Valeria Gaudieri

Coronary atherosclerotic burden vs. coronary vascular function in diabetic and nondiabetic patients with normal myocardial perfusion: a propensity score analysis

PurposeTo assess the relationship between coronary atherosclerotic burden and vascular function in diabetic and nondiabetic patients after balancing for coronary risk factors.MethodsWe studied 672 patients without overt coronary artery disease and normal myocardial perfusion on stress 82Rb PET/CT imaging. To account for differences in baseline characteristics between diabetic patients and nondiabetic patients, we created a propensity score-matched cohort considering clinical variables and coronary risk factors.ResultsBefore matching, diabetic patients had higher coronary artery calcium (CAC) scores (p < 0.001) and lower coronary flow reserve (CFR; p < 0.001) than nondiabetic patients. After matching, CAC scores were comparable between diabetic and nondiabetic patients, but diabetic patients still had lower hyperaemic myocardial blood flow (p < 0.001) and CFR (p < 0.05). Patients were categorized by ln(CAC score) quartiles. There was a decrease in CFR with increasing CAC score quartile in both diabetic patients (p for trend < 0.01) and nondiabetic patients (p for trend < 0.005). Diabetes was associated with lower CFR across quartile categories (p < 0.002). In a multivariable linear regression analysis, CAC score was inversely related to CFR in both diabetic patients (p < 0.05) and nondiabetic patients (p < 0.001).ConclusionDiabetic patients had higher CAC scores than nondiabetic patients, but the difference disappeared when clinical characteristics were taken into account. Of note, diabetic patients also had lower CFR regardless of CAC score than nondiabetic patients after matching. Thus, coronary atherosclerotic burden and vascular function have to be seen as two different entities.

Radionuclide Imaging of Cardiac Device Infection

Purpose of ReviewAccurate diagnosis of cardiac device infection is critical for clinical decision-making and represents a challenge for current diagnostic methods. A non-invasive test with sufficient sensitivity and specificity to confirm or exclude infection would be desirable. 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) has been emerging as a promising diagnostic tool for cardiac implantable electrophysiological devices (CIED) infection and its complications. The aim of this review is to describe the role of radionuclide imaging in cardiac device infection according to the different clinical presentations.Recent Findings18F-FDG PET/CT plays an important role in the diagnosis of CIED infection. It has been demonstrated that PET/CT imaging can accurately diagnose and distinguish deep pocket infection from superficial soft tissue infection. In lead infection, this technique has high specificity and is helpful when transthoracic echocardiography (TTE) does not detect vegetation. In addition, PET/CT may be useful in patients with suspected prosthesis valve endocarditis, in whom the initial TEE is negative or indeterminate.SummaryThe use of 18F-FDG PET/CT in the diagnosis of CIED infection has been implemented to respond to specific clinical needs. Different studies provided important data on the optimal conditions of PET/CT acquisition to better discriminate the infection. However, multicenter trials performed under standardized protocols for both acquisition and quantification of FDG uptake are needed. These efforts could help to achieve the level of evidence allowing FDG PET/CT to be included in clinical guidelines.

Noninvasive Cardiac Imaging in Obesity: Challenges and Opportunities

Obesity has been associated with a higher prevalence of type 2 diabetes mellitus, coronary artery disease (CAD), heart failure, atrial fibrillation, respiratory complications, malignancies, osteoarthritis, and spinal impairment [1]. Obesity is a major determinant for the development and severity of cardiovascular risk factors such as hypertension, dyslipidemia, and glucose intolerance or diabetes [2]. It has been also reported that excess adiposity is a risk factor for cardiovascular disease independently on age, dyslipidemia, smoking, diabetes, and hypertension [3]. Adipose tissue is an active endocrine organ that synthesizes and releases a variety of substances involved in quite a few pathways such as insulin resistance, upregulation of sympathetic nervous system, and downregulation of ß-adrenergic receptors [4]. The accumulation of adipose tissue is linked with altered adipokine levels, higher oxidative stress, and disorders of hemostatic and fibrinolytic systems involved in endothelial dysfunction and atherosclerosis [5]. Body weight is also directly related to the development of heart failure. Increased volume overload induces dilatation of the left ventricle leading to diastolic dysfunction. On the other hand, increased volume after load causes left ventricle eccentric hypertrophy leading to systolic dysfunction [1]. More recently, it has been shown that obesity is associated with improved survival once the diagnosis of heart failure is established [6], and this obesity paradox has been observed in other cardiovascular diseases [7]. It has been also suggested that obesity should be considered more a risk marker than a risk factor [8]. Nevertheless, diagnosis and risk stratification of cardiovascular impairment in obese population are important to identify those subjects who might benefit from more straight therapeutic strategies.

A New Relational Database Including Clinical Data and Myocardial Perfusion Imaging Findings in Coronary Artery Disease

BACKGROUND The aim of this study was to test a relational database including clinical data and imaging findings in a large cohort of subjects with suspected or known Coronary Artery Disease (CAD) undergoing stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging. METHODS We developed a relational database including clinical and imaging data of 7995 subjects with suspected or known CAD. The software system was implemented by PostgreSQL 9.2, an open source object-relational database, and managed from remote by pgAdmin III. Data were arranged according to a logic of aggregation and stored in a schema with twelve tables. Statistical software was connected to the database directly downloading data from server to local personal computer. RESULTS There was no problem or anomaly for database implementation and user connections to the database. The epidemiological analysis performed on data stored in the database demonstrated abnormal SPECT findings in 46% of male subjects and 19% of female subjects. Imaging findings suggest that the use of SPECT imaging in our laboratory is appropriate. CONCLUSION The development of a relational database provides a free software tool for the storage and management of data in line with the current standard.

Assessment of cardiovascular impairment in obese patients: Limitations and troubleshooting of available imaging tools

The prevalence and severity of obesity have increased over recent decades, reaching worldwide epidemics. Obesity is associated to coronary artery disease and other risk factors, including hypertension, heart failure and atrial fibrillation, which are all increased in the setting of obesity. Several noninvasive cardiac imaging modalities, such as echocardiography, cardiac computed tomography, magnetic resonance and cardiac gated single-photon emission computed tomography, are available in assessing coronary artery disease and myocardial dysfunction. Yet, in patients with excess adiposity the diagnostic accuracy of these techniques may be limited due to some issues. In this review, we analyze challenges and possibilities to find the optimal cardiac imaging approach to obese population.

Ik-Kyung Jang (Ed): Cardiovascular OCT Imaging

This text is a guide to cardiovascular use of optical coherence tomography (OCT). The editor is Ik-Kyung Jang, Professor of Medicine, Harvard Medical School. He has pioneered the application of OCT in cardiology, establishing the OCTcriteria for plaque characterization and comparing OCT and intravascular ultrasonography in living patients. The book contains 15 chapters with a useful index, occupying 222 pages and including numerous representative illustrations. The first two chapters focus on the development of OCT with emphasis on fundamental notions, the process of technology translation and clinical applications, the first of which was in ophthalmology, where it has become a standard of care, and then more recently in cardiology, both as a diagnostic modality and research tool. The following chapters are devoted to OCT validation, comparing OCT images and histological findings of atherosclerotic plaque, calcification, fibroatheroma, thrombus and neointima formation, image interpretation and possible pitfalls and artifacts. However, the most interesting part centres on the clinical presentations of cardiovascular diseases, covering acute coronary syndrome and spontaneous coronary artery dissection, and on evaluation of early and late stents with regard to possible mechanisms of failure, such as malapposition, stent thrombosis and neoatherosclerosis. In chapter XIV, the authors review the conclusion of consensus documents released and highlight the importance of reaching agreement on the best OCT definitions to describe plaque anatomy and stented segments because researchers still use different criteria and descriptions. The last chapter focuses on future developments. Multimodal imaging is certainly a promising research field: the combinations of different modalities can provide unique information, overcoming the weaknesses of each technique alone. Although this volume is mainly addressed to interventional cardiologists, providing background and useful hints, we recommend this fascinating book to all clinicians interested in vascular biology to improve their understanding of the role and evolution of high-risk plaque in the pathogenesis of acute coronary syndrome.

Prevalence and Severity of Myocardial Perfusion Imaging Abnormalities in Inmate Subjects

Aim We evaluated the prevalence and severity of myocardial perfusion abnormalities among inmates undergoing cardiac single-photon emission computed tomography. We also compared the results with those obtained in a cohort of non-inmates. Methods Between January 2009 and December 2013, 2420 consecutive subjects (258 inmates and 2162 non-inmates) with suspected or known coronary artery disease underwent stress myocardial perfusion single-photon emission computed tomography (MPS) to our institution. The decision to submit inmates to MPS was taken by the physicians of the penal institutions or ordered by the court based on the survey of part. To account for differences in clinical characteristics between inmates and non-inmates, we created a propensity score-matched cohort considering clinical variables and stress type. Results Before matching, inmates were younger and had higher prevalence of male gender, smoking, chest pain, and previous myocardial infarction or revascularization (all p < 0.001). After matching, all characteristics were comparable in 258 inmates and 258 non-inmates. The total amount of abnormal myocardium was similar in inmates and non-inmates before and after matching. Infarct size and severity were larger in inmates before (p < 0.001) and after (p < 0.01) matching and left ventricular ejection fraction was lower in inmates compared to non-inmates (p < 0.01). Conclusions Detention is associated with larger infarct size compared to a general population of subjects referred to stress MPS also after matching for clinical variables and stress type. The similar prevalence of normal MPS in the matched cohort suggests that this imaging technique might be appropriate in inmates.

Francis A. Burgener, Christopher Herzog, Steven P. Meyers, Wolfgang Zaunbauer (eds): Differential Diagnosis in Computed Tomography (2nd edition)

This is the second edition of a successful book, much more extensive and detailed in respect to the first one, published 15 years ago, mainly as a consequence of the innovations in CT technology. In this sense, many chapters including new methodological applications have been added and most of the images have been replaced by new ones of better quality. The authors are Francis A. Burgener, Professor of Radiology, and Steven P. Meyers, Professor of Radiology and Neurosurgery, both working at the University of Rochester Medical Center, USA, Christopher Herzog from the Department of Radiology at the Rotkreuzklinikum of Munich, Germany and Wolfgang Zaunbauer from the Institute of Radiology at the Kantonsspital in St. Gallen, Switzerland. The contributions of Gregory Dieudonné, Scott A. Mooney and Richard T. White also have to be recognized. The book is organized into 6 parts, including 29 chapters comprising 854 pages and enriched by 2,146 beautiful and effective illustrations, accompanied by explanatory notes and tables. Each chapter, following an organization based on disease and type of lesion, includes both CT findings and comments. The first part is devoted to intracranial lesions and is divided into four chapters, which are very extensive and detailed. The introduction provides a brief overview of major diseases and their pathogenesis; the role of CT appears especially useful in the evaluation of bony structures and in cerebral infarcts. The second part focuses on the head and neck region and is organized into five chapters, each of which contains an excursus on the anatomy of the examined region. The third part deals with the spine with a greater focus on injuries and diseases of the skeletal compartment, which are well evaluated by CT. The fourth part, in five chapters, covers the musculoskeletal system; the chapter on trauma and fractures is particularly comprehensive and detailed. The fifth part is devoted to the chest and is divided into three chapters in which pulmonary diseases are widely considered while minor space is dedicated to the heart; in the treatment of the mediastinum the division into compartments is not considered. The sixth and final part, consisting of 11 chapters, deals with the abdomen and pelvis. While both diffuse and focal diseases of the liver are extensively treated, only focal lesions are considered for kidneys. In conclusion this volume certainly offers very good support for all readers interested in CT, because of the high quality of the images accompanied by a well-organized and easy readable didactic content. Although the book is primarily addressed to radiologists, we recommend it to all those clinicians, trainees and students who are interested in the interpretation of CT images, first of all to nuclear physicians working with hybrid machines. In fact, although ponderous, its strength is in a slender structure that allows easy reference. Therefore this book represents a useful publication also for the library of all nuclear medicine departments. V. Gaudieri (*) : L. Mansi Nuclear Medicine, Second University of Naples, Naples, Italy e-mail: v.gaudieri@libero.it