This document discusses stress imaging modalities for assessing cardiac ischemia and viability. It addresses debates around which stress modality to use, whether pharmacological or exercise stress is preferred, and which stressor provides the best diagnostic accuracy. The document also discusses indications for pharmacological stress imaging if exercise is inadequate and assesses the diagnostic accuracy and prognostic value of different stress modalities. Finally, it addresses the use of stress echocardiography and nuclear imaging in evaluating patients for coronary artery disease.
This document discusses myocardial perfusion imaging (MPI), a nuclear imaging technique used to detect coronary artery disease. It describes the indications for MPI, including detecting CAD, assessing stenosis, evaluating prognosis, and assessing medical therapy. Risk factors for CAD like smoking, obesity, and high cholesterol are outlined. The document details how CAD causes reduced blood flow and describes associated symptoms. Treatment options for CAD include drugs, angioplasty, stents, and bypass surgery. Imaging protocols and reconstruction techniques for MPI are also summarized.
Raja Lahiri provides an overview of coronary angiography. Key points include:
- Coronary angiography is the current gold standard for visualizing the coronary arteries through X-ray imaging with contrast injection.
- The history of coronary angiography began in the 1920s-1940s with early experiments in cerebral and cardiac catheterization.
- Modern techniques involve accessing arteries typically through the femoral or radial arteries to insert a catheter for contrast injection into the coronary arteries under X-ray imaging.
- Multiple angiographic views are needed to visualize different segments of the left and right coronary arteries. Coronary angiography is used to evaluate coronary artery disease, graft patency, and left ventricular function.
This document provides an overview of cardiac MRI techniques including gradient echo sequences which provide cine images of heart motion and white blood, spin echo sequences which produce static black blood images, and phase contrast imaging which uses Doppler to visualize blood flow direction and velocity. Delayed enhancement imaging identifies areas of scar or fibrosis by their contrast uptake several minutes after injection. Other techniques discussed are perfusion imaging, tissue tagging, and STIR imaging for edema detection. Common imaging planes and protocols are outlined along with common uses of cardiac MRI such as assessing function, cardiomyopathy, and viability.
This document discusses cardiac MRI (CMRI) and its clinical applications. CMRI provides anatomical and functional information to assess heart abnormalities through various sequences like ECG-gated bright and dark blood sequences. It is useful for evaluating congenital heart diseases, valvular heart diseases, ventricular function, coronary arteries, myocardial perfusion and viability, cardiac masses, and pericardial diseases. CMRI is more accurate than echocardiography for measuring ejection fraction, volumes, and assessing ventricular function and viability. It is useful for differentiating conditions like arrhythmogenic right ventricular dysplasia, restrictive vs constrictive cardiomyopathy, and determining feasibility of revascularization procedures.
The document provides an overview of coronary CT angiography (CCTA). It discusses recent advances in CCTA technology including perfusion imaging, spectral imaging, and fractional flow reserve CT (FFR-CT). The anatomy and physiology of the coronary arteries is described. The document outlines the equipment, indications, procedures, and post-processing techniques used in CCTA. It also discusses calcium scoring, artifacts, case studies, radiation dose, and limitations of CCTA.
Cardiac MRI provides concise summaries of medical documents in 3 sentences or less:
Cardiac MRI has a history dating back to the 1970s when the first MRI machine was developed and techniques for generating images were discovered, leading to the Nobel Prize. MRI uses magnetic fields and radio waves to generate detailed images of the heart and blood vessels without using ionizing radiation. Cardiac MRI is now used clinically to assess cardiac structure and function, detect ischemia and scar tissue, and evaluate various cardiomyopathies.
Carotid artery disease is a major cause of stroke. Left untreated, carotid stenosis over 75% carries a risk of stroke of 2-5% per year. Carotid endarterectomy has been shown in clinical trials such as NASCET and ACAS to significantly reduce stroke risk compared to medical management alone, with perioperative stroke or death rates of less than 6% for symptomatic patients and 3% for asymptomatic patients. Carotid artery stenting is an alternative treatment that utilizes embolic protection devices and stent placement to treat carotid stenosis, but requires technical expertise to achieve outcomes comparable to surgery.
This document discusses myocardial perfusion imaging (MPI), a nuclear imaging technique used to detect coronary artery disease. It describes the indications for MPI, including detecting CAD, assessing stenosis, evaluating prognosis, and assessing medical therapy. Risk factors for CAD like smoking, obesity, and high cholesterol are outlined. The document details how CAD causes reduced blood flow and describes associated symptoms. Treatment options for CAD include drugs, angioplasty, stents, and bypass surgery. Imaging protocols and reconstruction techniques for MPI are also summarized.
Raja Lahiri provides an overview of coronary angiography. Key points include:
- Coronary angiography is the current gold standard for visualizing the coronary arteries through X-ray imaging with contrast injection.
- The history of coronary angiography began in the 1920s-1940s with early experiments in cerebral and cardiac catheterization.
- Modern techniques involve accessing arteries typically through the femoral or radial arteries to insert a catheter for contrast injection into the coronary arteries under X-ray imaging.
- Multiple angiographic views are needed to visualize different segments of the left and right coronary arteries. Coronary angiography is used to evaluate coronary artery disease, graft patency, and left ventricular function.
This document provides an overview of cardiac MRI techniques including gradient echo sequences which provide cine images of heart motion and white blood, spin echo sequences which produce static black blood images, and phase contrast imaging which uses Doppler to visualize blood flow direction and velocity. Delayed enhancement imaging identifies areas of scar or fibrosis by their contrast uptake several minutes after injection. Other techniques discussed are perfusion imaging, tissue tagging, and STIR imaging for edema detection. Common imaging planes and protocols are outlined along with common uses of cardiac MRI such as assessing function, cardiomyopathy, and viability.
This document discusses cardiac MRI (CMRI) and its clinical applications. CMRI provides anatomical and functional information to assess heart abnormalities through various sequences like ECG-gated bright and dark blood sequences. It is useful for evaluating congenital heart diseases, valvular heart diseases, ventricular function, coronary arteries, myocardial perfusion and viability, cardiac masses, and pericardial diseases. CMRI is more accurate than echocardiography for measuring ejection fraction, volumes, and assessing ventricular function and viability. It is useful for differentiating conditions like arrhythmogenic right ventricular dysplasia, restrictive vs constrictive cardiomyopathy, and determining feasibility of revascularization procedures.
The document provides an overview of coronary CT angiography (CCTA). It discusses recent advances in CCTA technology including perfusion imaging, spectral imaging, and fractional flow reserve CT (FFR-CT). The anatomy and physiology of the coronary arteries is described. The document outlines the equipment, indications, procedures, and post-processing techniques used in CCTA. It also discusses calcium scoring, artifacts, case studies, radiation dose, and limitations of CCTA.
Cardiac MRI provides concise summaries of medical documents in 3 sentences or less:
Cardiac MRI has a history dating back to the 1970s when the first MRI machine was developed and techniques for generating images were discovered, leading to the Nobel Prize. MRI uses magnetic fields and radio waves to generate detailed images of the heart and blood vessels without using ionizing radiation. Cardiac MRI is now used clinically to assess cardiac structure and function, detect ischemia and scar tissue, and evaluate various cardiomyopathies.
Carotid artery disease is a major cause of stroke. Left untreated, carotid stenosis over 75% carries a risk of stroke of 2-5% per year. Carotid endarterectomy has been shown in clinical trials such as NASCET and ACAS to significantly reduce stroke risk compared to medical management alone, with perioperative stroke or death rates of less than 6% for symptomatic patients and 3% for asymptomatic patients. Carotid artery stenting is an alternative treatment that utilizes embolic protection devices and stent placement to treat carotid stenosis, but requires technical expertise to achieve outcomes comparable to surgery.
Myocardial viability testing is important in patients with coronary disease and severely reduced left ventricular systolic function to determine whether revascularization may improve outcomes by identifying dysfunctional but still viable myocardium. Revascularization of viable myocardium can help recover function and symptoms, whereas predominantly scarred myocardium will not benefit from revascularization.
This document provides an overview of nuclear cardiology techniques used in the assessment of coronary artery disease (CAD). It discusses the history and development of nuclear medicine imaging including planar imaging and SPECT/PET. Key aspects summarized are:
1. SPECT imaging involves injection of radiotracers like thallium-201 or technetium-99m which distribute to the myocardium proportional to blood flow. Gamma photons are detected and reconstructed to provide 3D images of radiotracer distribution.
2. PET imaging uses positron-emitting radiotracers like rubidium-82 or ammonia-13 for perfusion and fluorodeoxyglucose for metabolism. It provides higher resolution functional imaging
The document discusses the history, anatomy, angiographic views, variations, and clinical relevance of coronary arteries. It provides a detailed overview of the typical anatomy and branches of the left main, left anterior descending, left circumflex, and right coronary arteries. It also describes common anatomical variations and anomalies seen in coronary arteries and their clinical implications. Angiographic classification methods for different coronary artery segments are presented.
This document discusses coronary guidewires used in percutaneous coronary intervention (PCI). It begins by outlining the history of angioplasty and guidewire development. It then covers the purpose, components, classifications, and appropriate uses of guidewires. The main components include the core, tip, coils, covers, and coatings. Guidewires are classified based on flexibility, device support, and clinical usage. Complications like vessel perforation, pseudolesions, and entrapment are also discussed. Proper guidewire manipulation and strategies for difficult lesions are outlined to maximize safety and efficacy.
This document discusses myocardial perfusion scintigraphy, which uses radiopharmaceuticals and gamma camera imaging to evaluate regional myocardial blood flow and detect any perfusion abnormalities. It describes the key aspects of the technique, including the mechanisms of radiotracer uptake, imaging modalities like SPECT, stress testing protocols, and factors that can influence image interpretation like soft tissue attenuation. Common radiotracers like Thallium-201, Technetium-99m sestamibi, and tetrofosmin are also covered in terms of their properties and localization within heart tissue.
Coronary CT angiography is a noninvasive imaging modality used to evaluate coronary artery disease. It has a high sensitivity of 87-99% and specificity of 93-96% for detecting coronary artery stenosis. Coronary CT angiography is most useful in low- to intermediate-risk patients with chest pain to rule out coronary artery disease given its high negative predictive value of 93-100%. Coronary CT angiography involves acquiring images using ionizing radiation as the patient holds their breath and synchronizing the images with the patient's ECG signal.
Ionizing Radiation -How is Gray different from Sievert -Deterministic & Stochastic Radiation Risks -Air Kerma-Time, Distance and Shielding Principles -Dosimetry
A detailed description of ct coronary angiography and calcium scoring with various aspects regarding the preparation, procedure, limitations and a short review regarding post CABG imaging.
A CT coronary angiogram (CTCA) uses computed tomography to non-invasively image the coronary arteries. It provides useful information about coronary artery disease. Specialists who interpret CTCAs must complete training requirements, including a minimum number of cases. CTCA is a low-risk, low-radiation exam that can accurately detect narrowings or anomalies in the coronary arteries. It may benefit those with suspected coronary artery disease, atypical chest pain, or to check grafts. Indications include chest pain with low-intermediate risk or family history. Preparation includes fasting and potentially taking a beta-blocker to lower the heart rate.
This document provides information on imaging of the carotid arteries and carotid angiography. It discusses various imaging modalities used to image the carotid arteries including ultrasound, CT, MRI, CT angiography, MR angiography, duplex ultrasound, and plain films. It then provides detailed information on carotid angiography including definitions, indications, complications, techniques, and how to avoid complications. Transcranial ultrasound in premature infants is also briefly discussed.
Non-invasive imaging plays an important role in the management of cardiovascular diseases. Different imaging modalities have advantages and limitations. Echocardiography is useful for assessing cardiac structure and function but limited for coronary artery disease evaluation. Nuclear imaging can evaluate perfusion and function but not coronary anatomy directly. CT and MRI can assess coronary anatomy in addition to function but CT involves radiation. The appropriate choice of imaging modality depends on the clinical question and no single test can replace all others for evaluating cardiovascular diseases. Integrating complementary information from different tests provides the most comprehensive assessment.
Peripheral angiography is a radiological procedure used to examine arteries and veins after injecting contrast media. It involves puncturing an artery such as the femoral artery using the Seldinger technique and threading a catheter over a guidewire to inject contrast media and obtain images. The procedure is used to diagnose and treat various vascular conditions. Precise positioning, sterile equipment and contrast injection are needed to obtain diagnostic images of the peripheral vasculature.
This document outlines the protocol for performing CT angiography (CTA) from the cerebral arteries to the lower limbs. It discusses indications for CTA including aneurysms, stenosis, dissections, and more. The preparation, positioning, and scanning protocols are provided for CTA of the head to lower limbs as well as the subclavian arteries. Pediatric protocols are also summarized. The document concludes with examples of CTA findings and references.
This document provides an overview of cardiac MRI techniques, including coils, cardiac and respiratory motion compensation, pulse sequences, and clinical applications. It discusses using array coils and parallel imaging to reduce scan time. It describes ECG triggering for cardiac motion compensation and respiratory navigators for motion compensation. The main pulse sequences used in cardiac MRI are described as fast spin echo for black blood imaging and gradient echo, steady-state free precession, and echo-planar imaging for bright blood imaging. Clinical applications like function, perfusion, and flow are mentioned.
Cardiac MRI provides detailed images of the heart and blood vessels without using radiation. It has advanced significantly since its introduction in the 1980s. Developments in pulse sequences have improved image quality and allowed for faster acquisition times. Techniques like T2-weighted imaging and delayed enhancement MRI can identify heart muscle damage. Perfusion MRI evaluates blood flow and identifies areas with reduced flow. Further advances may integrate sequences, allow free breathing scans, and expand MRI's clinical and research roles in cardiology.
Intravascular ultrasound (IVUS) uses sound waves to visualize the inside of arteries. There are two types of IVUS systems - mechanical systems using a rotating internal cable and solid-state systems using externally mounted transducers. Both produce 360-degree images with a resolution of 100-150 μm. IVUS is used to assess plaque, vessel dimensions, stent deployment, and more. It produces cross-sectional images showing the lumen, layers of the artery wall, and plaque composition and size. Measurements include diameters, areas, plaque burden, and indices of eccentricity. IVUS helps identify vulnerable plaque and has diagnostic and interventional applications.
1. Nuclear cardiology uses radiotracers and imaging techniques like SPECT and PET to evaluate myocardial perfusion and function.
2. SPECT imaging involves injection of tracers like thallium-201 or technetium-99m sestamibi followed by gamma camera detection of radiotracer distribution in the heart.
3. PET imaging allows quantification of regional blood flow and metabolism using tracers like rubidium-82, ammonia-13, or fluorodeoxyglucose taken up in proportion to flow or metabolism.
Left ventricular angiography is used to assess global and regional left ventricular function and anatomy. It involves inserting a catheter into the left ventricle and injecting contrast dye to visualize the ventricle on x-ray imaging. The procedure provides key information on mitral valve function, ventricular shape and wall motion abnormalities, and congenital defects like VSD. LV volumes and ejection fraction are calculated from the images to quantify function. Regional wall motion is graded and correlated to coronary artery territories. Characteristic appearances are seen in conditions like cardiomyopathy, mitral regurgitation, and septal defects. Potential complications include arrhythmias and endocardial injury.
This document discusses the presentation, testing, and management of pituitary adenomas and hypothalamic syndromes. It provides guidance on testing a 66-year-old man with a confirmed pituitary adenoma discovered on MRI after presenting with stroke symptoms. Testing strategies and their limitations are reviewed. Factors affecting decisions around intervention and appropriate follow-up strategies are also discussed, drawing on literature to support recommendations. Long-term management of patients with prolactinomas on dopamine agonists is explored, including monitoring, treatment withdrawal, and surveillance of side effects.
This exploratory analysis of the CRASH-2 trial examined the effects of tranexamic acid on death due to bleeding within 28 days in trauma patients who received treatment within 8 hours of injury. It found that tranexamic acid significantly reduced death due to bleeding when given within 3 hours of injury, with no apparent benefit after 3 hours. The results suggest tranexamic acid may be most effective when given very early after major bleeding due to trauma.
Myocardial viability testing is important in patients with coronary disease and severely reduced left ventricular systolic function to determine whether revascularization may improve outcomes by identifying dysfunctional but still viable myocardium. Revascularization of viable myocardium can help recover function and symptoms, whereas predominantly scarred myocardium will not benefit from revascularization.
This document provides an overview of nuclear cardiology techniques used in the assessment of coronary artery disease (CAD). It discusses the history and development of nuclear medicine imaging including planar imaging and SPECT/PET. Key aspects summarized are:
1. SPECT imaging involves injection of radiotracers like thallium-201 or technetium-99m which distribute to the myocardium proportional to blood flow. Gamma photons are detected and reconstructed to provide 3D images of radiotracer distribution.
2. PET imaging uses positron-emitting radiotracers like rubidium-82 or ammonia-13 for perfusion and fluorodeoxyglucose for metabolism. It provides higher resolution functional imaging
The document discusses the history, anatomy, angiographic views, variations, and clinical relevance of coronary arteries. It provides a detailed overview of the typical anatomy and branches of the left main, left anterior descending, left circumflex, and right coronary arteries. It also describes common anatomical variations and anomalies seen in coronary arteries and their clinical implications. Angiographic classification methods for different coronary artery segments are presented.
This document discusses coronary guidewires used in percutaneous coronary intervention (PCI). It begins by outlining the history of angioplasty and guidewire development. It then covers the purpose, components, classifications, and appropriate uses of guidewires. The main components include the core, tip, coils, covers, and coatings. Guidewires are classified based on flexibility, device support, and clinical usage. Complications like vessel perforation, pseudolesions, and entrapment are also discussed. Proper guidewire manipulation and strategies for difficult lesions are outlined to maximize safety and efficacy.
This document discusses myocardial perfusion scintigraphy, which uses radiopharmaceuticals and gamma camera imaging to evaluate regional myocardial blood flow and detect any perfusion abnormalities. It describes the key aspects of the technique, including the mechanisms of radiotracer uptake, imaging modalities like SPECT, stress testing protocols, and factors that can influence image interpretation like soft tissue attenuation. Common radiotracers like Thallium-201, Technetium-99m sestamibi, and tetrofosmin are also covered in terms of their properties and localization within heart tissue.
Coronary CT angiography is a noninvasive imaging modality used to evaluate coronary artery disease. It has a high sensitivity of 87-99% and specificity of 93-96% for detecting coronary artery stenosis. Coronary CT angiography is most useful in low- to intermediate-risk patients with chest pain to rule out coronary artery disease given its high negative predictive value of 93-100%. Coronary CT angiography involves acquiring images using ionizing radiation as the patient holds their breath and synchronizing the images with the patient's ECG signal.
Ionizing Radiation -How is Gray different from Sievert -Deterministic & Stochastic Radiation Risks -Air Kerma-Time, Distance and Shielding Principles -Dosimetry
A detailed description of ct coronary angiography and calcium scoring with various aspects regarding the preparation, procedure, limitations and a short review regarding post CABG imaging.
A CT coronary angiogram (CTCA) uses computed tomography to non-invasively image the coronary arteries. It provides useful information about coronary artery disease. Specialists who interpret CTCAs must complete training requirements, including a minimum number of cases. CTCA is a low-risk, low-radiation exam that can accurately detect narrowings or anomalies in the coronary arteries. It may benefit those with suspected coronary artery disease, atypical chest pain, or to check grafts. Indications include chest pain with low-intermediate risk or family history. Preparation includes fasting and potentially taking a beta-blocker to lower the heart rate.
This document provides information on imaging of the carotid arteries and carotid angiography. It discusses various imaging modalities used to image the carotid arteries including ultrasound, CT, MRI, CT angiography, MR angiography, duplex ultrasound, and plain films. It then provides detailed information on carotid angiography including definitions, indications, complications, techniques, and how to avoid complications. Transcranial ultrasound in premature infants is also briefly discussed.
Non-invasive imaging plays an important role in the management of cardiovascular diseases. Different imaging modalities have advantages and limitations. Echocardiography is useful for assessing cardiac structure and function but limited for coronary artery disease evaluation. Nuclear imaging can evaluate perfusion and function but not coronary anatomy directly. CT and MRI can assess coronary anatomy in addition to function but CT involves radiation. The appropriate choice of imaging modality depends on the clinical question and no single test can replace all others for evaluating cardiovascular diseases. Integrating complementary information from different tests provides the most comprehensive assessment.
Peripheral angiography is a radiological procedure used to examine arteries and veins after injecting contrast media. It involves puncturing an artery such as the femoral artery using the Seldinger technique and threading a catheter over a guidewire to inject contrast media and obtain images. The procedure is used to diagnose and treat various vascular conditions. Precise positioning, sterile equipment and contrast injection are needed to obtain diagnostic images of the peripheral vasculature.
This document outlines the protocol for performing CT angiography (CTA) from the cerebral arteries to the lower limbs. It discusses indications for CTA including aneurysms, stenosis, dissections, and more. The preparation, positioning, and scanning protocols are provided for CTA of the head to lower limbs as well as the subclavian arteries. Pediatric protocols are also summarized. The document concludes with examples of CTA findings and references.
This document provides an overview of cardiac MRI techniques, including coils, cardiac and respiratory motion compensation, pulse sequences, and clinical applications. It discusses using array coils and parallel imaging to reduce scan time. It describes ECG triggering for cardiac motion compensation and respiratory navigators for motion compensation. The main pulse sequences used in cardiac MRI are described as fast spin echo for black blood imaging and gradient echo, steady-state free precession, and echo-planar imaging for bright blood imaging. Clinical applications like function, perfusion, and flow are mentioned.
Cardiac MRI provides detailed images of the heart and blood vessels without using radiation. It has advanced significantly since its introduction in the 1980s. Developments in pulse sequences have improved image quality and allowed for faster acquisition times. Techniques like T2-weighted imaging and delayed enhancement MRI can identify heart muscle damage. Perfusion MRI evaluates blood flow and identifies areas with reduced flow. Further advances may integrate sequences, allow free breathing scans, and expand MRI's clinical and research roles in cardiology.
Intravascular ultrasound (IVUS) uses sound waves to visualize the inside of arteries. There are two types of IVUS systems - mechanical systems using a rotating internal cable and solid-state systems using externally mounted transducers. Both produce 360-degree images with a resolution of 100-150 μm. IVUS is used to assess plaque, vessel dimensions, stent deployment, and more. It produces cross-sectional images showing the lumen, layers of the artery wall, and plaque composition and size. Measurements include diameters, areas, plaque burden, and indices of eccentricity. IVUS helps identify vulnerable plaque and has diagnostic and interventional applications.
1. Nuclear cardiology uses radiotracers and imaging techniques like SPECT and PET to evaluate myocardial perfusion and function.
2. SPECT imaging involves injection of tracers like thallium-201 or technetium-99m sestamibi followed by gamma camera detection of radiotracer distribution in the heart.
3. PET imaging allows quantification of regional blood flow and metabolism using tracers like rubidium-82, ammonia-13, or fluorodeoxyglucose taken up in proportion to flow or metabolism.
Left ventricular angiography is used to assess global and regional left ventricular function and anatomy. It involves inserting a catheter into the left ventricle and injecting contrast dye to visualize the ventricle on x-ray imaging. The procedure provides key information on mitral valve function, ventricular shape and wall motion abnormalities, and congenital defects like VSD. LV volumes and ejection fraction are calculated from the images to quantify function. Regional wall motion is graded and correlated to coronary artery territories. Characteristic appearances are seen in conditions like cardiomyopathy, mitral regurgitation, and septal defects. Potential complications include arrhythmias and endocardial injury.
This document discusses the presentation, testing, and management of pituitary adenomas and hypothalamic syndromes. It provides guidance on testing a 66-year-old man with a confirmed pituitary adenoma discovered on MRI after presenting with stroke symptoms. Testing strategies and their limitations are reviewed. Factors affecting decisions around intervention and appropriate follow-up strategies are also discussed, drawing on literature to support recommendations. Long-term management of patients with prolactinomas on dopamine agonists is explored, including monitoring, treatment withdrawal, and surveillance of side effects.
This exploratory analysis of the CRASH-2 trial examined the effects of tranexamic acid on death due to bleeding within 28 days in trauma patients who received treatment within 8 hours of injury. It found that tranexamic acid significantly reduced death due to bleeding when given within 3 hours of injury, with no apparent benefit after 3 hours. The results suggest tranexamic acid may be most effective when given very early after major bleeding due to trauma.
INDUCTION CHEMOTHERAPY WITH TPF IN HEAD & NECK CANCERS Paul George
Three key points about induction chemotherapy for head and neck cancer:
1) Several trials have shown that a taxane-based induction chemotherapy regimen of docetaxel, cisplatin, and fluorouracil (TPF) improves overall survival compared to cisplatin and fluorouracil (PF) alone when followed by concurrent chemoradiotherapy. TPF also decreases locoregional and distant failures.
2) A large meta-analysis found TPF significantly improved overall survival, progression-free survival, organ preservation, and reduced cancer mortality compared to PF. However, no evidence shows TPF plus radiotherapy is superior to concurrent chemoradiotherapy alone.
3) While TPF is now considered standard
The document discusses treatment options for locally advanced cervical cancer. It summarizes several meta-analyses and clinical trials that show concurrent chemoradiation (CCT-RT) is the standard of care, rather than neoadjuvant chemotherapy followed by surgery (NACT+Surgery). While some older trials showed a benefit of NACT+Surgery, most recent evidence suggests it does not provide benefits and adds unnecessary morbidity compared to CCT-RT. The takeaway message is that in clinical practice, only standard guidelines accepted by major organizations like NCCN and NCI should be followed, and experimental treatments belong only in clinical trials.
1. Intracranial pressure (ICP) monitoring is important for managing patients with severe traumatic brain injury. ICP above 20-25 mmHg should be treated to reduce pressure.
2. Maintaining a cerebral perfusion pressure above 70 mmHg is effective, while pressures below 50 mmHg should be avoided. Additional monitoring of cerebral blood flow and oxygenation can help guide treatment.
3. Surgical decompression through craniectomy is an effective treatment for reducing high ICP and may improve outcomes, though results are still controversial. Younger patients and earlier surgery seem to benefit most.
This document discusses how randomized clinical trials that use fixed treatment protocols can produce unintended consequences and invalidate study results when current clinical practice involves titrating treatment based on patient characteristics and disease severity. Two such studies, TRICC and ARMA, are examined. For both, the document argues the trials' results were influenced by "practice misalignments" that occurred when subgroups of patients received treatment levels contrary to standard practice based on their individual presentation. This calls into question whether the studies' conclusions reflect how patients are actually treated and responds to in clinical settings. Better trial design is needed to minimize such misalignments, potentially through methods like simulating standard practices or including a current practices comparison arm.
1) The VISSIT trial compared outcomes of 112 patients with symptomatic intracranial stenosis randomized to balloon-expandable stent plus medical therapy or medical therapy alone. At 1 year, the stent group had a higher risk of stroke or TIA compared to the medical therapy group.
2) The CADISS trial randomized 250 patients with carotid or vertebral artery dissection to antiplatelet drugs or anticoagulant drugs for 3 months. Both groups had low risks of stroke, with no significant difference between treatments.
3) The ATTEST trial compared tenecteplase to alteplase in 104 patients with acute ischemic stroke within 4.5 hours of onset. There were no significant differences in pen
This 40-year-old man presented with night sweats, hemoptysis, dyspnea and weight loss. Imaging showed a cavitary lung lesion and filling defects in the main pulmonary artery suggestive of a pulmonary embolism. Further PET-CT imaging and biopsy revealed primary pulmonary artery angiosarcoma. This is a rare and aggressive malignancy with poor prognosis. Treatment is largely palliative.
Reperfusion strategy in patients with ST-Segment Elevation Myocardial Infarct...Premier Publishers
Reperfusion therapy is the cornerstone in management of STEMI. This study was designed to evaluate both In-hospital and 30 days outcome in patients with STEMI treated with primary percutaneous coronary intervention (PPCI) versus fibrinolysis. This prospective, controlled, study included 140 patients with STEMI who were eligible for reperfusion therapy. In hospital and 30 days major adverse cardiovascular events (MACE) were reported and head to head comparison was done between PPCI versus fibrinolysis. All-cause mortality was reported in 5% of patients (10% versus 0% in fibrinolysis and PPCI respectively, p=0.07), recurrence of ischemic symptoms was reported in 18% of patients (30% versus 7% in fibrinolysis and PPCI respectively, P =0.02), heart failure was evident in 22% of patients (33% versus 10% in fibrinolysis and PPCI respectively, P =0.02). PPCI is safe and effective treatment option for patients with STEMI
This document discusses stereotactic body radiation therapy (SBRT) for head and neck cancers. It provides an overview of SBRT indications, efficacy, toxicity profiles, quality of life outcomes, fractionation schedules, target definition, constraints, and the role of cetuximab. Several studies on SBRT for recurrent head and neck cancers, primary cancers metastatic to the head and neck region, and target volume delineation are summarized. Toxicities are generally low but carotid blowout syndrome remains a concern, especially for tumors adjacent to carotid arteries.
Academic Report On The Pitfalls Of Clinical Trial For Medical DevicesAsia Medical Supplies
This summarizes an academic report on the pitfalls of the BELIEF clinical trial for a medical device. The BELIEF trial was a randomized, double-blind trial that compared percutaneous myocardial laser therapy (PML) to a sham procedure for treating refractory angina. While the trial found PML provided better relief of angina symptoms than the sham, the report identifies several pitfalls, including potential unintentional disclosure between groups, short-term relief observed, imbalance in baseline characteristics between randomized groups, lack of compliance with EU regulations, and unknown primary mechanism of benefit. The report questions whether the BELIEF trial alone provides sufficient evidence for the treatment.
This study compared outcomes of patients with cerebral cavernous malformations (CCMs) and new-onset seizures who received either initial surgical treatment, initial conservative treatment, or delayed surgical treatment after failed conservative treatment. Results showed that patients who received initial surgical treatment or delayed surgery had better seizure control and were more likely to discontinue antiepileptic drugs than those who received only conservative treatment. However, operative morbidity was low and comparable between surgical groups and conservative treatment. The presence of residual hemosiderin on postoperative imaging was associated with continued seizures after surgery. Overall, the study provides observational evidence that early surgical treatment may improve seizure outcomes for CCM patients with new-onset seizures compared to initial conservative management.
MANAGEMENT OF COMPLICATIONS AFTER LRP: HOW TO IMPROVE EARLY CONTINENCE AND MA...Eduard Garcia Cruz
Mi presentación en las jornadas "MINIMALLY INVASIVE PROSTATE SURGERY" en Oporto del 24 y 25 de enero del 2014 - "Gestión de las complicaciones después de la prostatectomía radical laparoscópica (PRL): Cómo mejorar la incontinencia temprana y gestionar la disfunción eréctil".
Cardiac disease is a leading cause of death in the US. Various testing options are available for diagnosis including stress echocardiography, SPECT imaging, and PET imaging. PET imaging provides higher diagnostic accuracy than SPECT, shorter scan times, and lower radiation exposure. The increasing use of rubidium-82 for PET perfusion imaging allows for improved patient outcomes, enhanced practice revenue, and lower healthcare costs compared to older testing methods.
This case study evaluated the effectiveness of adding cetuximab to radiotherapy for the treatment of squamous-cell carcinoma of the head and neck. 424 patients were randomly assigned to receive radiotherapy alone or radiotherapy plus cetuximab. The study found that combining cetuximab with radiotherapy significantly increased both the duration of control of locoregional disease and overall survival rates compared to radiotherapy alone, with a 32% reduced risk of locoregional progression and a 26% reduced risk of death. Common adverse effects of cetuximab included rash and hypersensitivity reactions.
Austin Journal of Musculoskeletal Disorders is a peer-reviewed, open access journal published by Austin Publishers. It provides easy access to high quality Manuscripts in all related aspects of diseases and disorders that may adversely affect the function and overall effectiveness of the musculoskeletal system. The Journal focuses upon all the related aspects of musculoskeletal system disorders and the new advancements in the related treatments including Complex issues and injuries involving the musculoskeletal system and surgeries.
Austin Publishing Group is a successful host of more than hundred peer reviewed, open access journals in various fields of science and technology with intent to bridge the gap between academia and research access.
Austin Journal of Musculoskeletal Disorders accepts original research articles, review articles, case reports, mini reviews, rapid communication, opinions and editorials on all related aspects of diseases and disorders that may adversely affect the function and overall effectiveness of the musculoskeletal system.
L'ecografia nella BPCO: l'effetto dell'ostruzione delle vie aeree sull'escurs...Paj Ero
This document discusses using ultrasound to evaluate the diaphragm muscle in patients undergoing pulmonary rehabilitation.
The study examined over 1,300 patients using ultrasound before and after rehabilitation to measure diaphragm excursion. Ultrasound measurements improved in 76% of patients compared to 56% for the 6-minute walk test. Ultrasound was found to be a safe, fast, and reliable method for monitoring the effectiveness of rehabilitation.
The conclusions state that ultrasound evaluation of the diaphragm provides a valid, practical way to monitor treatment alongside traditional evaluation methods. Improvements measured by ultrasound correlate with improvements in walking tests and lung function tests. Ultrasound may be particularly useful for evaluating patients who cannot
This document summarizes the results of a journal club presentation on using stellate ganglion block (SGB) to treat electrical storm. The following key points were discussed:
1. SGB significantly reduced the number of ventricular arrhythmia episodes and defibrillator shocks per day compared to before SGB.
2. The efficacy of SGB in reducing arrhythmias was independent of left ventricular function, presence or type of cardiomyopathy, and subtype of ventricular arrhythmia.
3. While SGB shows promise as an effective treatment for electrical storm, larger prospective randomized studies are still needed due to limitations of current retrospective studies.
Similar to Stress imaging and viability assessment (20)
This document summarizes recent evidence on cardiovascular disease risk factors and lipid management. Key points include:
- Lowering LDL cholesterol and other apoB-containing lipoproteins reduces cardiovascular risk in a linear, dose-dependent manner with no lower limit.
- HDL cholesterol raising therapies have not been shown to reduce cardiovascular risk beyond modest reductions in apoB.
- Triglycerides associate with risk, but this is mediated by changes in non-HDL cholesterol and apoB levels rather than triglyceride levels alone.
- Calculated and direct LDL cholesterol measurements provide similar risk information in most cases, but direct measurement may be needed in some patients with high triglycerides or metabolic conditions.
Monogenic hypertension can be caused by three main mechanisms: excessive sodium reabsorption, hyperstimulation of mineralocorticoid receptors, and excess mineralocorticoid synthesis. Liddle syndrome is one form of monogenic hypertension caused by a gain-of-function mutation in the epithelial sodium channel (ENaC) that leads to constitutive sodium reabsorption and hypertension. Other forms include congenital adrenal hyperplasia caused by deficiencies in 11β-hydroxylase or 17α-hydroxylase, which lead to elevated mineralocorticoid levels and hypertension. Apparent mineralocorticoid excess is caused by mutations inhibiting the enzyme 11β-hydroxysteroid dehydrogenase type 2, preventing cortisol metabolism and
1. Chronic coronary syndromes (CCS) refer to conditions involving atherosclerotic plaque buildup in the coronary arteries that can cause various clinical presentations depending on the dynamic nature of the disease process.
2. The most common clinical scenarios in patients with suspected or established CCS involve those with stable angina symptoms, new onset of heart failure, recent acute coronary syndrome, or asymptomatic patients more than 1 year after initial diagnosis or revascularization.
3. Evaluation and management of patients with suspected CCS involves assessing symptoms, risk factors and comorbidities, performing basic testing, estimating pre-test probability of CAD, selecting appropriate non-invasive testing to confirm diagnosis when needed, calculating risk, and determining long-
The document discusses several factors related to arrhythmias and their potential to cause symptoms. The type and origin of the arrhythmia can influence whether it is symptomatic. Short, isolated episodes are less likely to cause symptoms than sustained episodes of the same rhythm abnormality. Faster heart rates, lower ejection fractions, and the presence of comorbidities make arrhythmias more likely to be symptomatic.
This document discusses various inotropic agents used to support cardiac function including dopamine, dobutamine, norepinephrine, and milrinone. While these drugs can improve hemodynamics in the short term, studies have shown that long term use is associated with increased mortality. Milrinone in particular is noted to increase morbidity and mortality with chronic oral administration. The document recommends against routine outpatient infusion of inotropic drugs and suggests they be reserved for bridging to transplantation or palliative care when other options are insufficient.
This document discusses the different types of ion channels in the heart. It describes how ion channels can be voltage-dependent, opening in response to changes in membrane potential. Voltage-dependent gating is the most common mechanism. Ion channels also have two mechanisms for closure: inactivation during depolarization and deactivation during repolarization. Additionally, ion channels can be ligand-dependent, opening when certain molecules like acetylcholine or ATP bind to the channel. The acetylcholine-activated potassium channel is discussed as a key example of ligand-dependent gating in the heart.
This document discusses diabetes and new antidiabetic drugs. It notes that diabetes cases are rising significantly worldwide and that diabetes increases the risk of serious health complications. It describes the different types of diabetes and their presentations. It recommends screening guidelines for prediabetes and notes the importance of lifestyle changes to prevent progression to diabetes. It discusses treatment targets and factors like hypoglycemia. It also provides an overview of various drug classes used to treat diabetes, including their mechanisms and effects.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler Community Health Nursing A Canadian Perspective, 5th Edition TEST BANK by Stamler Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Study Guide Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Studocu Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Course Hero Community Health Nursing A Canadian Perspective, 5th Edition Answers Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Course hero Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Studocu Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Study Guide Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Ebook Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Questions Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Studocu Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Stuvia
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
2. 2
Debates about the issue
1-Which modality to choose?
2-Pharmacological Vs exercise?
3-Inotropic Vs vasodilator stressor?
4-Diagnostic accuracy and prognostic value of each
modality.
5-Early Post MI ischemia and Viability Assessment.
7. 7
Debates about the issue:
1-Which modality to choose?
2-Pharmacological Vs exercise?
3-Inotropic Vs vasodilator stressor?
4-Diagnostic accuracy and prognostic value of each
modality.
5-Early Post MI ischemia and Viability Assessment.
8. 8
Indications for the use of pharmacological
imaging modalities:
1. Inadequate exercise secondary to neurological,
orthopedic, peripheral vascular or respiratory problems.
2.Poor image degradation with exercise.
3.Poor patient motivation to exercise
9. 9
Debates about the issue
1-Which modality to choose?
2-Pharmacological Vs exercise?
3-Inotropic Vs vasodilator stressor?
4-Diagnostic accuracy and prognostic value of each
modality.
5-Early Post MI ischemia and Viability Assessment.
10. 10
The choice of one pharmacological test over the
other as the preferred imaging modality may
depend upon local drug cost, tests safety, and
expertise available.
Vasodilator, inotropic, and exercise stresses are all
needed to optimize the enormous diagnostic and
prognostic potential of stress testing.
Whatever the test choice, the results of
physical(more physiological) or pharmacological
stress echo should be used as a “gatekeeper” to
coronary angiography.
15. 15
The use of stress echocardiography is advocated in
the ESC guidelines on suspected ACS (class I, level
A evidence) and is categorized as appropriate in
suspected ACS in North American guidelines.
In both guidelines , the use of stress
echocardiography is mainly recommended for
patients with no resting chest pain, normal ECG
findings, negative troponin, and a low risk score.
16. 16
In Europe, both the law and the referral guidelines for
medical imaging recommend a justified, optimized, and
responsible use of testing with ionizing radiation .
1-The justification principle : “if an exposure cannot be
justified, it should be prohibited”.
2- According to ALARA principle, “all doses due to medical
exposures must be kept (As Low As Reasonably
Achievable”), and the responsibility principle.
19. 19
Prognostic value:
SE has been shown to play an important role in
the prediction of mortality and composite cardiac
events in patients with known or suspected CAD.
A normal exercise SE is associated with a
mortality of <1%/year, while normal
pharmacological stress has been associated with
mortality <1.5% (patients undergoing
pharmacological stress have more comorbidities
and, hence, a greater cardiovascular disease
burden).
24. 24
Cost-effectiveness of functional cardiac testing in the diagnosis and
management of coronary artery disease: a randomized controlled trial. The
CECaT trial.
Sharples L1, Hughes V, Crean A, Dyer M, Buxton M, Goldsmith K, Stone D.
RESULTS:
The 898 patients were randomized to angiography (n = 222), SPECT (n = 224), MRI (n = 226) or stress echo (n =
226). Initial diagnostic tests were completed successfully with unequivocal results for 98% of angiography, 94% of
SPECT (p = 0.05), 78% of MRI (p < 0.001) and 90% of stress echocardiography patients (p < 0.001). Some 22%
of SPECT patients, 20% of MRI patients and 25% of stress echo patients were not subsequently referred for an
angiogram. Positive functional tests were confirmed by positive angiography in 83% of SPECT patients, 89% of
MRI patients and 84% of stress echo patients. Negative functional tests were followed by positive angiograms in
31% of SPECT patients, 52% of MRI patients and 48% of stress echo patients tested.
CONCLUSIONS:
Between 20 and 25% of patients can avoid invasive testing using functional testing as a gateway to angiography,
without substantial effects on outcomes. The SPECT strategy was as useful as angiography in identifying
patients who should undergo revascularization and the additional cost was not significant, in fact it would be
reduced further by restricting the rest test to patients who have a positive stress test. MRI had the largest
number of test failures and, in this study, had the least practical use in screening patients with suspected CAD,
although it had similar outcomes to stress echo and is still an evolving technology. Stress echo patients had a
10% test failure rate, significantly shorter total exercise time and time to angina at 6 months post-treatment, and
a greater number of adverse events, leading to significantly higher costs. Given the level of skill required for
stress echo, it may be best to reserve this test for those who have a contraindication to SPECT and are unable
or unwilling to have MRI
25. 25
Conclusion:
Recent European Society of Cardiology guidelines clearly
state that stress echocardiography provides similar
diagnostic and prognostic accuracy as radionuclide stress
perfusion imaging, but at a substantially lower cost, without
environmental impact, and with no biohazards for the
patient and the physician.
Different stresses (exercise, dipyridamole, dobutamine)
have comparable diagnostic and prognostic accuracy
according to evidence-based medicine mirrored in
European guidelines.
32. 32
Single-Photon Emission Computed Tomography (SPECT) Fleishmann et al
(1998), meta-analysis of 44 articles using Tl 201 or Tc 99m sestamibi
demonstrated that both exercise echocardiography and exercise SPECT
had similar sensitivities; 85% vs. 87%, respectively but with lower
specificity compared to echocardiography; 64 vs. 77%.
This result is in agreement with Kim et al (2001) ,meta-analysis, in which
using dobutamine with SPECT and ECHO showed similar sensitivities,
82% and 80%, respectively.
A meta-analysis by Imran et al, showed that stress SPECT(using exercise
in three studies, dobutamine in one study and dipyridamole in 6 studies)
had higher sensitivity (88% vs. 70%) and lower specificity (67% vs. 90%)
compared to ECHO.
34. 34
Head-to-head comparison of dipyridamole echocardiography
and stress perfusion scintigraphy for the detection of
coronary artery disease: a meta-analysis. Comparison between
stress echo and scintigraphy.
METHODS: We performed a meta-analysis of peer reviewed articles, published
in English language reporting head-to-head comparison of DET vs. SPS for the
diagnosis of CAD. Data of 10 studies comprising 651 patients from 10 different
institutions were analyzed. DET dose was 0.56 mg/kg (low dose) in two studies,
0.75 mg/kg in 10 min or 0.84 mg/kg in 10 min (high dose) in six studies, and 0.84
mg/kg in 6 min (accelerated high dose) in one study and 0.84 mg/kg in 10 min + 1
mg atropine co-administration (augmented dose) in one study. SPS was
performed with dipyridamole in six studies, with exercise n three studies and with
dobutamine in one study.
RESULTS: The overall diagnostic accuracy of the two tests was almost similar,
77% (95% CI = 74-81) for DET vs. 81% (95% CI = 78-84) for SPS (p = ns). SPS
gave higher sensitivity, 88% (95% CI = 85-89) than DET, 70% (95% CI = 66-75) in
cumulative data (p < 0.0001) while DET gave higher specificity, 90% (95% CI =
86-94) vs. 67% (95% CI = 60-73) (p < 0.0001). With state-of-the-art protocols, i.e.
accelerated dose and atropine augmented high dose, sensitivity of DET improved
and overall accuracy was better than SPS (p < 0.05).
CONCLUSION: DET and SPS have a similar diagnostic accuracy. DET has a
markedly higher specificity regardless of the dose employed. SPS shows a
superior sensitivity, however this sensitivity gap diminishes when more
aggressive dipyridamole dosage is used for the stress echocardiography.
35. 35
TI-201 is one of the longest used agents in MPI and has
been found to be effective in the detection of CAD with
an estimated sensitivity and specificity of 89% and 76%
respectively .
The limitations seen with the use of TI-201 include long
half life, poor count statistics, and low-energy emission.
Because of the higher radiation exposure when
compared to alternative agents, the use of thallium has
been discouraged unless there are no other options.
36. 36
An alternate option is Tc-99m, which is associated with
improved imaging quality secondary to higher photon
energy and the ability to administer higher doses
because of a shorter half-life 6 hours when compared to
thallium 72 hours.
In studies directly comparing SPECT using Tl-201 and
Tc-99m sestamibi, the sensitivity of Tc-99m sestamibi
was significantly greater that that for Tl-201 (93% versus
80%), although the specificity was similar for the two
agents.
37. 37
In the more recent ROBUST study of 2560
individuals randomized to undergo SPECT perfusion
imaging with either Tl-201, Tc-99m sestamibi, or Tc-
99m tetrofosmin, the sensitivities and specificities of
the three agents were similar in the subset of 137 who
underwent subsequent angiography.
However, image quality was superior for the studies
acquired with the Tc-99m-based agents, most likely
due in part to the lower energy of Tl-201.
38. 38
In conclusion: There are technical differences between the tracers.
Overall image quality score is superior using technetium, with less
low-count artefact and less attenuation.
Stress defect depth and extent are slightly greater using thallium,
with no difference between MIBI and tetrofosmin.
All three tracers perform well in clinical terms, with high sensitivity
and specificity for angiographic stenosis and no differences in
accuracy between the tracers.
39. 39
Prognostic Value of SPECT MPI:
Observational study of 1,187 consecutive patients showed
excellent 1-year outcome in patients with normal MPS
compared with those with abnormal MPS (0% MI/death versus
11% MI and 8% cardiac death, P < 0.001).
40. 40
Comprehensive strategy for the evaluation and triage of the chest
pain patient.
Tatum JL1, Jesse RL, Kontos MC, Nicholson CS, Schmidt KL, Roberts CS, Ornato JP.
METHODS: We conducted an observational study of 1,187 consecutive patients seen in the
ED of an urban tertiary care hospital with the chief complaint of chest pain. Within 60
minutes of presentation, each patient was assigned to one of five levels on the basis of his
or her risk of myocardial infarction (MI) or unstable angina (UA): level 1, MI; level 2, MI/UA;
level 3, probable UA; level 4, possible UA; and level 5, noncardiac chest pain. In the lower
risk levels (3 and 4), immediate resting myocardial perfusion imaging was used as a risk-
stratification tool alone (level 4) or in combination with serial markers (level 3).
RESULTS: Acute MI, early revascularization indicative of acute coronary syndrome, or both were
consistent with risk designations: level 1: 96% MI, 56% revascularization; level 2: 13% MI, 29%
revascularization; level 3: 3% MI, 17% revascularization; level 4: .7% MI; 2.5% revascularization.
Sensitivity of immediate resting myocardial perfusion imaging for MI was 100% (95% confidence interval
[CI], 64% to 100%) and specificity 78% (74% to 82%). In patients with abnormal imaging findings, risk for
MI (7% versus 0%, P < .001; relative risk [RR], 50; 95% CI, 2.8 to 889) and for MI or revascularization
(32% vs 2%, P < .001; RR, 15.5; 95% CI, 6.4 to 36) were significantly higher than in patients with normal
imaging findings. During 1-year follow-up, patients with normal imaging findings (n = 338) had an event
rate of 3% (revascularization) with no MI or death (combined events: negative predictive value, 97%; 95%
CI, 95% to 98%). Patients with abnormal imaging findings (n = 100) had a 42% event rate (combined
events: RR, 14.2; 95% CI, 6.5 to 30; P < .001), with 11% experiencing MI and 8% cardiac death.
CONCLUSION: This strategy is a safe, effective method for rapid triage of chest pain patients. Rapid
perfusion imaging plays a key role in the risk stratification of low-risk patients, allowing discrimination of
unsuspected high-risk patients who require prompt admission and possible intervention from those who
are truly at low risk.
41. 41
A growing consensus endorses PET as the most
effective imaging technique for myocardial perfusion
imaging and points to some very clear advantages
compared with SPECT.
PET imparts a higher specificity than SPECT, which is
most likely a consequence of its superior attenuation
correction, increased count-density images, and superior
spatial resolution.
PET has improved spatial resolution as 2–3 mm as
compared with the 6- to 8-mm resolution of conventional
SPECT imaging
42. 42
Despite this, cardiac Positron Emission Tomography (PET)
perfusion imaging has been recognized as superior to
standard SPECT imaging due to higher image quality and
a greater efficiency .
However, it has been infrequently used due to limited
availability of camera systems, radiopharmaceuticals and
technical difficulties in cardiac acquisition and processing.
43. 43
Recently, the number of PET Camera systems has
increased substantially and acquisition, processing and
display of Cardiac PET studies has vastly improved.
Thus, since its introduction in the early 1980s , the use
of Cardiac PET perfusion imaging has greatly increased
within the last 8 years
Its superior sensitivity and specificity over SPECT
myocardial perfusion imaging , as well as the routine
availability of Rubidium-82 (Rb-82), has made cardiac
PET an important tool in the detection and risk strati fi
cation of coronary artery disease.
44. 44
Several studies have demonstrated that PET offers a
superior diagnostic accuracy in detecting CAD.
A recent systematic review of PET by Al Moudi et al. ,
demonstrated a superior sensitivity and specificity of PET
when compared to SPECT leading to increased
diagnostic accuracy.
52. 52
Cardiac PET imaging acquisition protocols are much
more efficient than SPECT.
Most cardiac PET perfusion laboratory protocols can be
completed in 25–40 min. This is a greater than 50%
reduction in procedure time when compared to SPECT.
55. 55
Obese patients suspected of having coronary artery
disease may also benefit from a Cardiac PET perfusion
study for diagnosis or risk stratification.
Patients weighing over 250 lb, with a BMI greater than 30
should be considered for cardiac PET rather than
SPECT.
Cardiac PET isotopes generate a 3-fold higher energy
emission than SPECT can capture and therefore offer
better diagnostic accuracy without the attenuation artifact
that is often seen with SPECT in this patient population.
In addition, PET has a much more robust attenuation
correction protocol making it more reliable in this patient
population.
56. 56
One of the important qualities of cardiac PET is its
higher accuracy in detecting multivessel disease. When
contrasted to SPECT for the detection of multivessel
disease, the sensitivity is 71% for PET as compared to
48% for SPECT.
For this reason, cardiac PET may be a better option for
not only identifying territories that would benefit from
revascularization, but also for risk stratifying patients that
may have multivessel coronary artery disease.
57. Safety and radiation exposure
57
Both SPECT and PET will, albeit low, expose the patient to radiation.
However by following simple protocols this exposure can be minimized.
SPECT, tracer and protocol choice can substantially reduce the radiation
expose. Thallium results in 15–20 mSv of exposure while Technetium
results in 8–10.
In contrast, cardiac PET can reduce the exposure to as low as 3–5 mSv
primarily due to the more efficient protocol and better suited isotope.
These data demonstrate PET perfusion imaging has favorably radiation
dosimetry and should be considered for the appropriate patient.
60. 60
CMR is primarily a functional test; however it can identify
the anatomy of coronary arteries. Detection of myocardial
ischemia is mainly achieved by 2 main techniques;
assessment of wall motion abnormalities mainly with
dobutamine and assessment of myocardial perfusion
during vasodilators (adenosine and dipyridamole)
infusion.
Contrast agent “gadolinium- based contrast agents” or
(GBCAs) is used for this purpose. CMR is mainly
indicated for patients with intermediate pre-test likelihood
of CAD who do not have the ability to exercise.
61. 61
Stress Perfusion Imaging
MRI perfusion studies use the “first pass” of an
intravenously injected Gd contrast agent during
administration of a vasodilator (i.e. adenosine or
dipyridamole) to depict hemodynamically significant
coronary artery stenosis .
68. 68
Overall, the literature over the last 3 years supports the diagnostic superiority of
stress CMRI and PET over the alternatives.
However, these comparative studies look directly at myocardial perfusion
imaging.
This ignores the fact that stress CMRI is a comprehensive study, including gold
standard for quantitative functional analysis and high-resolution scar imaging
for viability assessment in segments with fixed perfusion defects.
In addition, rapid technological improvement in the field has improved the
speed, quality, and reliability of MR stress perfusion imaging.
73. 73
Edema Imaging
T2-relaxation time is linearly correlated to the
percentage of free water, and edema is visible on T2-
weighted MR sequences in infarcted myocardium as
bright areas (hyper-intense).
In acute MI patients, it is accepted that the bright
myocardium on T2-weighted imaging reflects the
myocardium at risk.
75. 75
The emergence of delayed enhancement imaging for
viability assessment represented a landmark in the
evolution of assessing myocardial viability and has since
spurred growing acceptance of CMRI as a valuable tool
for evaluation of IHD.
CMRI plays a valuable role In ischemic cardiomyopathy,
both suspected and confirmed CAD, and suspected MI.
76. 76
It has become the gold standard for quantification of
both right and left ventricular volumes and function and,
as the data above demonstrate, is a powerful tool for
viability evaluation prior to revascularization.
In addition, early data promises improved risk
stratification for defibrillator placement. Perhaps most
importantly, CMRI stands to reduce unnecessary
intervention, both by predicting functional recovery and
by proposing alternative diagnoses unrelated to IHD.
78. 78
CT perfusion imaging is a new promising
technology that aims to enhance the role of CTA in
practice by allowing it to detect coronary stenoses
and its functional significance in single test.
Moreover, a prospective multi-center international
trial (CORE 320)showed that combining CTA and
CT perfusion had a strong diagnostic accuracy in
determining flow-limiting coronary stenoses as
compared to ICA and SPECT-MPI
79. 79
A meta-analysis by Tashakkor et al
(2012) showed that CT perfusion
combined to CTCA had a sensitivity of
81%, specificity of 93%, PPV 87% and
NPV 88%.
84. 84
Debates about the issue:
1-Which modality to choose?
2-Pharmacological Vs exercise?
3-Inotropic Vs vasodilator stressor?
4-Diagnostic accuracy and prognostic value of each
modality.
5-Early Post MI ischemia and Viability Assessment.
90. 90
Conclusion:
The assessment of myocardial viability has become an
integrated part of the diagnostic and prognostic work-up of
patients with heart failure symptoms attributable to ischemic
cardiomyopathy.
The current analysis of pooled data showed that sensitivity for
prediction of functional recovery after revascularization is high
for all techniques reviewed here. Specificity is highest for
LDDE and lowest for Tl-201 stress– redistribution–reinjection
and Tl-201 rest–redistribution. Thus, the available evidence
favors the use of LDDE as the technique of first choice for
prediction of regional functional recovery in patients with
chronic ischemic LV dysfunction for whom revascularization is
contemplated
Editor's Notes
Answer for the first question
Why we do stress imaging?
1-Imaging to increase the number of correct diagnoses in the acute situation;
2- Imaging to rule out other than coronary causes of chest pain;
3- Use of imaging for risk stratification once MI has been ruled out in the chest pain units.
Answer for the first question
Why we do stress imaging?
1-Imaging to increase the number of correct diagnoses in the acute situation;
2- Imaging to rule out other than coronary causes of chest pain;
3- Use of imaging for risk stratification once MI has been ruled out in the chest pain units.
Answer for the first question
Why we do stress imaging?
1-Imaging to increase the number of correct diagnoses in the acute situation;
2- Imaging to rule out other than coronary causes of chest pain;
3- Use of imaging for risk stratification once MI has been ruled out in the chest pain units.
7.European Commission Referral Guidelines for imaging. Rad Protect 2001; 118:1–125. Available at: http://europa.eu.int/comm/environment/radprot/118/rp-118-en.pdf
8. Picano E. Sustainability of medical imaging. Education and Debate. BMJ 2004; 328:578–580
11. Metz LD, Beattie M, Hom R, et al., The prognostic value of normal exercise myocardial perfusion imaging and exercise echocardiography: a meta-analysis, J Am Coll Cardiol, 2007;49(2):227–37.
Prognostic Value of Stress Echocardiogram in Patients With
Angiographically Significant Coronary Artery Disease
Siu-Sun Yao, MDa,c, Omar Wever-Pinzon, MDb, Xiaoqian Zhang, MDb, Sripal Bangalore,
MDb, and Farooq A. Chaudhry, MDbAm J Cardiol. 2012 January 15; 109(2): 153–158. doi:10.1016/j.amjcard.2011.08.023.
Fox K, Garcia MA, Ardissino D, et al. Task Force on the Management of Stable Angina
Pectoris of the European Society of Cardiology; ESC Committee for Practice Guidelines
(CPG), Guidelines on the management of stable angina pectoris: Executive summary:
The Task Force on the Management of Stable Angina Pectoris of the European
Society of Cardiology
al Moudi M, Sun Z, Lenzo N. Diagnostic value of SPECT, PET and PET/CT in the diagnosis of
coronary artery disease: a systematic review. Biomed Imaging Interv J. 2010;7(2):e9.
Answer for the first question
Why we do stress imaging?
1-Imaging to increase the number of correct diagnoses in the acute situation;
2- Imaging to rule out other than coronary causes of chest pain;
3- Use of imaging for risk stratification once MI has been ruled out in the chest pain units.