David Wolinsky

American Society of Nuclear Cardiology and Society of Nuclear Medicine and Molecular Imaging Joint Position Statement on the Clinical Indications for Myocardial Perfusion PET

Expert Content Reviewers: Frank M. Bengel MD, Daniel S. Berman MD, Dennis A. Calnon MD, Paolo Camici MD, James A. Case PhD, Manuel D. Cerqueira MD, Panithaya Chareonthaitawee MD, Robert A. deKemp PhD, Dominique Delbeke MD, PhD, Marcelo F. Di Carli MD, Sharmila Dorbala MD, James W. Fletcher MD, Henry Gewirtz MD, K. Lance Gould MD, PhD, Robert Gropler MD, PhD, Justin A. Lundbye MD, Jamshid Maddahi MD, Terrence Ruddy MD, Heinz R. Schelbert MD, PhD, Thomas H. Schindler MD, Leslee J. Shaw PhD, H. William Strauss MD, and Patrick White MPH

Myocardial perfusion imaging in women for the evaluation of stable ischemic heart disease—state-of-the-evidence and clinical recommendations

This document from the American Society of Nuclear Cardiology represents an updated consensus statement on the evidence base of stress myocardial perfusion imaging (MPI), emphasizing new developments in single-photon emission tomography (SPECT) and positron emission tomography (PET) in the clinical evaluation of women presenting with symptoms of stable ischemic heart disease (SIHD). The clinical evaluation of symptomatic women is challenging due to their varying clinical presentation, clinical risk factor burden, high degree of comorbidity, and increased risk of major ischemic heart disease events. Evidence is substantial that both SPECT and PET MPI effectively risk stratify women with SIHD. The addition of coronary flow reserve (CFR) with PET improves risk detection, including for women with nonobstructive coronary artery disease and coronary microvascular dysfunction. With the advent of PET with computed tomography (CT), multiparametric imaging approaches may enable integration of MPI and CFR with CT visualization of anatomical atherosclerotic plaque to uniquely identify at-risk women. Radiation dose-reduction strategies, including the use of ultra-low-dose protocols involving stress-only imaging, solid-state detector SPECT, and PET, should be uniformly applied whenever possible to all women undergoing MPI. Appropriate candidate selection for stress MPI and for post-MPI indications for guideline-directed medical therapy and/or invasive coronary angiography are discussed in this statement. The critical need for randomized and comparative trial data in female patients is also emphasized.

The Role of I-123 Metaiodobenzylguanidine Imaging in Management of Patients With Heart Failure

Despite advances in evidence-based treatments, the morbidity and mortality of congestive heart failure remain exceedingly high. In addition, the costs associated with recurrent hospitalizations and advanced therapies, such as implantable cardiac defibrillators (ICDs), left ventricular assist devices, and heart transplantation, place a substantial financial burden on the health care system. The present criteria for risk stratification in patients with heart failure are inadequate and often prevent the allocation of appropriate treatment. Patients who have received ICDs as primary prevention for sudden cardiac death often receive no device therapy in their lifetime, whereas other patients with left ventricular dysfunction die suddenly without meeting criteria for ICD implantation.

EVALUATION AND IMPROVEMENT OF SPECT APPROPRIATENESS CRITERIA WITH CLINICAL OUTCOMES: A LONG-TERM FOLLOW-UP STUDY

results: Of 65,922 consecutive pts, 924 had SPECT. No significant MACE (n=59, 6.4%) between A and I (HR 1.23, p=0.47) over 1 year. Predictive A’s were: A30-New/worsening symptoms with abnormal prior imaging (26%, OR 5.65, p <0.001), and A55-Symptomatic pts post PCI or CABG (10%, OR 1.89, p=0.06). However, A43-Preop with ≥ 1 risk factor and <4 METS had a low MACE (3%, OR 0.4, p=0.3). Furthermore, relative high MACE was seen in I13-Intermediate CHD risk (15%, OR 2.79, p=0.07), I27-Asymptomatic, known CAD, prior stress test < 2 years (9%, OR 1.39, p=0.59), and I59-Asymptomatic pts < 2 years after PCI/CABG (11%, OR 1.89, p=0.24). Based on the MACE, 4 ACs were reclassified: A43 to I; I13, I27, and I59 to U. Reclassification resulted in significant delineation of MACE in A and I (HR 1.94, p <0.05).

Growth and development with an all-inclusive ASNC

As ASNC president, it is very easy be overwhelmed by non-clinical issues: reimbursement, test substitution, radiology benefits managers, radioisotope cost and availability. These problems are my responsibility as they threaten to rock the foundation and growth of nuclear cardiology. It is therefore easy to forget who we are—a scientific community committed to improving patients’ experience and cardiovascular outcomes with procedures that help guide optimal therapy. We have been extraordinarily successful over the last two decades— cardiovascular morbidity and mortality have decreased in part to ischemia-guided therapy. As a community, we are unique in the fact that many large scientific studies come not only from academic centers but also from private clinically-oriented practices. The results of these studies have helped mold clinical guidelines and form the foundation for much of the research behind Appropriate Use Criterion (AUC). Clinical and academic nuclear cardiologists have worked together not only in research but as leaders of ASNC. Clinical expertise was shared and this led to high quality testing being performed in a variety of clinical settings. ASNC continues to offer education in a variety of ways—Annual Meeting, regional programs, such as, Nuclear Cardiology Today, self-assessment modules, board prep courses, both live and on-line, on-line education, CME from Journal Nuclear Cardiology to name a few. As we strive to derive the maximum value from nuclear cardiology throughout the world, it is mandatory that we expand our training and education beyond what is delivered to those who are most likely to attend our major meetings. We, as a society must expand our focus to fellows-in-training, technologists, and international practitioners of nuclear cardiology. ASNC has made great strides in these directions.

DO ALL SPECT APPROPRIATENESS CRITERIA PREDICT LONG-TERM CLINICAL OUTCOMES? A 3-YEAR FOLLOW-UP STUDY

SPECT Appropriateness Criteria (AC) has been established for quality of care since 2005. Our prior study (JACC 2013;61:10S) showed AC predictive power in 1 year follow-up. This study sought to evaluate the effectiveness of appropriate (A) vs. inappropriate (I) AC to predict MACE in 3-year follow-up