simple easily adopted tool for consistent reporting.

Echocardiography is the most widely used noninvasive modality to evaluate the structure and function of the cardiac muscle in daily practice. However, up to 15-20% of echocardiograms are considered suboptimal. To enable accurate assessment of cardiac function and wall motion abnormality, the use of ultrasound microbubble contrast has shown substantial benefits in cases of salvaging nondiagnostic studies and enhancing the diagnostic accuracy in daily practice. DEFINITY

Karthik Ananthasubramaniam, E. Gordon DePuey, John J. Mahmarian, Raymond Russell III, Randall C. Thompson, and R. Glenn Wells are section lead authors.

Purpose: Echocardiography and nuclear perfusion imaging studies ordered for appropriate indications by Appropriate Use Criteria (AUC) have been shown more likely to impact management than studies deemed inappropriate or uncertain. We sought to evaluate the appropriateness of indications for all cardiac magnetic resonance imaging (CMR) testing done at our institution in 2011, and to what extent appropriateness of CMR was associated with impact on patient management. Methods: This was a single-center retrospective cohort study including 239 consecutive patients who received CMR over the 12-month calendar period in 2011. CMR studies were classified as appropriate, uncertain or inappropriate based on the 2006 AUC. A study was deemed to have had impact if it changed or clarified the patient’s diagnosis or directly influenced downstream decision-making by subspecialty referral, further testing or treatment changes. Results: The most common indications for CMR included evaluation of cardiomyopathy (79%), valvular pathology (8%), suspected myocarditis (8%), and cardiac masses (5%). Of CMRs performed, 96% were appropriate, 1% inappropriate, and 3% uncertain. Appropriate CMRs were more likely to be associated with changes in management (90%) than inappropriate or uncertain studies (40%), with an odds ratio of 21.5:1. The most common reasons CMR classified as appropriate did not change management were 1) incomplete study, 2) physician judgment not to take action based on the CMR result and 3) hypertrophic cardiomyopathy in specific circumstances. Conclusions: Appropriate CMR studies were more likely to impact management than inappropriate/uncertain studies. When ordered for appropriate indications, CMR has demonstrable impact on patient management decisions.

Background: Altered myocardial sympathetic innervation activity (AMSI) is known to be present in systolic heart failure patients (SHF) and recently SPECT imaging using I-123 mIBG heart to mediastinum (H/M) ratio

Medically managed significant left main (LM) stem disease has been considered a determinant of increased cardiac mortality approaching 50% at 3-year follow-up. Despite the clinical significance of LM disease, studies comparing the various diagnostic modalities, especially noninvasive, are sparse. Clinicians, particularly imagers, should be aware of the strengths and weaknesses of existing modalities to diagnose LM disease as integrating many clues (history, symptoms, electrocardiogram, and stress hemodynamics are essential to suspect this diagnosis and proceed to the next step). Here we review the existing data on the current role of electrocardiography, nuclear myocardial perfusion imaging (single photon emission computed tomography and positron emission tomography), stress echocardiography, cardiac computed tomography, and cardiac magnetic resonance imaging in diagnostic evaluation of LM disease. Wherever applicable we have extended our discussion to multivessel coronary artery disease encompassing scenarios where LMS can present as LM equivalent with or without extensive multivessel coronary artery disease.

A vast array of noninvasive imaging modalities is available for the evaluation of the presence and severity of coronary artery disease (CAD). Choosing the right test can be challenging but is critical for proper patient diagnosis and management. Presently available imaging tests for CAD include: (1) nuclear myocardial perfusion imaging procedures (single-photon emission tomography) and positron emission tomography, (2) stress echocardiography, (3) computed tomography coronary angiography, and (4) cardiac magnetic resonance imaging. Exercise treadmill testing electrocardiography is another alternative that we will discuss briefly. Selection of the most appropriate imaging modality requires knowledge of the clinical question being addressed, patient characteristics (pretest probability and prevalence of disease), the strengths, limitations, risks, costs, and availability of each procedure. To assist with test selection, we review the relevant literature in detail to consider the relative merits of cardiac imaging modalities for: (1) detection of CAD, (2) risk stratification and prognostication, and (3) guiding clinical decision making.

Purpose: Regadenoson (REG) is currently becoming the stress agent of choice in patients undergoing pharmacologic single photon emission computed tomography (SPECT). However, in patients with left bundle branch block (LBBB) and ventricular paced rhythm (VPR), hesitation exists amongst clinicians to use REG-SPECT due to the concern that the increased heart rate could cause false positive SPECT results. We sought to evaluate the comparability of A-SPECT and REG-SPECT in patients with LBBB and VPR. Methods: Retrospective study of 30 patients who served as their own controls. All 30 patients who underwent REG-SPECT (Grp 1) were compared to their prior A-SPECT (Grp 2) done within two years prior to REG-SPECT. Heart rate (HR) and blood pressure (BP) parameters, ECG, stress perfusion and gated variables, SPECT ischemia, and side-effects were evaluated. Statistical significance was set at P could be found between the two groups among SPECT parameters. Muscle pain was significantly higher in REG (10.0% vs. 0.0%, P = 0.083) and so was the use of aminophylline (16.7% vs. 0.0%, P = 0.025) to relieve the side-effect. Conclusion: REG-SPECT can be administered in patients with LBBB and VPR patients based on favorable and comparable hemodynamic responses and arrhythmia occurrences to A-SPECT. REG-SPECT can also be used for adequate interpretation of presence or absence of SPECT ischemia particularly in the LAD territory without any concern for false positive perfusion defects.

While myocardial perfusion imaging (MPI) remains the most validated and extensively utilized modality in the evaluation and prognostication of coronary artery disease (CAD), it has come under unprecedented scrutiny in the past few years both due to the expansive growth of cardiac imaging and increasing concerns of patient radiation exposure over their lifetime. In one study, nuclear cardiac imaging was reported to be contributing up to 22% of radiation exposure amongst all imaging. Over the past few years, major cardiac societies such as the American College of Cardiology/American Heart Association in collaboration with many other imaging societies have taken proactive steps to guide the use of cardiac imaging. Appropriate use criteria for nuclear cardiology, echocardiography, CT/MRI, and most recently, cardiac catheterization and percutaneous coronary interventions have been published to ensure that clinicians in most instances are ‘‘doing the right test for the right patient at the right time.’’ Specifically ASNC has been a leader in this effort and has taken numerous initiatives including publication of important documents with practical importance in JNC toward educating physicians regarding the appropriate use of MPI. The recent comprehensive ASNC preferred practice statement, ‘‘Patient Centered Imaging’’ by Depuey et al outlines various MPI protocols with existing isotopes and their advantages disadvantages and best use in daily clinical practice. This document reiterates an important point which physicians practicing nuclear cardiology should embrace namely ‘‘One size does not fit all.’’ Most nuclear laboratories perform single day lowdose rest-first, followed by high-dose stress imaging. This enables higher count statistics in the stress portion enabling better images and reliable gating but comes with the disadvantage of lasting about 4 hours and delivering a cumulative radiation dose of 12-15 mSv for a standard 10/30 mCi rest-stress Tc-99m MPI scan. Some laboratories, however, have been successfully performing stress first imaging (SFI) protocol where a ‘‘normal’’ stress obviates the need for the rest portion [converting the nuclear scan essentially to a stress-only imaging (SOI)]. SFI/SOI protocols have recently been shown to be very safe and feasible as compared with a normal stress-rest scan or a normal rest-stress scan. These studies have enrolled over 16,000 patients and have demonstrated excellent comparable results both for interpretability and a very favorable prognosis extending to over 4.5 years follow up. The concept of SFI/SOI imaging is extremely attractive especially when taken in the context that over 70% of MPI studies performed in nuclear labs are interpreted as ‘‘normal’’; thus, a substantial portion of rest studies performed could be avoided and by doing so the advantages are obvious. For a nuclear physician to conclusively label a stress study normal and avoid the rest scan, the study as a whole must be ‘‘completely normal’’ including the stress perfusion images, gated imaging parameters such as ejection fraction ([50%), cavity size, and wall motion. Furthermore, stress ECG and planar images must be reviewed, and attenuation correction (AC) or prone imaging should be used if available as an adjunct for the stress study. AC enhances the confidence of the reader to call the stress portion normal as approximately 50-78% of non-attenuation-corrected images have artifacts. This constellation of findings in a SFI study eliminates the need for a rest study and makes it a SOI study. From the Heart and Vascular Institute, Henry Ford Hospital, Detroit, MI. Research grant support/speakers bureau: Astellas Pharma US Inc (KA), Lantheus Medical Imaging. Reprint requests: Karthik Ananthasubramaniam, MD, FACC, FASE, FASNC, FRCP(Glas), Heart and Vascular Institute, Henry Ford Hospital, K-14, Detroit, MI 48202; kananth1@hfhs.org. J Nucl Cardiol 2012;19:1106–9. 1071-3581/$34.00 Copyright 2012 American Society of Nuclear Cardiology. doi:10.1007/s12350-012-9623-9

Coronary CT angiography (CCTA) has matured to be a fast noninvasive imaging test in the evaluation of coronary artery disease (CAD). It has demonstrated excellent accuracy for defining the presence and the severity of luminal coronary artery stenoses and is probably the best noninvasive test to reliably exclude atherosclerotic coronary disease. Furthermore, accumulating CCTA data indicate that it can identify individuals at risk for all-cause mortality. It is also well known that despite the wealth of data regarding diagnostic and prognostic values of stress testing in CAD, up to 10% of stress imaging studies are considered inconclusive, leading to subsequent invasive coronary angiography for definitive diagnosis often with negative results. Moreover, recent data indicate that up to 30 % of patients undergoing angiography have no significant CAD despite a majority of them having had a prior stress test. Whether CCTA can serve as a cost-effective methodology to invasive angiography has been a source of active research. In this context, we will discuss the implications of the recently published data from the Advanced Cardiovascular Imaging Consortium registry looking at the use of CCTA after stress testing in Michigan.

Background Coronary computed tomography angiography (CCTA) is an emerging noninvasive anatomical method for evaluation of patients with suspected coronary artery disease (CAD). Multicenter clinical registries are key to efforts to establish the role of CCTA in CAD diagnosis and management. The Advanced Cardiovascular Imaging Consortium (ACIC) is a statewide, multicenter collaborative quality initiative with the intent to establish quality and appropriate use of CCTA in Michigan. Methods The ACIC is sponsored by the Blue Cross Blue Shield of Michigan/Blue Care Network, and its 47 sites include imaging centers that offer CCTA and meet established structure and process standards for participation. Patients enrolled include those with suspected ischemia with or without known CAD, and individuals across the entire spectrum of CAD risk. Patient demographics, history, CCTA scan-related data and findings, and 90-day follow-up data are entered prospectively into a centralized database with strict validation tools and processes. Collaborative quality initiatives include radiation dose reduction and appropriate CCTA use by education and feedback to participating sites and referring physicians. Conclusions Across a wide range of institutions, the ACIC permits evaluation of “real-world” utilization and effectiveness of CCTA and examines an alternative, nontraditional approach to utilization management wherein physicians and payers collaborate to address the growing problem of cardiac imaging overutilization.

Background: The predictive value of Dobutamine Stress Echocardiography (DSE) in the obese African American patient population is not well known. Methods: We conducted a retrospective study of 555 African American patients between 1/1/2001-12/31/2001. DSE responses were classified into normal, ischemia, scar, or scar +/? ischemia. End-points utilized were all cause death (ACD) and major adverse cardiac events (MACE). Results: There were a total of 409 obese patients and 146 non-obese patients. By multi-variate analysis only the scar group in the obese population predicted ACD (p = 0.003) and combined MACE (p = 0.014). Kaplan Meir analysis demonstrated that only the scar group was associated with decrease in freedom from all cause death (p < 0.001) and combined MACE (p < 0.001). Conclusion: DSE retains its prognostic power in the obese African American population and scar has important impli-cations for MACE.

The safety and tolerability of regadenoson (REG), a newer adenosine A2a receptor agonist, has not been tested in orthotopic heart transplant (OHT) patients. Retrospective review of a tertiary care center experience of OHT patients who underwent a REG single-photon emission computed tomography (SPECT) study as part of the work-up for cardiac allograft vasculopathy. The control group included those same patients who had prior adenosine-based SPECT. A total of 40 patients met the above criteria. Mean time from OHT to adenosine-SPECT and REG-SPECT was 8.2 ± 4.8 years vs 9.8 ± 4.5 years, respectively (P

Pharmacokinetic studies suggest delayed clearance of Regadenoson (REG), a new selective A2A receptor agonist in chronic kidney disease (CKD). The safety of REG in large series of CKD patients in daily clinical practice remains unstudied.Retrospective study of patients with eGFR 60 mL/min (n = 411, Grp 1, CKD) were compared to patients with eGFR ≥ 60 mL/min (n = 638, Grp 2, Control) undergoing REG-SPECT from Jan to Nov 2009. Patient demographics, REG-SPECT data, side effects, and arrhythmia occurrences were evaluated.No major adverse events were noted immediately after REG-SPECT or at 1 week of follow-up. There were no differences in any arrhythmias in between the two groups (Grp 1, 47.2% vs Grp 2, 42.9%, P = ns). Ninety-nine percent of arrhythmias in CKD patients were PACs or PVCs. Transient junctional rhythm was observed in one CKD patient. There were no occurrences of second degree or higher degree AV block. Grp 1 had a blunted heart rate response (16.6 ± 16.1 vs 24.9 ± 20.3 bpm, P ≤ .001) and greater systolic blood pressure drop response (-7.4 ± 21.1 vs -1.4 ± 20.9 mm Hg, P ≤ .001) compared to Grp 2. Transient headache was more in Grp 2 (15.8% vs 22.6%, P ≤ .007). Aminophylline use to ward-off the side effects was comparable (9.5% vs 9.9%, P = ns).REG-SPECT can be safely performed in CKD non-dialysis patients with excellent tolerability, minimal side effects, and favorable hemodynamic responses compared to control group.

Denervation super-sensitivity to adenosine is well described in cardiac transplant (CT) patients particularly early after transplant. The safety and hemodynamic effects of adenosine SPECT (A-SPECT) has not been described in a large series of CT patients. Single center retrospective study of 102 CT patients undergoing A-SPECT were compared to an age-gender matched patients in a 2:1 fashion who underwent A-SPECT in the same time period. Multivariate logistic regression model were used to identify independent predictors of advanced AV block. The average time from CT to A-SPECT was 8.5 ± 4.5 years. Average age was 57 years with 80% males. In comparison to the control group, adenosine infusion was associated with a higher incidence of sinus pause (4.9% vs. 0%), 2nd (11.8% vs. 4.9%) and 3rd degree AVB (2.9% vs. 0%) in CT patients (all P < 0.05). Prior use of aspirin and baseline 1st degree AVB were significant independent predictors of adenosine induced AVB. Baseline right or left bundle branch block, beta-blockers, calcium blockers or digoxin were not associated with occurrence of AVB. Only 1.9% of A-SPECT studies were terminated due to bradyarrythmia with 1 patient requiring aminophylline. There were no significant immediate or long term adverse events in these patients. Adenosine pharmacologic stress is associated with a higher incidence of AVB and sinus pause in CT patients reflecting persistence of super sensitivity late after CT. Nevertheless these bradyarrythmias are transient without any sequelae suggesting that A-SPECT can be performed safely in CT patients.

Objectives The aim of this study was to assess the performance of β-methyl-p-[123I]-iodophenyl-pentadecanoic acid (BMIPP) single-photon emission computed tomography (SPECT) to detect acute coronary syndromes (ACS) in emergency department patients with chest pain. Background Emergency department diagnosis of chest pain is problematic, often requiring prolonged observation and stress testing. BMIPP SPECT detects abnormalities in fatty acid metabolism resulting from myocardial ischemia, even many hours after symptom cessation. Methods Emergency department patients with suspected ACS were enrolled at 50 centers. Patients received 5 mCi BMIPP within 30 h of symptom cessation. BMIPP SPECT images were interpreted semiquantitatively by 3 blinded readers. Initial clinical diagnosis was based on symptoms, initial electrocardiograms, and troponin, whereas the final diagnosis was based on all available data (including angiography and stress SPECT) but not BMIPP SPECT. Final diagnoses were adjudicated by a blinded committee as ACS, intermediate likelihood of ACS, or negative for ACS. Results A total of 507 patients were studied and efficacy was evaluated in 448 patients with sufficient data. The sensitivity of BMIPP by 3 blinded readers for a final diagnosis of ACS and intermediate likelihood of ACS was 71% (95% confidence interval [CI]: 64% to 79%), 74% (95% CI: 68% to 81%), and 69% (95% CI: 62% to 77%); the corresponding specificity of BMIPP was 67% (95% CI: 61% to 73%), 54% (95% CI: 48% to 60%), and 70% (95% CI: 64% to 76%). Compared with the initial diagnosis alone, BMIPP + initial diagnosis increased sensitivity from 43% to 81% (p Conclusions The addition of BMIPP data to the initially available clinical information adds incremental value toward the early diagnosis of an ACS, potentially allowing determination of the presence or absence of ACS to be made earlier in the evaluation process. (Safety and Efficacy Iodofiltic Acid I 123 in the Treatment of Acute Coronary Syndrome [Zeus-ACS]; NCT00514501 )

Background The aim of this retrospective study was to assess if negative treadmill echocardiographic (NTME) results retained their favorable prognosis over a long period of follow-up (median, 95 months) in the setting of ischemic stress electrocardiographic (ISECG) results. Methods Consecutive patients with NTME results were analyzed as 2 groups (those with ISECG results and those with normal stress electrocardiographic results). Patients were followed up for a median duration of 95 months to identify major adverse cardiac events (MACEs), including all-cause death, myocardial infarction, and coronary revascularization. Results Six hundred seventy-seven patients fulfilled the inclusion criteria. Fifty-eight patients had MACEs (8.6%). The annual event rate was 1%. There was an increased unadjusted rate of MACEs among patients with ISECG results (15% vs 8%; P = .025). After adjusting for clinical and stress variables, ISECG results were not independently predictive of MACEs ( P = .2). Female gender, prior coronary artery disease, metabolic equivalents achieved, and chest pain at stress were the independent predictors of MACEs. Conclusions Patients with NTME results had excellent long-term outcomes, regardless of ISECG results, over a median 95-month follow-up period. The findings of this study reaffirm the importance of benign long-term outcomes in the setting of good exercise capacity.

The predictive accuracy of stress echocardiography (SE) for adverse cardiac events has been variable in the population with end-stage renal disease undergoing renal transplantation (RT).We performed a retrospective study of 149 patients who had pretransplant SE before RT between 1997 and 2003. Patients were followed up for a mean of 2.85 years for major adverse cardiovascular events (MACE).Of 149 patients studied, 139 had a negative SE, 65% were African American; 12 underwent cardiac catheterization. Only 1 patient required pre-RT revascularization. Sixteen MACE occurred over the follow-up period. SE had 37.5% sensitivity, 95.3% specificity, 33.3% positive predictive value, and 96.1% negative predictive value for MACE in the first year post-RT. First-year posttransplant event rates were 4.0% versus 30% (P.001) for patients with a negative SE and positive SE, respectively. Multivariate predictors of MACE were positive SE (hazard ratio [HR] 7.64), hemoglobin less than 11 g/dL post-RT (HR 4.44), and calcium channel blocker use posttransplant (HR 2.90).A negative SE has low incidence of MACE in this intermediate- to high-risk patient subset. A positive SE predicts a sevenfold higher risk of cardiovascular events regardless of the need for revascularization before the transplant.

We illustrate a case of midventricle obstructive HCM and apical aneurysm diagnosed with appropriate use of multimodality imaging. A 75-year-old African American woman presented with a 3-day history of chest pain and dyspnea with elevated troponins. Her electrocardiogram showed sinus rhythm, left atrial enlargement, left ventricular hypertrophy, prolonged QT, and occasional ectopy. After medical therapy optimization, she underwent coronary angiography for an initial diagnosis of non-ST segment elevation myocardial infarction. Her coronaries were unremarkable for significant disease but her left ventriculogram showed hyperdynamic contractility of the midportion of the ventricle along with a large dyskinetic aneurysmal apical sac. A subsequent transthoracic echocardiogram provided poor visualization of the apical region of the ventricle but contrast enhancement identified an aneurysmal pouch distal to the midventricular obstruction. To further clarify the diagnosis, cardiac magnetic resonance imaging with contrast was performed confirming the diagnosis of midventricular hypertrophic cardiomyopathy with apical aneurysm and fibrosis consistent with apical scar on delayed enhancement. The patient was medically treated and subsequently underwent elective implantable defibrillator placement in the ensuing months for recurrent nonsustained ventricular tachycardia and was initiated on prophylactic oral anticoagulation with warfarin for thromboembolic risk reduction.

Background The missed diagnosis of acute myocardial infarction has been studied in the Emergency Department, but few studies have investigated how often coronary ischemia is correctly identified in the outpatient setting. Methods This was a single center retrospective observational study of patients with Health Alliance Plan medical insurance hospitalized at a US tertiary center with acute myocardial infarction in 2004. Outpatient encounters in the 30 days preceding acute myocardial infarction were reviewed by two independent cardiologists for presenting symptoms and diagnostic decision-making in order to classify patient presentations as acute coronary ischemia, stable angina or neither. Results There were 331 patients with acute myocardial infarction, including 190 (57%) with a primary diagnosis of AMI and evaluated by a physician in the preceding 30 days. This group included 68 patients with 95 documented outpatient encounters by a primary care physician, cardiologist, or other internal medicine specialist which formed the final study population. Mean interval between these encounters and AMI was 17 ± 11 days. Of these patients, 7 (10%) had symptoms of acute coronary ischemia, 5 (7%) had stable angina symptoms, and 56 (83%) had no symptoms of coronary ischemia at their outpatient encounters. Of the 7 patients with acute coronary ischemic symptoms, 5 were correctly identified and 2 were misidentified. Conclusion A majority of patients with subsequent AMI visit an outpatient provider in the month preceding AMI. However, few present with symptoms of coronary ischemia in the outpatient setting (10%) and these symptoms are not always identified as such.

Sarcoidosis is a systemic disease and recognition of cardiac involvement remains challenging. We report a case and illustrate the integral role of cardiac PET perfusion-metabolic imaging in evaluating various stages of cardiac sarcoidosis. A 61-year-old African-American male presented with a 6-month history of progressive exertional dyspnea, cough, palpitations, and atypical chest pain. Physical exam was consistent with acute heart failure and his baseline EKG showed sinus rhythm with frequent premature ventricular contractions. Chest x-ray showed bilateral hilar adenopathy and telemetry monitoring was significant for multiple runs of nonsustained ventricular tachycardia. Echocardiography showed ejection fraction of 30% with global biventricular hypokinesis. Patient underwent coronary angiogram revealing minimal coronary atherosclerosis. A gadolinium-enhanced cardiac MRI was obtained (Figure 1), and a diagnosis of pulmonary and cardiac sarcoidosis was made following which a dual chamber defibrillator was implanted. Prednisone 20 mg daily and methotrexate 12.5 mg weekly was planned. However, given that treatment response and disease progression assessment could not be achieved with serial cardiac MRI (ICD placed), a baseline rest Rubidium 82/F-18 flourodeoxyglucose (Rb-82/18-FDG) cardiac PET was obtained prior to treatment to be used to then assess treatment response with serial scans as indicated showing pattern consistent with active cardiac sarcoidosis (Figure 2). Treatment was initiated and methotrexate titrated up to 15 mg weekly. He was seen in the clinic five months after medical therapy was initiated. Subjectively reported minimal to no symptoms. A repeat cardiac PET was done (Figure 3) using same protocol to assess response to therapy showed marked improvement. His dose of prednisone was decreased to 10 mg daily and then discontinued. Few months later, amiodarone and methotrexate were discontinued due to early development of interstitial lung disease. Seven months after discontinuation of medical therapy, he developed recurrent heart failure symptoms. Echocardiogram EF was 30%-35%. Repeat cardiac PET was done (Figure 4) showing recurrence of active cardiac sarcoidosis. He was reinitiated on prednisone at 50 mg but refused to take it due to weight gain and did not return for follow-up appointments. This case highlights the role of cardiac PET not only in situations where MRI cannot be used but also following treatment response and disease reactivation which is challenging to assess with cardiac MRI. The emerging importance of cardiac PET in cardiac sarcoidosis is now acknowledged in the recent consensus documents and nuclear societies recommendations 1,2 as an indicator of cardiac sarcoidosis in contrast to prior older imaging criteria for CS which included on SPECT or MRI abnormalities. 3 Whole body imaging to evaluate sarcoid activity in other extra cardiac organs apart from the heart and quantitation of standardized uptake values (SUVmax) to enhance diagnosis of disease activity and response to therapy were not available in our study but are key methods to better evaluate and assess sarcoidosis as shown in recent studies. 4

Background: The neurohormonal effects of angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) are well recognized. Recent molecular studies have also demonstrated novel immune-modulating properties of ACEI/ARB through reduction of pro-inflammatory cytokines. In a recent study, obese trauma patients on pre-injury ACEI/ARB had reduced multi-organ failure scores and improved T cell function and monocyte maturation as compared to those not on ACEI/ARB. We sought to determine whether pre-hospital use of ACEI/ARB conferred improvements in outcomes in patients with septic shock (SS). Methods: We evaluated 248 patients admitted to the ICU with SS from January 2011 to April 2013. Comprehensive baseline demographic, clinical and echocardiographic data was obtained at time of ICU admission. We identified 90 patients on ACEI/ARB prior to ICU admission. Chi-square and t-tests were used to assess for differences in clinical parameters and outcomes in patients who were on ACE/ARB prior to ICU admission (ACE/ARB group) versus those not on ACEI/ARB prior to ICU admission (non-ACEI/ARB group). Results: Patients in the ACE/ARB group (36%) had significantly lower heart rate (95.8 bpm vs 102.3 bpm, p Conclusion: ACEI/ARB use prior to ICU admission is associated with improved outcomes in SS patients, not explained by laboratory or echocardiographic differences. This provides further support for the possible immunomodulating benefits of ACEI/ARBs; however, more studies are needed to confirm these findings.

Non-Doppler, 2-dimensional strain imaging is a new echocardiographic technique for obtaining strain and strain rate measurements, which serves as a major advancement in understanding myocardial deformation. It analyzes motion in ultrasound imaging by tracking speckles in 2 dimensions. There are a lot of data emerging with multiple applications of strain imaging in the clinical practice of echocardiography. As incorporation of strain imaging in daily practice has been challenging, we intend to systematically highlight the top 10 applications of speckle-tracking echocardiography, which every cardiologist should be aware of: chemotherapy cardiotoxicity, left ventricular assessment, cardiac amyloidosis, hypertrophic obstructive cardiomyopathy, right ventricular dysfunction, valvular heart diseases (aortic stenosis and mitral regurgitation), cardiac sarcoidosis, athlete heart, left atrial assessment, and cardiac dyssynchrony.

Transient ischemic dilatation (TID) of the left ventricle observed during single photon myocardial perfusion emission computed tomography (SPECT) is an important non-perfusion finding that may not only suggest underlying significant (usually multi-vessel) coronary artery disease (CAD) but also an independent prognostic factor of adverse outcomes regardless of abnormal or normal perfusion finding. We present a patient with no significant epicardial coronary disease who had significant TID and considerable decrease in the left ventricular ejection fraction with left ventricular dilatation after a rest-stress Tc-99 tetrofosmin SPECT study in the setting of severe aortic stenosis. With the advent of gated SPECT imaging the additive value of determining rest and post stress EF, as demonstrated in this case, aided in the recognition of TID and transient decrease in the left ventricular ejection fraction. These are not necessarily related to obstructive epicardial coronary disease, but are a result of severe aortic valve disease causing subendocardial ischemia in the setting of multilple other non-ischemic etiologies of TID such as left ventricular hypertrophy and diabetes mellitus.

Study objectives To evaluate the incidence, patient characteristics, and clinical significance of segmental early relaxation phenomenon (SERP) in stress echocardiography. Design Retrospective interpretation of digitized rest/stress echocardiographic images of 244 consecutive patients undergoing exercise or dobutamine echocardiography with subsequent patient follow-up for outcomes. Setting Tertiary care referral center. Patients Two hundred forty-four consecutive patients referred for stress echocardiography (exercise or dobutamine) for various clinical indications. Interventions None. Measurements and results SERP was diagnosed as a sudden outward motion of a portion of the left ventricle during early diastole (using frame-by-frame analysis) after peak systole prior to mitral valve opening at rest and after stress. Stress-associated SERP was observed in 71 patients (29.1%), with 25 patients having SERP in more than one segment. Five patients had resting SERP, with two persisting during stress. Ninety-six of 3,658 analyzed segments were positive for SERP. The apical septum and midseptum were most commonly involved in 49% and 18%, respectively. Only 5 of 96 patients (5.2%) had new hypokinesis and SERP in the same segment. No significant differences existed in demographic, clinical, or echocardiographic variables in patients with and without SERP. Follow-up revealed no significant differences in event rates in those with and without SERP. Conclusions This is the first stress echocardiographic study demonstrating that SERP is a distinct and relatively common stress echocardiographic phenomenon occurring in early diastole regardless of type of stress. SERP occurs predominantly in apical and midseptum in the distribution of the left anterior descending coronary artery. It should not be mistaken for atypical septal motion, ischemia, or dyskinesia, and does not seem related solely to the presence of underlying coronary disease or stress-induced ischemia. No adverse long-term outcomes are seen in patients with SERP and no inducible ischemia.

The Impact of Appropriate Use of Coronary Cardiac Computed Tomography on Downstream Resource Utilization and Patient Management Background: The effects of appropriate use (AUC) of cardiac computed tomography angiography (CCTA) on downstream resource utilization, coronary angiography, revascularization, and medication changes are not well studied in daily practice. Methods: Single center study to address AUC CCTA impact on downstream resource utilization. CCTA studies classified according to 2010 AUC as appropriate, inappropriate, or uncertain and its impact on downstream resource utilization and management was evaluated at 90 days and 1 year. Results: Overall, 402 (87.8%) of the studies were appropriate, 37 (8.1%) were inappropriate, and 19 (4.2%) were uncertain. Additional cardiac testing at 90 days (5.2% vs. 10.8%, p=0.149) and 12 months (13.9% vs. 21.6%, p=0.205) were similar among all 3 groups. Significantly more patients in the inappropriate group underwent coronary angiography (21.6% vs. 9.7%, p=0.045), but revascularization rates were similar (8.1% vs. 5.0%, p=0.43). There was greater cardiac medication initiation once coronary artery disease was detected by CCTA (52.4% vs. 5.5%, p

Utility of Routine Transthoracic Echocardiography in Hospitalized Syncope Patients Risk Stratified by EGSYS Score Background: The yield of routine transthoracic echocardiography (TTE) in the diagnosis and risk stratification of syncope has been a subject of debate. Purpose and Methods: To compare the yield of TTE in different risk categories of syncope patients, we performed a retrospective study of patients who had a TTE with an admission diagnosis of syncope. The patients were then stratified into low and high risk categories based on their Evaluation of Guidelines in Syncope Study (EGSYS) score of 3, respectively. Three downstream health resources were evaluated: cardiology consultation, further testing and therapeutic interventions after TTE was done. Results: Of the study group, 65% (295/456) of patients were found to have utilized no downstream health resources. The remaining 35% (161/456) had at least used 1 resource; 29.2% (133/456) utilized 1, 5% (23/456) utilized 2 and 1.1% (5/456) utilized all 3 of these resources. Of the total study group, 51% (233/456) were low risk for cardiac syncope according to the EGSYS score. Only 23.2% (54/233) of these low risk patients utilized 1 or more of the downstream health resources, but no patients in this group needed any cardiac intervention. Conclusion: There was a significant difference of the yield and thus incremental value of TTE between high and low risk group categories based on the EGSYS score. A low EGSYS score seems to be a good initial tool in identifying patients who likely will not require additional interventions related to further downstream testing.

Conflicting evidence remains regarding the value of fragmented QRS (fQRS) on surface electrocardiogram (EKG). We present the 5-year outcome of patients with fQRS on EKG and its correlation to SPECT and coronary angiography (CA).We retrospectively studied EKG's in 248 consecutive patients undergoing SPECT and CA with known or suspected coronary artery disease (CAD). The presence of fQRS or Q waves in two contiguous EKG leads was correlated with major coronary artery distributions on SPECT and cath. Patients with bundle-branch block, paced-rhythm or absence of EKG within one month of SPECT were excluded. The final EKG data for 238 patients were analyzed and compared with myocardial scar on SPECT and the presence of significant (50%) coronary stenosis on CA. Predictors of MACE (death, MI, heart failure) were evaluated. Freedom from all-cause mortality was assessed by Kaplan-Meier analysis.Of 238 patients, no significant difference was noted in the presence of scar on SPECT in fQRS (3/77; 3.8%) versus no fQRS (11/161; 6.8%) (P=0.56); or CA based CAD (55/77; 71% fQRS) and no fQRS (99/161, 61.4%) (P=0.20). EKG Q wave presence was similar in both groups: (12/77; 15.5% fQRS), (17/161; 10.5% no fQRS) (P=0.3). Patients with CA based significant LAD disease were 3.680 times more likely to have fQRS (P=0.04), however, fQRS was not significantly associated with MACE (P=0.92) or all-cause mortality (P=0.93).This study does not support routine assessment of fQRS on surface EKG as a reliable predictor of SPECT myocardial scar, MACE or all-cause mortality over a long period of follow-up.

Patients with chronic kidney disease (CKD) have worse cardiovascular outcomes. The prognostic value of the new pharmacological stressor regadenoson (REG) in patients with varying levels of kidney function is not known (REG-SPECT). Furthermore, the impact of varying levels of kidney dysfunction on cardiac outcomes in patients undergoing REG-SPECT has not been defined. Our objective was to evaluate the prognostic value of regadenoson stress imaging in patients with different levels of kidney dysfunction.We followed 1107 consecutive patients who underwent REG-SPECT for a mean duration of 1.8 ± 0.8 years. CKD was defined as estimated glomerular filtration rate (GFR) 60 mL/min/1.73 m(2). Kaplan-Meier survival analysis was performed to evaluate survival, free of major adverse cardiac events (MACE). CKD patients with GFR60 (47% male, mean age 70 years) had a higher prevalence of cardiac risk factors and a history of coronary artery disease and were on significantly more cardiac medications (P0.001) than those with GFR60. Patients with GFR60 were significantly more likely to develop adverse cardiac outcomes including congestive heart failure (CHF) (P = 0.02), cardiac death (P0.001), all-cause death (P0.001), and MACE (P0.001) over the period of follow-up. Cardiac death increased with worsening levels of perfusion defects (SSS) across the entire spectrum of renal function (P0.001). GFR60 was an independent predictor of MACE with a hazard ratio (HR) of 1.49 (95% CI: 1.06-2.08). The presence of transient ischaemic dilation (TID) was associated with an HR of 5.06 (95% CI: 1.43-17.90).Renal function is a powerful risk predictor in patients undergoing REG-SPECT. REG-SPECT provides robust prognostication across the entire spectrum of renal function.

Study objectives To identify the risk ofthromboembolism after withholding or reversing the effect of warfarintherapy following a major hemorrhage. Design Retrospective medical record review. Setting Tertiary-care hospital. Patients Twenty-eightpatients with prosthetic heart valves receiving warfarin werehospitalized for major hemorrhage from 1990 to 1997. The mean ± SDage was 61 ± 11 years (15 men and 13 women). Twenty patientshad St. Jude valves, 4 patients had Carpentier-Edwards bioprostheticvalves, 2 patients had Starr Edwards valves, and 2 patients had, Bjork-Shiley valves. Valves were in the mitral position in 12 patients, the aortic position in 12 patients, and both mitral and aorticpositions in 4 patients. The average interval from valve surgery toindex bleeding was 7 years. Twenty-five patients had GI orretroperitoneal hemorrhage, 2 patients had an intracranial hemorrhage, and 1 patient had a subdural hematoma. Interventions Vitamin K was administered to five patients and fresh frozen plasma wasgiven to seven patients to reverse anticoagulation. The meanduration of anticoagulation withholding was 15 ± 4 days. Measurements and results None of the patients hadthromboembolic complications. There were four in-hospital deaths. Twenty-two of the 24 hospital survivors resumed warfarin therapy athospital discharge. At 6-month follow-up, 10 of 19 patients remainingon warfarin therapy had recurrent GI bleeding. Conclusions Thromboembolic risk is low in prosthetic heartvalve patients hospitalized with major hemorrhage when their warfarintherapy is reversed or withheld. Recurrent bleeding within 6 months ofthe resumption of anticoagulation is common, and aggressive treatmentof the bleeding source and the risk-benefit ratio of continuedanticoagulation need to be considered.

Heparin remains the most commonly used parenteral medication in hospitalized patients. Heparin induced thrombocytopenia (HIT) and heparin induced thrombocytopenia with thrombosis syndrome or the white clot syndrome are important complications of heparin use. This article provides an indepth review of the etiopathogenesis, clinical manifestations, diagnosis, and management options in patients with HIT. Clinical problems associated with HIT such as antiphospholipid antibody syndrome and venous gangrene are described. The management options of HIT patients during cardiac interventional procedures and coronary surgery as well as recent advances in therapeutic options are summarized. Copyright © 2000 by W.B. Saunders Company Progress in Cardiovascular Diseases, Vol. 42, No. 4 (January/February), 2000: pp 247-260

Background and hypothesis: Limited data exist regarding racial differences in heart failure. The objective of this prospective study was to document racial differences in the baseline demographics and patterns of health care utilization and outcomes in patients with heart failure. Methods: The data on 163 consecutive patients (113 black, 50 white) admitted with a diagnosis of heart failure confirmed by pulmonary congestion on chest x-ray were prospectively evaluated. Patient demographics, physical examination findings at admission, comorbid conditions, and medications at admission and discharge were analyzed. Follow-up was performed to document visits to the physician's office after discharge and readmission rate during a 6-month time period. Results: Compared with whites, blacks were younger in age (mean age 63.8 ± 13.7 years vs. 70.8 ± 13.1, p = 0.003), and had a higher prevalence of hypertension (86 vs. 66%, p = 0.004), left ventricular hypertrophy (24 vs. 8%, p=0.02), ejection fraction

Although hypertrophic obstructive cardiomyopathyremains the most common cause of sudden cardiac death in young people, rarer causes, such as arrhythmogenic right ventricular dysplasia (ARVD), are now being increasingly recognized to lead to sudden cardiac death in the younger population. Recent advances in the understanding of the genetic inheritance, etiopathogenesis, diagnosis, and treatment options of ARVD have prompted a lot of research in this form of right ventricular cardiomyopathy. The purpose of this report is to review the etiopathogenesis, clinical manifestations, diagnosis and treatment modalities for ARVD, and recent advances in the understanding of this disease entity.

Regadenoson (REG), a selective adenosine A2a receptor agonist, is becoming the preferred pharmacologic agent for stress myocardial perfusion imaging (MPI). Hemodynamic and stress variables, immediate safety and use of aminophylline when using REG combined with low-level exercise (REG WALK MPI) compared with REG MPI, have not been well studied and formed the basis of our study. Retrospective evaluation of patients who underwent REG MPI (n = 887) was compared to patients undergoing REG WALK MPI (n = 485) from January to November 2009. Patient demographics, hemodynamic parameters, REG MPI data, side effects, immediate major clinical events, and use of aminophylline were evaluated. Patients in REG WALK MPI group tended to be younger, male and obese compared to patients in REG MPI group. REG WALK MPI patients had higher stress heart rate (103 ± 20.5 vs 84 ± 19 bpm, P = .001), higher heart rate reserve (36.3 ± 19 vs 14.7 ± 15.5 bpm, P

Regadenoson (REG) is a A2a receptor selective pharmacologic SPECT imaging agent. Its safety in unselected chronic obstructive pulmonary disease (COPD) or asthma (AM) undergoing SPECT imaging has not been well evaluated. We retrospectively identified 228 patients (COPD n = 126 and AM n = 102, Grp 1) undergoing REG SPECT from Jan to Nov 2009 and compared to 1,142 patients without COPD and AM (control, Grp 2). A standard 400 μg REG bolus was used and gated Tc-99 m tetrofosmin SPECT done. Patient demographics, REG SPECT data, side effects, arrhythmia occurrences, and any exacerbation of COPD or AM leading to treatment, hospitalization or death were evaluated. The side effect profile of Grp 1 was also compared to a historical cohort who underwent intravenous dipyridamole thallium-201 imaging and adenosine SPECT. Both groups were comparable with regards to baseline characteristics. There was 0% incidence of clinical exacerbation of COPD or AM after REG. COPD patients had more non-significant arrhythmias (58.3% vs. Grp 2, 43%, P = 0.004). There was 0% incidence of any atrio-ventricular block and only 2 instances of brief supraventricular tachycardia. When compared to the historical cohort of COPD who underwent IV dipyridamole thallium imaging, COPD in Grp 1, had more dyspnea and flushing and when compared to COPD/AM patients who underwent adenosine SPECT, Grp 1 pts had more of flushing and headache (24.9% vs. 2.8%, P =

To evaluate impact of echocardiography on patient management based on published transthoracic echocardiography (TTE) Appropriate Use Criteria (AUC). A prospective analysis of 170 consecutive outpatients who underwent TTE over a period of 2 months. Echo studies were classified into appropriate (A), inappropriate (I), or uncertain (U) based on the 2007/2011 AUC. A fourth group of studies which were not addressed by the 2007 AUC and therefore have unclassifiable category (UC) were also included in the analysis. The impact of AUC categorized echo results on patient management were evaluated by review of patient records in the ensuing 2 months. Based on 2007 AUC, 77% (131/170) were A, 9% were I, and 14% were UC category. Echo studies classified as A were more likely to be associated with new and major findings, (P = 0.034) and (P = 0.028) respectively when compared to all other studies. Furthermore, patient care intervention as defined in the study protocol was significantly associated with A studies as opposed to I and UC studies (P = 0.004). A studies were also more likely to have an impact on patient management when compared to other studies (P = 0.022). When studies were re-evaluated based on the 2011 AUC, all prior UC studies were now included in the U group in the new AUC of 2011, and there was no change in A or I study classification. This study demonstrates that the 2007/2011 AUC are helpful in evaluating practice patterns in a majority of outpatients undergoing TTE. Implementing AUC have a direct clinical impact as A studies are significantly more likely to reveal new and major findings, and more likely to result in a patient care intervention based on the echo findings.

[Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4] A 52-year-old man with a history of hypertension presented to the emergency department with 2 days of retrosternal chest pain and dyspnea. Blood pressure was 223/106 mm Hg on both arms. Cardiac auscultation revealed decreased S2

Persistent left sided superior vena cava is a congenital abnormality encountered not uncommonly by the echocardiographer or cardiac radiologist. Recognition of its presence is important in the differential diagnosis of dilatation of the coronary sinus. We discuss the echocardiographic and computed tomography findings of this congenital abnormality, and the implications for clincal practice.

Background— Patients with diabetes mellitus have accelerated progression of heart failure and often have impaired cardiac sympathetic innervation. The present study examines the implications for heart failure progression of cardiac sympathetic denervation, assessed by I-123 metaiodobenzylguanidine imaging, in diabetic compared with nondiabetic subjects. Methods and Results— We evaluated 343 diabetic and 618 nondiabetic subjects with New York Heart Association class II or III heart failure and a left ventricular ejection fraction ≤35% over a median follow-up of 17 months. A multivariable Cox proportional hazards model was used to examine the influence of clinical variables, b-type natriuretic peptide, plasma norepinephrine, left ventricular ejection fraction, and I-123 metaiodobenzylguanidine imaging parameters on time to a heart failure event. The late heart-to-mediastinum (H/M) ratio and the interaction term of diabetes mellitus with the prospectively selected late H/M ratio Conclusions— The combination of diabetes mellitus and I-123 metaiodobenzylguanidine H/M ratio is an independent predictor of heart failure progression, confirming the high risk of diabetic subjects with impaired cardiac sympathetic nerve function. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00126438 and NCT00126425.