Kim A. Williams

ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 Appropriate Use Criteria for Cardiac Radionuclide Imaging

Peter Alagona, JR, MD, FACC* Timothy M. Bateman, MD, FACC† Manuel D. Cerqueira, MD, FACC, FAHA, FASNC† James R. Corbett, MD, FACC‡ Anthony J. Dean, MD, FACEP§ Gregory J. Dehmer, MD, FACC, FAHA* Peter Goldbach, MD, FACC Leonie Gordon, MB, CHB¶ Frederick G. Kushner, MD, FACC# Raymond Y. Kwong, MD, MPH, FACC** James Min, MD, FACC†† Miguel A. Quinones, MD, FACC‡‡ R. Parker Ward, MD, FACC† Michael J. Wolk, MD, MACC* Scott H. Yang, MD, PHD, FACC*

Effect of Long-Term Exposure to Lower Low-Density Lipoprotein Cholesterol Beginning Early in Life on the Risk of Coronary Heart Disease: A Mendelian Randomization Analysis

OBJECTIVES The purpose of this study was to estimate the effect of long-term exposure to lower plasma low-density lipoprotein cholesterol (LDL-C) on the risk of coronary heart disease (CHD). BACKGROUND LDL-C is causally related to the risk of CHD. However, the association between long-term exposure to lower LDL-C beginning early in life and the risk of CHD has not been reliably quantified. METHODS We conducted a series of meta-analyses to estimate the effect of long-term exposure to lower LDL-C on the risk of CHD mediated by 9 polymorphisms in 6 different genes. We then combined these Mendelian randomization studies in a meta-analysis to obtain a more precise estimate of the effect of long-term exposure to lower LDL-C and compared it with the clinical benefit associated with the same magnitude of LDL-C reduction during treatment with a statin. RESULTS All 9 polymorphisms were associated with a highly consistent reduction in the risk of CHD per unit lower LDL-C, with no evidence of heterogeneity of effect (I(2) = 0.0%). In a meta-analysis combining nonoverlapping data from 312,321 participants, naturally random allocation to long-term exposure to lower LDL-C was associated with a 54.5% (95% confidence interval: 48.8% to 59.5%) reduction in the risk of CHD for each mmol/l (38.7 mg/dl) lower LDL-C. This represents a 3-fold greater reduction in the risk of CHD per unit lower LDL-C than that observed during treatment with a statin started later in life (p = 8.43 × 10(-19)). CONCLUSIONS Prolonged exposure to lower LDL-C beginning early in life is associated with a substantially greater reduction in the risk of CHD than the current practice of lowering LDL-C beginning later in life.

Anatomic versus physiologic assessment of coronary artery disease. Role of coronary flow reserve, fractional flow reserve, and positron emission tomography imaging in revascularization decision-making.

Angiographic severity of coronary artery stenosis has historically been the primary guide to revascularization or medical management of coronary artery disease. However, physiologic severity defined by coronary pressure and/or flow has resurged into clinical prominence as a potential, fundamental change from anatomically to physiologically guided management. This review addresses clinical coronary physiology-pressure and flow-as clinical tools for treating patients. We clarify the basic concepts that hold true for whatever technology measures coronary physiology directly and reliably, here focusing on positron emission tomography and its interplay with intracoronary measurements.

An Effective Approach to High Blood Pressure Control: A Science Advisory From the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention

Cardiovascular diseases, including heart disease, hypertension, and heart failure, along with stroke, continue to be leading causes of death in the United States.1,2 Hypertension currently affects nearly 78 million* adults in the United States and is also a major modifiable risk factor for other cardiovascular diseases and stroke.1 According to data from the National Health and Nutrition Evaluation Survey (NHANES) in 2007 to 2010, 81.5% of those with hypertension are aware they have it, and 74.9% are being treated, but only 52.5% are under control, with significant variation across different patient subgroups.1,4–7 Of those with uncontrolled hypertension, 89.4% reported having a usual source of health care, and 85.2% reported having health insurance.3 This is the current status, despite the fact that therapies to lower blood pressure and associated risks of cardiovascular events and death have been available for decades, and various education and quality improvement efforts have been targeted at patients and healthcare providers. The direct and indirect costs of hypertension are enormous, considering the number of patients and their families impacted, and the healthcare dollars spent on treatment and blood pressure–related complications.8 Currently, hypertension affects 46% of patients with known cardiovascular disease and 72% of those who have had a stroke, and it is listed as a primary or contributing cause in ≈15% of the 2.4 million deaths in 2009.1 In 2008, the total estimated direct and indirect cost of hypertension was estimated at

Left ventricular function in patients with coronary artery disease assessed by gated tomographic myocardial perfusion images. Comparison with assessment by contrast ventriculography and first-pass radionuclide angiography.

69.9 billion.8 Thus, it is imperative to identify, disseminate, and implement more effective approaches to achieve optimal control of this condition. High-quality blood pressure management is multifactorial and requires the engagement of patients, families, providers, and healthcare delivery systems and communities. This includes expanding patient and healthcare provider awareness, appropriate lifestyle …

Patient management after noninvasive cardiac imaging: Results from SPARC (Study of myocardial perfusion and coronary anatomy imaging roles in coronary artery disease)

OBJECTIVES This study evaluated the use of gated single-photon emission computed tomographic (SPECT) myocardial perfusion images for determination of left ventricular ejection fraction. BACKGROUND Gated SPECT has expanded the applications of myocardial perfusion imaging to include the evaluation of left ventricular size, regional wall motion and regional systolic thickening. Accurate automated or semi-automated methods for quantitation of left ventricular ejection fraction from tomographic perfusion images would provide additional valuable clinical information. METHODS Rest gated SPECT was performed on the stress distribution of technetium-99m sestamibi, using eight frames per cardiac cycle. Mid-horizontal long-axis and vertical long-axis gated tomographic perfusion images were analyzed after digital matrix inversion, which enhances edge detection, for ejection fraction determination. These ejection fractions were compared with those determined by contrast ventriculography (n = 54, including 45 biplane and 9 single plane) and first-pass radionuclide angiography (n = 38) in patients with coronary artery disease. RESULTS Myocardial perfusion SPECT image inversion-derived ejection fractions were slightly lower (2.7 ejection fraction units, p < 0.01), and first-pass ejection fractions were much lower (8.0 ejection fraction units, p < 0.001) than those obtained with contrast ventriculography. There was excellent correlation between SPECT and contrast ventriculographic ejection fractions (r = 0.93) over a wide range of ejection fractions (14% to 89%). Good correlation was also observed between first-pass radionuclide angiography and both contrast ventriculography (r = 0.83) and SPECT (r = 0.87). Reproducibility of SPECT image inversion ejection fractions was excellent (intraobserver r = 0.99, interobserver r = 0.93). CONCLUSIONS Semiautomated ejection fractions can be obtained from gated SPECT technetium-99m sestamibi perfusion images using the image inversion technique. These results are reproducible and correlate well with results of first-pass radionuclide angiography but are closer in value to those obtained with contrast ventriculography.

2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

OBJECTIVES This study examined short-term cardiac catheterization rates and medication changes after cardiac imaging. BACKGROUND Noninvasive cardiac imaging is widely used in coronary artery disease, but its effects on subsequent patient management are unclear. METHODS We assessed the 90-day post-test rates of catheterization and medication changes in a prospective registry of 1,703 patients without a documented history of coronary artery disease and an intermediate to high likelihood of coronary artery disease undergoing cardiac single-photon emission computed tomography, positron emission tomography, or 64-slice coronary computed tomography angiography. RESULTS Baseline medication use was relatively infrequent. At 90 days, 9.6% of patients underwent catheterization. The rates of catheterization and medication changes increased in proportion to test abnormality findings. Among patients with the most severe test result findings, 38% to 61% were not referred to catheterization, 20% to 30% were not receiving aspirin, 35% to 44% were not receiving a beta-blocker, and 20% to 25% were not receiving a lipid-lowering agent at 90 days after the index test. Risk-adjusted analyses revealed that compared with stress single-photon emission computed tomography or positron emission tomography, changes in aspirin and lipid-lowering agent use was greater after computed tomography angiography, as was the 90-day catheterization referral rate in the setting of normal/nonobstructive and mildly abnormal test results. CONCLUSIONS Overall, noninvasive testing had only a modest impact on clinical management of patients referred for clinical testing. Although post-imaging use of cardiac catheterization and medical therapy increased in proportion to the degree of abnormality findings, the frequency of catheterization and medication change suggests possible undertreatment of higher risk patients. Patients were more likely to undergo cardiac catheterization after computed tomography angiography than after single-photon emission computed tomography or positron emission tomography after normal/nonobstructive and mildly abnormal study findings. (Study of Perfusion and Anatomys Role in Coronary Artery [CAD] [SPARC]; NCT00321399).

An effective approach to high blood pressure control: a science advisory from the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention.

Paul K. Whelton, MB, MD, MSc, FAHA, Chair, Writing Committee, Robert M. Carey, MD, FAHA, Vice Chair, Writing Committee, Wilbert S. Aronow, MD, FACC, FAHA, Writing Committee Member, Donald E. Casey, Jr., MD, MPH, MBA, FAHA, Writing Committee Member, Karen J. Collins, MBA, Writing Committee Member, Cheryl Dennison Himmelfarb, RN, ANP, PhD, FAHA, Writing Committee Member, Sondra M. DePalma, MHS, PA-C, CLS, AACC, Writing Committee Member, Samuel Gidding, MD, FACC, FAHA, Writing Committee Member, Kenneth A. Jamerson, MD, Writing Committee Member, Daniel W. Jones, MD, FAHA, Writing Committee Member, Eric J. MacLaughlin, PharmD, Writing Committee Member, Paul Muntner, PhD, FAHA, Writing Committee Member, Bruce Ovbiagele, MD, MSc, MAS, MBA, FAHA, Writing Committee Member, Sidney C. Smith, Jr., MD, MACC, FAHA, Writing Committee Member, Crystal C. Spencer, JD, Writing Committee Member, Randall S. Stafford, MD, PhD, Writing Committee Member, Sandra J. Taler, MD, FAHA, Writing Committee Member, Randal J. Thomas, MD, MS, FACC, FAHA, Writing Committee Member, Kim A. Williams, Sr., MD, MACC, FAHA, Writing Committee Member, Jeff D. Williamson, MD, MHS, Writing Committee Member, Jackson T. Wright, Jr., MD, PhD, FAHA, Writing Committee Member

Evaluation of the American College of Cardiology Foundation/American Society of Nuclear Cardiology appropriateness criteria for SPECT myocardial perfusion imaging.

Cardiovascular diseases, including heart disease, hypertension, and heart failure, along with stroke, continue to be leading causes of death in the United States [(1,2)][1]. Hypertension currently affects nearly 78 million[∗][2] adults in the United States and is also a major modifiable risk

Patient-Centered Imaging: Shared Decision Making for Cardiac Imaging Procedures With Exposure to Ionizing Radiation

Background. The American College of Cardiology Foundation/American Society of Nuclear Cardiology appropriateness criteria (AC) were created to guide responsible use of single photon emission computed tomography (SPECT). Clinical applicability of the AC has not been evaluated.Methods and Results. Indications for testing were determined in 1209 patients and categorized as having appropriate, uncertain, or inappropriate indications; the specialty of the ordering physician was noted. There were 940 (80%) appropriate, 154 (13%) inappropriate, and 79 (7%) uncertain tests; 36 tests were labeled “no category,” as these were ordered for indications not clearly addressed in the AC. Inappropriate studies had more normal and lower summed stress scores, although there remained a high proportion of abnormal SPECT studies in this group (26% of women and 50% of men). Women had lower summed stress scores and more normal tests in the appropriate and inappropriate groups. Studies ordered by anesthesiologists for preoperative evaluation were more likely to be deemed inappropriate than other specialty groups.Conclusion. In evaluating the AC in a single-center academic setting, the majority of studies are appropriate, but a large proportion of ordered SPECT studies were categorized as uncertain, inappropriate, or no category. Although the inappropriate studies showed less ischemia than other groups, especially in women, a substantial portion of these studies (32%) were abnormal.