Coronary Artery Disease: Berman DS

Raff GL, Abidov A, Achenbach S, Berman DS, Boxt LM, Budoff MJ, Cheng V, DeFrance T, Hellinger JC, Karlsberg RP, Anonymous00022. · Society of Cardiovascular Computed Tomography, 2400 N Street NW, Washington, DC 20037, USA. · J Cardiovasc Comput Tomogr. · Pubmed #19272853 No free full text.

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Klocke FJ, Baird MG, Lorell BH, Bateman TM, Messer JV, Berman DS, O'Gara PT, Carabello BA, Russell RO, Cerqueira MD, St John Sutton MG, DeMaria AN, Udelson JE, Kennedy JW, Verani MS, Williams KA, Antman EM, Smith SC, Alpert JS, Gregoratos G, Anderson JL, Hiratzka LF, Faxon DP, Hunt SA, Fuster V, Jacobs AK, Gibbons RJ, Russell RO, Anonymous00288, Anonymous00289, Anonymous00290. · No affiliation provided · J Am Coll Cardiol. · Pubmed #14522503 No free full text.

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Klocke FJ, Baird MG, Lorell BH, Bateman TM, Messer JV, Berman DS, O'Gara PT, Carabello BA, Russell RO, Cerqueira MD, St John Sutton MG, DeMaria AN, Udelson JE, Kennedy JW, Verani MS, Williams KA, Antman EM, Smith SC, Alpert JS, Gregoratos G, Anderson JL, Hiratzka LF, Faxon DP, Hunt SA, Fuster V, Jacobs AK, Gibbons RJ, Russell RO, Anonymous00249, Anonymous00250, Anonymous00251. · No affiliation provided · Circulation. · Pubmed #12975245 links to  free full text

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Mieres JH, Shaw LJ, Hendel RC, Miller DD, Bonow RO, Berman DS, Heller GV, Mieres JH, Bairey-Merz CN, Berman DS, Bonow RO, Cacciabaudo JM, Heller GV, Hendel RC, Kiess MC, Miller DD, Polk DM, Shaw LJ, Smanio PE, Walsh MN, Anonymous00349. · American Society of Nuclear Cardiology, Bethesda, MD 20814-1699, USA. · J Nucl Cardiol. · Pubmed #12569338 No free full text.

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Mieres JH, Shaw LJ, Hendel RC, Miller DD, Bonow RO, Berman DS, Heller GV, Mieres JH, Bairey-Merz CN, Berman DS, Bonow RO, Cacciabaudo JM, Heller GV, Hendel RC, Kiess MC, Miller DD, Polk DM, Shaw LJ, Smanio PE, Walsh MN, Anonymous00349. · American Society of Nuclear Cardiology, Bethesda, MD 20814-1699, USA. · J Nucl Cardiol. · Pubmed #12569338 No free full text.

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Wolak A, Berman DS. · No affiliation provided · J Cardiovasc Comput Tomogr. · Pubmed #19083939 No free full text.

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Abidov A, Germano G, Berman DS. · No affiliation provided · J Nucl Cardiol. · Pubmed #17679057 No free full text.

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Shaw LJ, Berman DS. · No affiliation provided · J Nucl Cardiol. · Pubmed #16084424 No free full text.

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Abidov A, Berman DS. · No affiliation provided · J Nucl Cardiol. · Pubmed #15944529 No free full text.

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Berman DS. · No affiliation provided · J Nucl Cardiol. · Pubmed #15295405 No free full text.

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Min JK, Shaw LJ, Berman DS. · Division of Cardiology, Department of Medicine, Weill Medical College of Cornell University, New York Presbyterian Hospital, 520 E 70th Street, K415, New York, NY 10021, USA. · Expert Rev Cardiovasc Ther. · Pubmed #18095906 No free full text.

Abstract: Computed tomography has been introduced as a noninvasive imaging modality used for coronary artery calcium scoring in asymptomatic individuals and contrast-enhanced coronary angiography in symptomatic individuals. As the rising costs of healthcare reflect, in part, the development of these types of new expensive technologies for cardiac diagnosis, the economic considerations that surround them should be of interest to clinicians and payers alike. In this review, we discuss basic principles underlying economic efficiency analyses of medical products, using computed tomography in coronary artery disease as a case in point.

Berman DS, Shaw LJ, Hachamovitch R, Friedman JD, Polk DM, Hayes SW, Thomson LE, Germano G, Wong ND, Kang X, Rozanski A. · Department of Imaging and Medicine, Cedars-Sinai Medical Center, CSMC Burns and Allen Research Institute, Los Angeles, CA 90048, USA. · Semin Nucl Med. · Pubmed #17161035 No free full text.

Abstract: Noninvasive cardiac imaging has undergone a recent resurgence with the development of new approaches for imaging coronary atherosclerosis. Non-contrast computed tomography (CT) for imaging the extent of coronary artery calcification (CAC) and contrast CT for noninvasive coronary angiography (CTA) are developments with a growing evidence base regarding risk assessment and the diagnosis of obstructive coronary disease. This review discusses the role of CAC for risk assessment of asymptomatic individuals and for the use of coronary CTA in symptomatic patients. By comparison, gated myocardial perfusion scintigraphy (MPS) is a well-established noninvasive imaging modality that is a core element in evaluation of patients with stable chest pain syndromes. Stress MPS is the most commonly used stress imaging technique for patients with suspected or known coronary disease. In contrast to the nascent evidence noted with coronary CTA, MPS has a robust evidence base, including the support of numerous clinical guidelines. We highlight the current evidence supporting the diagnostic accuracy and risk stratification data for MPS for symptomatic patients with known or suspected coronary artery disease. It is likely that assessing the extent of atherosclerosis using CAC or coronary CTA will become an increasing part of mainstream cardiovascular imaging practices. In some patients, further ischemia testing with MPS will be required. Similarly, in some patients referred for MPS, anatomic definition of atherosclerosis using CAC by CT may be appropriate. Thus, this review also provides a synopsis of the available literature on imaging that integrates both CT and MPS in combined strategies for the assessment of atherosclerotic and obstructive coronary disease burden. We also propose possible risk-based strategies through which imaging might be used to identifying candidates for more intensive prevention and risk factor modification strategies as well as those who would benefit from referral to coronary angiography and revascularization.

Berman DS, Hachamovitch R, Shaw LJ, Friedman JD, Hayes SW, Thomson LE, Fieno DS, Germano G, Wong ND, Kang X, Rozanski A. · Department of Imaging and Medicine, Cedars-Sinai Medical Center, Burns and Allen Research Institute, Los Angeles, California 90048, USA. · J Nucl Med. · Pubmed #16818945 links to  free full text

Abstract: This review deals with noninvasive imaging for risk stratification and with a conceptual approach to the selection of noninvasive tests in patients with suspected or known chronic coronary artery disease (CAD). Already widely acknowledged with SPECT, there is an increasing body of literature data demonstrating that CT coronary calcium assessment is also of prognostic value. The amount of coronary atherosclerosis, as can be extrapolated from CT coronary calcium score, has been shown to be highly predictive of cardiac events. The principal difference between myocardial perfusion SPECT (MPS) and CT coronary calcium for prognostic application appears to be that the former is an excellent tool for assessing short-term risk, thus effectively guiding decisions regarding revascularization. In contrast, the atherosclerosis imaging methods are likely to provide greater long-term risk assessment and, thus, are more useful in determination of the need for aggressive medical prevention measures. Although the more recent development of CT coronary angiography is promising for diagnosis, there has been no information to date regarding the prognostic value of the CT angiographic data. Similarly, cardiac MRI has not yet been adequately studied for its prognostic content. The selection of the most appropriate test for a given patient depends on the specific question being asked. In patients with a very low likelihood of CAD, no imaging test may be required. In screening the remaining asymptomatic patients, atherosclerosis imaging may be beneficial. In symptomatic patients, MPS, CT coronary angiography, and cardiac MRI play important roles. We consider it likely that, with an increased emphasis on prevention and a concomitant aging of the population, many forms of noninvasive cardiac imaging will continue to grow, with nuclear cardiology continuing to grow.

Hecht HS, Budoff MJ, Berman DS, Ehrlich J, Rumberger JA. · Lenox Hill Heart and Vascular Institute, New York, NY 10021, USA. · Am Heart J. · Pubmed #16781212 No free full text.

Abstract: BACKGROUND: Coronary artery calcium (CAC) scanning is being increasingly used for cardiac risk assessment in asymptomatic patients, particularly in those with a Framingham 10-year risk of 10% to 20%. Physician awareness of this technology and its appropriate uses and limitations is crucial to appropriate use. METHODS: With the goal of establishing clinical paradigms, this document integrates the results of key published articles, Framingham Risk Score, National Cholesterol Education Program Adult Treatment Plan III guidelines, American College of Cardiology/American Heart Association exercise testing and angiographic guidelines, and the authors' extensive clinical experience. RESULTS: Coronary artery calcium scanning is best used in the asymptomatic population with a 10% to 20% risk of cardiac events over 10 years, with selected application in higher and lower risk categories. In the 10%-20% risk patient, coronary artery calcium scores >100 or >75th percentile for age and sex transform the moderately high-risk patient to higher risk status with the attendant recommendation for more aggressive therapy; scores from 11 to 100 and <75th percentile are consistent with the 10%-20% 10-year risk status and scores from 0 to 10 and <75th percentile convert the patient to lesser risk categories. If stress testing is planned in the asymptomatic patient, it should be preceded by coronary artery calcium scanning and performed only for scores >400; it should always precede coronary angiography in these patients. CONCLUSIONS: Coronary artery calcium scanning is an important risk assessment tool with direct clinical applications; it is of particular utility in the Framingham 10%-20% 10-year risk population.

Shaw LJ, Taylor A, Raggi P, Berman DS. · Cedars-Sinai Medical Center and David Geffen School of Medicine at UCLA, Los Angeles, Calif 90048, USA. · J Nucl Cardiol. · Pubmed #16580949 No free full text.

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Berman DS, Hachamovitch R, Shaw LJ, Friedman JD, Hayes SW, Thomson LE, Fieno DS, Germano G, Slomka P, Wong ND, Kang X, Rozanski A. · Department of Imaging and Medicine, Cedars-Sinai Medical Center, Burns and Allen Research Institute, Los Angeles, California 90048, USA. · J Nucl Med. · Pubmed #16391190 links to  free full text

Abstract: Noninvasive cardiac imaging is now central to the diagnosis and management of patients with known or suspected chronic coronary artery disease (CAD). Although rest echocardiography has become the most common of the techniques, nuclear cardiology and more recently cardiac computed tomography (CCT) and cardiac magnetic resonance (CMR) play important roles in this regard. This review examines the current applications and interactions of noninvasive cardiac imaging approaches for the assessment of patients with suspected CAD. In addition to considering the strengths and weaknesses of each technique, this review attempts to provide a guide to the selection of a test (or tests) that is based on the question being asked and the ability of each test to answer this question. In patients with suspected CAD, the pretest likelihood of disease, a clinical assessment, becomes the most important determinant of the initial test. If the likelihood is very low, no testing is needed. However, if the likelihood is low, recent data suggest that assessment of early atherosclerosis is likely to be the most useful and cost-effective test. In patients who have an intermediate likelihood of CAD, nuclear cardiology with myocardial perfusion SPECT (MPS) becomes highly valuable; however, coronary CT angiography (CTA), with fast 16-slice or greater scanners, may emerge as the initial test of choice. MPS would then be used if the CTA is inconclusive or if there is a need to assess the functional significance of a stenosis defined by CTA. Coronary CTA, however, is not yet widely available and is limited in patients with dense coronary calcification. In older patients with a high likelihood of CAD, MPS may be the initial test of choice, since a high proportion of these patients have too much coronary calcium to allow accurate assessment of the presence of coronary stenoses. PET/CT or SPECT/CT could emerge as important modalities combining the advantages of each modality. While CMR has great promise as a radiation-free and contrast-free "one-stop" shop, it currently lags behind CTA for noninvasive coronary angiography. Nonetheless, CMR clearly has the potential for this application and has already emerged as a highly effective method for assessing ventricular function, myocardial mass, and myocardial viability, and there is increasing use of this approach for clinical rest and stress perfusion measurements. CMR is particularly valuable in distinguishing ischemic from nonischemic cardiomyopathy. While CT and CMR are likely to grow considerably in diagnostic evaluation over the next several years, MPS and PET will continue to be very valuable techniques for this purpose.

Shaw LJ, Berman DS. · Department of Medicine and Imaging, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA. · Am J Cardiol. · Pubmed #16246651 No free full text.

Abstract: The utility of stress myocardial perfusion imaging (MPI) for the diagnosis and prognosis of coronary artery disease (CAD) has been firmly established in numerous clinical studies and has become an essential component of clinical practice. Stress MPI is now used regularly to guide initial risk stratification and management of patients with CAD. Because stress MPI provides an assessment of the physiologic significance of CAD, it is a particularly attractive procedure for assessing follow-up risk. Today, sequential stress MPI is being used increasingly to track disease progression, assess follow-up risk, detect restenosis following revascularization, and evaluate the efficacy of aggressive medical therapy and risk-factor modification. By providing serial snapshots of the disease and its impact on perfusion, sequential stress MPI may alter treatment decisions and ultimately improve long-term patient management and outcomes. Use of sequential stress MPI to detect changes in perfusion following surgical or medical therapies is being tested currently in the Clinical Outcomes Using Revascularization and Aggressive Drug Evaluation (COURAGE) and Adenosine Sestamibi Single-Photon Emission Computed Tomography Postinfarction Evaluation (INSPIRE) trials.

Abidov A, Hachamovitch R, Berman DS. · Department of Cardiac Imaging, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA. · Minerva Cardioangiol. · Pubmed #15729211 links to  free full text

Abstract: Congestive heart failure (CHF) has become a large social burden in modern Western society, with very high morbidity and mortality and extremely large financial costs. The largest cause of CHF is coronary heart disease, with ventricular dysfunction that may or may not be reversible by revascularization. Thus, evaluation of the viable myocardial tissue in patients with ischemic left ventricular (LV) dysfunction has important clinical and therapeutic implications. Furthermore, since patients with ventricular dysfunction are at higher operative risk, cardiologists and cardiac surgeons are commonly faced with issues regarding the balance between the potential risk vs benefit of revascularization procedures. Cardiac nuclear imaging [myocardial perfusion SPECT (MPS) and positron emission tomography (PET)] provide objective information that augments standard clinical and angiographic assessments of patients with ventricular dysfunction with respect to diagnosis (etiology), prognosis, and potential benefit from intervention. Development of the technology and methodology of gated MPS, now the routine method for MPS, allows assessment of the extent and severity of inducible ischemia as well as hypoperfused but viable myocardium, and also provides measurements of LV ejection fraction, regional wall motion, LV volume measurements, diastolic function and LV geometry. With PET, myocardial metabolism and blood flow reserve can be added to the measurements provided by nuclear cardiology procedures. This paper provides insight into the current evidence regarding settings in which nuclear cardiac imaging procedures are helpful in assessment of patients in the setting of coronary artery disease with severe LV dysfunction. A risk-benefit approach to MPS results is proposed, with principal focus on identifying patients at risk for major cardiac events who may benefit from myocardial revascularization.

Raggi P, Berman DS. · Tulane University School of Medicine, New Orleans, LA 70112-2699, USA. · J Nucl Cardiol. · Pubmed #15682370 No free full text.

Abstract: Cardiac computed tomography (CT) has seen an exponential increase in interest as applications expanded from identification of coronary artery calcification to noninvasive coronary angiography and, more recently, identification of soft and noncalcified plaques. The interest arises from the well-known fact that cardiovascular disease remains the most prevalent cause of death in the Western hemisphere and the fact that in a large proportion of patients the initial event is either sudden death or a disabling myocardial infarction or stroke. Although traditional risk factors are extremely helpful in determining risk in a population, the prognostic ability of risk factors alone in the individual patient is limited. Hence, researchers have turned their attention to noninvasive modalities to image the atherosclerotic plaque in its preclinical stages, hoping to better address this ailment at its inception and change the natural history of the disease. Measurements of coronary artery calcium (CAC) serve as a quantitative reflection of the severity of coronary artery atherosclerosis, and greater calcium burdens correlate with more advanced disease. Indeed, CAC has been shown to add prognostic value to traditional risk factors in patients at intermediate risk, and in this group of patients, it is most cost-effective. Furthermore, CAC measurements providing an assessment of coronary atherosclerotic plaque burden appear to be complementary to myocardial perfusion single photon emission computed tomography that offers information regarding inducible ischemia. In this manner, a better assessment of risk in a patient suspected of harboring preclinical or early coronary artery disease can be achieved. In this article we review the most relevant literature regarding the utilization of CAC testing as a tool to refine risk assessment and use several case studies to exemplify the combination of CT imaging and functional myocardial perfusion studies, which may provide a better identification of patients in need of aggressive medical therapy and those needing invasive assessment for possible coronary revascularization.

Hachamovitch R, Berman DS. · Department of Imaging, Division of Nuclear Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA. · Semin Nucl Med. · Pubmed #15645395 No free full text.

Abstract: Extensive data exist to support the role of myocardial perfusion single-photon emission computed tomography (MPS) in risk stratification. Normal MPS studies usually are associated with very low risk, and patient risk increase significantly as a function of MPS results. Ventricular function measurements from gated single-photon emission computed tomography further augment risk stratification, particularly with respect to identifying patients at risk of cardiac death. Ancillary findings are prognostically important, particularly in the setting of normal or near-normal MPS results. Recent data suggest that MPS results can identify which patients will benefit from revascularization versus medical therapy and have expanded the understanding of how stress MPS is helpful in the identification of risk, enhanced the means of identifying risk, and improved its use as a means to identify optimal posttest treatment.

Abidov A, Hachamovitch R, Berman DS. · Department of Cardiac Imaging, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA. · Semin Thorac Cardiovasc Surg. · Pubmed #15619195 No free full text.

Abstract: Cardiac surgeons are commonly faced with issues regarding the balance between the potential risk and the potential benefit of a surgical procedure. Nuclear cardiology procedures [myocardial perfusion SPECT (MPS) and positron emission tomography (PET)] provide the surgeon with objective information that augments standard clinical and angiographic assessments with respect to diagnosis, prognosis, and potential benefit from intervention. Development of the technology and methodology of gated MPS acquisition and interpretation allows assessment of the extent and severity of hypoperfused but viable myocardium, as well as global LVEF and LV volume measurements, diastolic function, and LV geometry. With PET, myocardial metabolism and blood flow reserve can also be measured. This chapter provides insight into the current evidence regarding settings in which nuclear cardiology procedures are helpful to the surgeon in assessment of patients having or being considered for cardiac surgery in the setting of coronary artery disease (CAD). Overall, a risk-benefit approach to MPS results is proposed, with principal focus on identifying patients at risk for major cardiac events who may benefit from a surgical procedure.

Hachamovitch R, Berman DS. · Cardiovascular Division, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA. · Curr Opin Cardiol. · Pubmed #14597891 No free full text.

Abstract: PURPOSE OF REVIEW: The purpose of this review is to review the recent published literature since 2002 for studies using stress myocardial perfusion single photon emission computed tomography for determination of the prognostic value of testing. RECENT FINDINGS: A series of manuscripts dealing with myocardial perfusion single photon emission computed tomography have been published over the past 2 years that have altered a number of the most basic concepts defining risk stratification. These studies may have redefined the manner in which noninvasive stress imaging results will be interpreted and applied. SUMMARY: Recent studies have expanded the understanding of how stress myocardial perfusion single photon emission computed tomography is helpful in the identification of risk, enhanced the means of identifying risk, and improved its use as a means to identify optimal posttest treatment.

Shaw LJ, Miller DD, Berman DS, Hachamovitch R. · Emory University, Atlanta, Georgia 30322, USA. · Q J Nucl Med. · Pubmed #10967624 No free full text.

Abstract: The future of nuclear medicine procedures, as understood within our current economic climate, depends upon its ability to provide relevant clinical information at similar or lower comparative costs. With an ever-increasing emphasis on cost containment, outcome assessment forms the basis of preserving the quality of patient care. Today, outcomes assessment encompasses a wide array of subjects including clinical, economic, and humanistic (i.e., quality of life) outcomes. For nuclear cardiology, evidence-based medicine would require a threshold level of evidence in order to justify the added cost of any test in a patient's work-up. This evidence would include large multicenter, observational series as well as randomized trial data in sufficiently large and diverse patient populations. The new movement in evidence-based medicine is also being applied to the introduction of new technologies, in particular when comparative modalities exist. In the past 5 years, we have seen a dramatic shift in the quality of outcomes data published in nuclear cardiology. This includes the use of statistically rigorous risk-adjusted techniques as well as large populations (i.e., > 500 patients) representing multiple diverse medical care settings. This has been the direct result of the development of multiple outcomes databases that have now amassed thousands of patients worth of data. One of the benefits of examining outcomes in large patient datasets is the ability to assess individual endpoints (e.g., cardiac death) as compared with smaller datasets that often assess combined endpoints (e.g., death, myocardial infarction, or unstable angina). New technologies for the diagnosis of coronary artery disease have contributed to the rising costs of care. In the United States and in Europe, costs of care have risen dramatically, consuming an ever-increasing amount of available resources. The overuse of diagnostic angiography often leads to unnecessary revascularization that does not lead to improvement in outcome. Thus, the potential exists that stress SPECT imaging, a highly effective diagnostic tool, could effect substantial change in reducing inappropriate use of an invasive procedure resulting in cost effective cardiac care. A synthesis of current economic evidence in gated SPECT imaging will be presented. In conclusion, a current state of the evidence review is presented on the clinical and economic data using nuclear cardiology imaging.

Berman DS, Germano G. · University of California, Los Angeles, USA. · Rev Port Cardiol. · Pubmed #10750437 No free full text.

Abstract: Gated myocardial perfusion SPECT is a technique that is rapidly becoming widespread in the nuclear cardiology arena, and it currently accounts for a majority of all perfusion SPECT acquisitions performed in the USA. Its main advantage is that of providing important incremental clinical information over SPECT perfusion assessment alone, at essentially no extra cost. With respect to the diagnosis of cardiac disease, gated SPECT has been demonstrated to improve specificity by helping identify attenuation artifacts in patients with suspected coronary artery disease, and is also key in identifying patients with non-ischemic cardiomyopathies. In prognostic assessment, gated SPECT-derived measurements of ejection fraction achieve substantial incremental stratification of patients at risk for cardiac death or myocardial infarction, compared to perfusion scores, and volume measurements further improve risk stratification. New quantitative algorithms allow the fast, accurate and reproducible measurement of parameters of global cardiac function (ejection fraction, end-systolic and end-diastolic volume) as well as regional cardiac function (myocardial wall motion and thickening), all of which have been validated against a wide variety of gold standards.

Berman DS, Germano G, Shaw LJ. · Department of Medicine, UCLA School of Medicine, Los Angeles, CA, USA. · Semin Nucl Med. · Pubmed #10534232 No free full text.

Abstract: This review suggests that the field of nuclear cardiology is alive, well, and thriving, providing relevant information that aids in everyday clinical decision making for nuclear medicine and referring physicians alike. Despite the competition from other modalities, the clinically appropriate applications of nuclear cardiology techniques are likely to increase. The foundation of this optimism is based on the vast amount of data documenting cost-effective clinical applications for diagnosis, risk stratification, and assessing therapy in both chronic and acute coronary artery disease (CAD), the powerful objective quantitative analysis of perfusion and function provided by the technique, and the increasing general availability of the approach.