Peter L. Tilkemeier

2013 ACCF/ACR/ASE/ASNC/SCCT/SCMR appropriate utilization of cardiovascular imaging in heart failure: A joint report of the American college of radiology appropriateness criteria committee and the American college of cardiology foundation appropriate use criteria task force

Peter Alagona, MD[⁎][1] Gerard Aurigemma, MD[‡][2] Javed Butler, MD, MPH[§][3] Don Casey, MD, MPH, MBA[∥][4] Ricardo Cury, MD[#][5] Scott Flamm, MD[¶][6] Tim Gardner, MD[⁎⁎][7] Rajesh Krishnamurthy, MD[††][8] Joseph Messer, MD[⁎][1] Michael W. Rich, MD[‡‡][9] Henry

ACCF/ACR/AHA/ASE/ASNC/HRS/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR 2008 Health Policy Statement on Structured Reporting in Cardiovascular Imaging

Joseph P. Drozda, Jr, MD, FACC, Chair Vincent J. Bufalino, MD, FACC Joseph G. Cacchione, MD, FACC Christopher P. Cannon, MD, FACC W. Don Creighton, MD Pamela S. Douglas, MD, MACC T. Bruce Ferguson, Jr, MD, FACC Raymond J. Gibbons, MD, FACC Harlan M. Krumholz, MD, FACC Frederick A. Masoudi

ACC/AHA/ACR/ASE/ASNC/HRS/NASCI/RSNA/SAIP/SCAI/ SCCT/SCMR/SIR 2008 Key Data Elements and Definitions for Cardiac Imaging

The American College of Cardiology (ACC) and the American Heart Association (AHA) support their members’ goal to improve the prevention and care of cardiovascular diseases through professional education, research, development of guidelines and standards, and by fostering policy that supports optimal patient outcomes. The ACC and AHA recognize the importance of the use of clinical data standards for patient management, to assess outcomes, and conduct research, and the importance of defining the processes and outcomes of clinical care, whether in randomized trials, observational studies, registries, or quality improvement initiatives. Hence, clinical data standards strive to define and standardize data relevant to clinical topics in cardiology, with the primary goal of assisting data collection by providing a platform …

Radiation Safety in Nuclear Cardiology—Current Knowledge and Practice: Results From the 2011 American Society of Nuclear Cardiology Member Survey

N uclear stress testing is well recognized as an effective technique for diagnosing coronary disease, predicting patient outcomes, and guiding management. Numerous evidence-based appropriate indications and practice guideline recommendations have been published regarding accepted uses of nuclear stress tests (NSTs) across a wide spectrum of patients with known or suspected coronary disease. However, the approximate 10 million NSTs performed annually account for greater than 10% of the entire ionizing radiation burden to the US population. One recent study, while pointing out that cancer risk from a single NST is small, projected on a population level that NSTs may result in thousands of radiation-attributable cancers annually, partially offsetting their benefits.

Quality of life and anxiety in a phase II cardiac rehabilitation program.

Purpose: Cardiac rehabilitation programs increasingly attempt to improve both quantity and quality of life (QOL). Documenting QOL changes requires appropriate instruments, and interpreting QOL data requires an understanding of the factors that influence such reports. Methods: To address both issues, we assessed QOL among 77 patients before and after participation in a 12-wk phase II cardiac rehabilitation program. Individual psychological differences in trait anxiety and defensiveness were also assessed. The sample was 76.6% male, 70.1% married, and had a mean age of 58.8 yr. Results: The QOL scales detected changes which occurred over the 12-wk testing period. QOL reports were strongly and differentially influenced by individual differences in trait anxiety, such that patients reporting high trait anxiety displayed poorer QOL than those low in trait anxiety. More specifically, trait anxiety influenced affect reports most strongly, functional aspects moderately, and physical aspects of QOL reports the least. Conclusions: Defensiveness was unrelated to QOL reports. The 17% of participants who voluntarily left the rehabilitation program prematurely were characterized as younger, having better self-perceived health, having a less severe cardiac history, and being high in both trait anxiety and defensiveness. Study benefits and limitations are discussed.

Emergency Department Use of Aspirin in Patients with Possible Acute Myocardial Infarction

Prompt administration of thrombolytic agents is strongly emphasized in the management of patients who have acute myocardial infarction [1, 2]. In contrast, timely use of aspirin in patients who have acute coronary syndromes has received less attention despite the proven efficacy of aspirin [3] and guidelines that advocate immediate administration of aspirin [4]. Several studies have reported suboptimal use of aspirin. Ellerbeck and colleagues [5] reported that 77% of patients who were hospitalized for myocardial infarction received aspirin when discharged. Krumholz and colleagues [6] reported that 61% of patients older than 65 years of age received aspirin during the first 2 days of hospitalization. To date, no in-depth study has analyzed the administration and timing of aspirin therapy in emergency department patients who have suspected or potential acute myocardial infarction. Our study, the Brown Acute Aspirin Intervention Review (BAAIR) Study, evaluated the use of aspirin in hospital emergency settings. Methods We conducted a retrospective analysis of admissions to the emergency departments of four hospitals affiliated with Brown University. Each hospital represented a different patient population and a different level of cardiovascular service. One was a Veterans Administration hospital without a cardiac catheterization laboratory, two were community hospitals with diagnostic cardiac catheterization laboratories, and one was a community hospital with an active referral center where percutaneous cardiovascular revascularization procedures and cardiac surgery are performed. After we received approval from the institutional review board of each hospital, we evaluated the records of all patients who were admitted between 1 January 1994 and 31 December 1994. We identified patients who had any of the following discharge diagnoses: acute myocardial infarction, other acute and subacute ischemic heart diseases, angina pectoris, other ischemic heart diseases, heart failure, other heart diseases, and chest pain (diagnosis-related group codes 410, 411, 413, 414, 428, 429, and 786.4). Records were excluded if documentation was incomplete, if the patient was directly admitted or transferred [that is, if an emergency department record did not exist], if the hospital record could not be located or was incomplete, or if an acute coronary syndrome had not been suspected by the emergency department physician. We tabulated 1) demographic variables; 2) history of cardiovascular disease and its risk factors [whether patients were older than 55 years of age; had a history of diabetes, hypertension, or hypercholesterolemia; had a family medical history positive for cardiovascular disease; and had a previous coronary event]; 3) current medical therapy; 4) initial clinical impression of the emergency department physician [acute myocardial infarction, unstable angina, chest pain with high or low suspicion of myocardial ischemia, and congestive heart failure]; 5) interpretation of the initial electrocardiogram; 6) allergy or contraindication to aspirin [history of a hemorrhagic stroke, gastrointestinal bleeding, or a bleeding disorder]; 7) amount of time between arrival in the emergency department and initiation of aspirin therapy; and 8) documentation of acute myocardial infarction during the subsequent hospital stay (the diagnosis was made if creatine kinase-MB levels increased to above normal as documented by serial measurement or if two of the following three criteria were met: chest pain, twofold elevation of the creatine kinase level, or new Q waves on the electrocardiogram). The mean age SD was determined, and the Student t-test was used to evaluate significant differences (P < 0.05) in aspirin administration (yes or no) as the grouping variable. Frequency tables were generated for remaining variables. The Pearson chi-square test was used for these data. Results Demographic and Clinical Characteristics We found 2383 medical records that met our study criteria (Table 1). Hypertension was the most prevalent cardiac risk factor (58% of patients); 43% of patients had previously documented coronary artery disease, and 35% reported receiving long-term aspirin therapy. Allergy or contraindication to aspirin was confirmed in 101 patients (4%). The initial electrocardiogram taken by emergency department staff showed an acute injury pattern in 190 patients (8%). Aspirin use was higher in younger persons, particularly those with ST-segment elevation on electrocardiography (P < 0.001). Aspirin was also used more frequently in male patients, current smokers, and patients with a family history of heart disease. Table 1. Characteristics of Study Patients Many factors were associated with less frequent use of aspirin. Among the patients already receiving long-term aspirin therapy, 23% received aspirin in the emergency department compared with 33% of patients who were not previously receiving an aspirin regimen (P < 0.001). Similarly, 17% of patients receiving long-term warfarin therapy were given aspirin compared with 31% of patients who were not receiving warfarin therapy (P < 0.001). Diagnosis on Admission to the Emergency Department The initial diagnosis made by the emergency department physician (Table 2) was acute myocardial infarction in 220 patients (9%), unstable angina in 911 patients (38%), chest pain with high suspicion of ischemia in 561 patients (24%), chest pain with low suspicion of ischemia in 262 patients (11%), and congestive heart failure in 382 patients (16%). In 47 patients (2%), the diagnosis on admission to the emergency department was not documented. Table 2. Initial Clinical Impression and Treatment Decision in the Emergency Department Compared with Discharge Diagnosis Timing and Relation of Aspirin Therapy to Diagnosis The overall frequency of the use of aspirin by emergency department physicians was 30% (712 of 2383 patients). The difference in the use of aspirin on the basis of initial clinical impression was significant: More patients received aspirin if the physician initially believed that they had acute myocardial infarction (P < 0.001) (Table 2). Of the patients who received aspirin, 22% received it within 30 minutes of arrival, 24% received it between 30 and 60 minutes of arrival, and 54% received it 1 hour after arrival. According to hospital records, acute myocardial infarction was subsequently diagnosed in 463 patients (19%); 253 of these patients (55%) did not receive aspirin in the emergency department. The discharge diagnosis of acute myocardial infarction was established in 17% of patients whose initial diagnosis had been unstable angina or congestive heart failure. Less than 5% of patients who had chest pain associated with a low likelihood of ischemia had a discharge diagnosis of acute myocardial infarction. Discussion Our study demonstrates that aspirin is underutilized in patients who are admitted with suspected myocardial infarction and related syndromes that prove to be acute myocardial infarctions at discharge. Furthermore, of the patients who did receive aspirin in the emergency department, the delay in administration of aspirin after arrival was substantial. Overall, 45% of patients who had been documented at discharge as having had acute myocardial infarction had received aspirin in the emergency department. Aspirin was most likely to be used when acute myocardial infarction was initially suspected. That this diagnosis also proved to be accurate in 17% of patients who were admitted with unstable angina or congestive heart failure is noteworthy. A rigid approach that restricts aspirin use to patients who are admitted with the strongest evidence of acute myocardial infarction deprives many others of the benefits of early aspirin therapy. Guidelines published in 1994 recommended the immediate administration of 160 mg of aspirin to patients in whom myocardial infarction is suspected [4]; this recommendation was recently reaffirmed [7]. Strong clinical evidence supports the efficacy of aspirin. The ISIS-2 (Second International Study of Infarct Survival) trial [3] that involved more than 17 000 patients with suspected myocardial infarction revealed a 23% reduction in the mortality rate of patients who received aspirin alone and an additional 19% reduction when aspirin was given with streptokinase. The incidence of nonfatal myocardial infarction was also reduced by 49% [3]. In patients who had unstable angina, several studies have shown strong evidence that supports the role of aspirin [8-10]. The use of aspirin has apparently been influenced by clinical trials. Between 1987 and 1990, aspirin use before myocardial infarction increased from 16% to 24% and aspirin use after myocardial infarction increased from 39% to 72% [11]. Krumholz and colleagues [6] reported that aspirin therapy was initiated in 56% of elderly Medicare patients within the first 24 hours of hospitalization. However, they did not evaluate the use of aspirin in emergency departments. Other evaluations of aspirin therapy have also shown that practitioners who refer patients for hospital admission underutilize aspirin therapy [12, 13]. Our data show that 17% of patients who were admitted with a diagnosis of unstable angina proved to have acute myocardial infarction at discharge. An identical rate was noted in patients who presented with congestive heart failure. Many elderly patients who have acute myocardial infarction may initially show signs of pulmonary congestion in the absence of chest pain. On the basis of our data, we propose that emergency department physicians give aspirin to all patients who are to be admitted to the hospital for possible myocardial infarction, with the possible exception of patients in whom suspicion of an acute coronary event is low. Aspirin may be particularly useful in elderly patients who present with unexplained heart failure. Our study, which addresses the underutilization of aspirin in patients wi

Prevalence and characteristics of multiple psychiatric disorders in cardiac rehabilitation patients.

PURPOSE Anxiety and depressive disorders have been established as independent risk factors for the development of and recovery from coronary heart disease (CHD). However, few studies have reported on the prevalence and personal characteristics of comorbid psychiatric disorders (PD) among cardiac populations. This project examined the prevalence of comorbid depressive and anxiety disorders among men and women with CHD commencing cardiac rehabilitation (CR) and the demographic, medical, and psychosocial characteristics among those meeting multiple PD criteria. METHODS Participants were 143 CHD patients (M age, 61 years; SD, 11.2; 70% men, 91% Caucasian, 64% married) entering CR who were evaluated via a semistructured, psychiatric interview to assess both current and lifetime prevalence rates of PD. Demographic, medical, and psychosocial variables were also assessed. RESULTS Approximately 45% met criteria for at least 1 anxiety disorder, and 20% met criteria for either major depressive disorder or dysthymic disorder either at the time of evaluation or in their lifetime. Across all participants, 26% met criteria for ≥2 PD. Of those with a depressive disorder, 76% also met criteria for at least 1 anxiety disorder. Participants with comorbid PD were of younger age and female and reported less education (P < .01). Comorbidity was also associated with self-reported overall diminished physical, emotional, and social quality of life, depression, and anxiety. CONCLUSION Comorbid PD are highly prevalent in the CR setting and are associated with specific demographic characteristics and reduced quality of life. These data offer additional support that routine screening for PD is warranted in outpatient cardiac settings.

ACCF/ACR/AHA/ASE/ASNC/HRS/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR 2008 Health Policy Statement on Structured Reporting in Cardiovascular Imaging. Endorsed by the Society of Nuclear Medicine [added].

WRITING COMMITTEE MEMBERS Pamela S. Douglas, MD, MACC, FAHA, FASE, Chair; Robert C. Hendel, MD, FACC, FAHA, Co-Chair; Jennifer E. Cummings, MD, FACC*; John M. Dent, MD, FACC, FASE†; John McB. Hodgson, MD, FACC, FSCAI‡; Udo Hoffmann, MD, MPH§; Robert J. Horn III ; W. Gregory Hundley, MD, FACC, FAHA¶; Charles E. Kahn, Jr, MD, MS#; Gerard R. Martin, MD, FACC; Frederick A. Masoudi, MD, MSPH, FACC; Eric D. Peterson, MD, MPH, FACC, FAHA; Geoffrey L. Rosenthal, MD, PhD, FACC; Harry Solomon**; Arthur E. Stillman, MD, PhD, FAHA††; Shawn D. Teague, MD‡‡; James D. Thomas, MD, FACC, FAHA§§; Peter L. Tilkemeier, MD, MMM, FACC, FAHA, FASNC ; Wm. Guy Weigold, MD, FACC¶¶

ASNC ImageGuide™: Cardiovascular imaging data registry

Many important milestones have been achieved in the field of nuclear cardiology starting with the initial clinical use of thallium 40 years ago. This was followed by the introduction of SPECT perfusion imaging and technetium-based radiopharmaceuticals. Another major event was the founding of the American Society of Nuclear Cardiology (ASNC) in 1993. With the founding of the Society came the formalization of nuclear cardiology guidelines and practice statements, as well as an increased understanding of the practice of nuclear cardiology globally. Over the next 20 years, there were significant technological advancements with the introduction of gated SPECT imaging, attenuation correction and high efficiency cameras. During this same time period, the significant growth in nuclear cardiology necessitated the development of the first set of appropriate use criteria. We will soon be achieving yet another major milestone: ImageGuide, a registry for cardiovascular imaging, will become a reality in the very near future. The registry is well on its way toward clinical implementation. Less than a year ago, ASNC secured funding, and began to evaluate potential partners to assist with the programmatic development of ImageGuide. In the early spring of 2013, work commenced when Duke Clinical Research Institute (DCRI) was selected as the partner of choice. ASNC and DCRI leadership met with nuclear cardiology interpretive software vendors in an all-day session at the end of May to outline timelines, common goals, and proposed operations for ImageGuide. One important outcome of this meeting was the decision to embrace Health Level-7 (HL7) clinical data architecture as the foundation for data collection in this registry; a cutting-edge decision in this current era of electronic health data. Since then, innumerable hours of work have resulted in a final set of data elements and definitions, predicated on previously developed and accepted standards. These initial data elements were released to interpretative software vendors at the end of August. The HL7 clinical data architecture will allow flexibility for ImageGuide to harmonize with other clinical data sources, such as electronic health records and claims data, in the future. These unprecedented accomplishments, in less than 6 months, demonstrate the exceptional level of commitment and expertise of the ImageGuide team members and further establishes ASNC’s pledge to support this registry and its positive contribution to the field of cardiology. We expect the next major milestone, initial data submission by a clinical laboratory to ImageGuide, to occur in early 2014. This landmark achievement will only be possible through the collaboration of a large number of vendors, partners and, most importantly, physician and technologist leadership at clinical sites. As discussed in the prior two articles in this series, the development and implementation of ImageGuide is essential to so many aspects of nuclear cardiology, particularly clinical care and regulatory issues. ImageGuide will allow nuclear cardiologists and technologists to assess both the process of care, patient management decisions and outcome quality measures. Process measures, such as dosimetry and timeliness of reporting, are essential to the field of nuclear cardiology, and will be targeted for analysis as soon as possible after ImageGuide is launched. Later phases will focus on appropriateness, clinical outcomes, and the potential to interface with other clinical data sources to strengthen the value statement for cardiovascular imaging. For J Nucl Cardiol 2013;20:1186–7. 1071-3581/

The role of noninvasive testing in evaluating patients for coronary artery disease.

34.00 Copyright 2013 American Society of Nuclear Cardiology. doi:10.1007/s12350-013-9789-9