Coronary Artery Disease: Labovitz AJ

Douglas PS, Khandheria B, Stainback RF, Weissman NJ, Peterson ED, Hendel RC, Stainback RF, Blaivas M, Des Prez RD, Gillam LD, Golash T, Hiratzka LF, Kussmaul WG, Labovitz AJ, Lindenfeld J, Masoudi FA, Mayo PH, Porembka D, Spertus JA, Wann LS, Wiegers SE, Brindis RG, Douglas PS, Hendel RC, Patel MR, Peterson ED, Wolk MJ, Allen JM, Anonymous00094, Anonymous00095, Anonymous00096, Anonymous00097, Anonymous00098, Anonymous00099, Anonymous00100, Anonymous00101. · No affiliation provided · J Am Coll Cardiol. · Pubmed #18342240 No free full text.

Abstract: The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE) together with key specialty and subspecialty societies, conducted an appropriateness review for stress echocardiography. The review assessed the risks and benefits of stress echocardiography for several indications or clinical scenarios and scored them on a scale of 1 to 9 (based upon methodology developed by the ACCF to assess imaging appropriateness). The upper range (7 to 9) implies that the test is generally acceptable and is a reasonable approach, and the lower range (1 to 3) implies that the test is generally not acceptable and is not a reasonable approach. The midrange (4 to 6) indicates a clinical scenario for which the indication for a stress echocardiogram is uncertain. The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Use of stress echocardiography for risk assessment in patients with coronary artery disease (CAD) was viewed favorably, while routine repeat testing and general screening in certain clinical scenarios were viewed less favorably. It is anticipated that these results will have a significant impact on physician decision making and performance, reimbursement policy, and will help guide future research.

Douglas PS, Khandheria B, Stainback RF, Weissman NJ, Peterson ED, Hendel RC, Stainback RF, Blaivas M, Des Prez RD, Gillam LD, Golash T, Hiratzka LF, Kussmaul WG, Labovitz AJ, Lindenfeld J, Masoudi FA, Mayo PH, Porembka D, Spertus JA, Wann LS, Wiegers SE, Brindis RG, Douglas PS, Patel MR, Wolk MJ, Allen JM, Anonymous00125, Anonymous00126, Anonymous00127, Anonymous00128, Anonymous00129, Anonymous00130, Anonymous00131, Anonymous00132. · Duke University Medical Center, Durham, NC, USA. · Circulation. · Pubmed #18316491 links to  free full text

Abstract: The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE) together with key specialty and subspecialty societies, conducted an appropriateness review for stress echocardiography. The review assessed the risks and benefits of stress echocardiography for several indications or clinical scenarios and scored them on a scale of 1 to 9 (based upon methodology developed by the ACCF to assess imaging appropriateness). The upper range (7 to 9) implies that the test is generally acceptable and is a reasonable approach, and the lower range (1 to 3) implies that the test is generally not acceptable and is not a reasonable approach. The midrange (4 to 6) indicates a clinical scenario for which the indication for a stress echocardiogram is uncertain. The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Use of stress echocardiography for risk assessment in patients with coronary artery disease (CAD) was viewed favorably, while routine repeat testing and general screening in certain clinical scenarios were viewed less favorably. It is anticipated that these results will have a significant impact on physician decision making and performance, reimbursement policy, and will help guide future research.

Douglas PS, Khandheria B, Stainback RF, Weissman NJ, Peterson ED, Hendel RC, Stainback RF, Blaivas M, Des Prez RD, Gillam LD, Golash T, Hiratzka LF, Kussmaul WG, Labovitz AJ, Lindenfeld J, Masoudi FA, Mayo PH, Porembka D, Spertus JA, Wann LS, Wiegers SE, Brindis RG, Douglas PS, Hendel RC, Patel MR, Peterson ED, Wolk MJ, Allen JM, Anonymous00137, Anonymous00138, Anonymous00139, Anonymous00140, Anonymous00141, Anonymous00142, Anonymous00143, Anonymous00144, Anonymous00145, Anonymous00146. · Duke University Medical Center, Durham, NC, USA. · Catheter Cardiovasc Interv. · Pubmed #18314889 No free full text.

Abstract: The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE) together with key specialty and subspecialty societies, conducted an appropriateness review for stress echocardiography. The review assessed the risks and benefits of stress echocardiography for several indications or clinical scenarios and scored them on a scale of 1 to 9 (based upon methodology developed by the ACCF to assess imaging appropriateness). The upper range (7 to 9) implies that the test is generally acceptable and is a reasonable approach, and the lower range (1 to 3) implies that the test is generally not acceptable and is not a reasonable approach. The midrange (4 to 6) indicates a clinical scenario for which the indication for a stress echocardiogram is uncertain.The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Use of stress echocardiography for risk assessment in patients with coronary artery disease (CAD) was viewed favorably, while routine repeat testing and general screening in certain clinical scenarios were viewed less favorably. It is anticipated that these results will have a significant impact on physician decision making and performance, reimbursement policy, and will help guide future research.

Gutierrez ME, Labovitz AJ. · Division of Cardiology, Saint Louis University School of Medicine, St Louis, Missouri 63110, USA. · Am J Cardiovasc Drugs. · Pubmed #15631535 No free full text.

Abstract: Coronary artery disease continues to be the leading cause of death in the US. Several classes of drugs available today have shown benefit in decreasing the progression of coronary artery disease and its associated symptoms. When a patient experiences an acute coronary syndrome, beta-adrenoceptor antagonists are considered one of the cornerstones of medical therapy.Over the past 25 years, trials have demonstrated morbidity and mortality benefit when this class of drugs was given early in the post-myocardial infarction period. Subsequent substantial data have confirmed their beneficial effect on outcomes in other high-risk populations such as the elderly, those with left ventricular dysfunction, peripheral vascular disease, diabetic patients, and selected patients with reactive airway disease.Several reviews of hospital discharge data revealed that beta-adrenoceptor antagonists remain significantly underutilized in patients with acute, as well as chronic coronary artery disease. Misconceptions about the adverse effects and who would benefit probably account for physician reluctance to prescribe these medications. With rare exception, the overwhelming evidence currently supports the practice of prescribing beta-adrenoceptor antagonists to all patients immediately post-myocardial infarction and therapy to be continued indefinitely.

Dolan MS, Gala SS, Dodla S, Abdelmoneim SS, Xie F, Cloutier D, Bierig M, Mulvagh SL, Porter TR, Labovitz AJ. · Division of Cardiology, Saint Louis University Hospital, St. Louis, Missouri 63110-0250, USA. · J Am Coll Cardiol. · Pubmed #19118722 No free full text.

Abstract: OBJECTIVES: The authors sought to define the risks versus benefits of ultrasound contrast agents in patients undergoing stress echocardiography. BACKGROUND: The Food and Drug Administration recently placed a "black box" warning on the ultrasound contrast agents Definity (Bristol-Myers Squibb Medical Imaging, Billerica, Massachusetts) and Optison (GE Healthcare, Princeton, New Jersey) after their use was temporally related to 4 deaths. The safety of contrast has not been systematically evaluated. METHODS: We retrospectively analyzed 42,408 patients at 3 different institutions who had baseline suboptimal images and/or underwent myocardial perfusion imaging and received contrast agents; 18,749 of these underwent stress echocardiography. The outcomes (death and myocardial infarction [MI]) within 30 min, 24 h, and during long-term follow-up were recorded. RESULTS: No deaths or MIs were observed within 30 min; 1 death and 5 nonfatal MIs were observed within 24 h. This was not different from a matched cohort of 15,989 patients not receiving contrast. At 1 h and at 30 days after contrast administration, no significant differences in death rates or MIs were observed between patients who did and did not receive contrast during their stress echocardiogram. Endocardial border visualization in patients with suboptimal images resulted in comparable sensitivity (81% vs. 73%, p = NS) and diagnostic accuracy (82% vs. 77%, p = NS) for wall motion analysis compared with patients with optimal image quality. At long-term follow-up, abnormal wall motion and/or myocardial perfusion predicted adverse outcomes (20.6%) when compared with patients with normal studies (3.7%). CONCLUSIONS: Despite recent warnings regarding echocardiographic contrast, our findings indicate it is a safe and useful diagnostic tool in assessment of patients suspected of having coronary artery disease.

Bierig SM, Ryan A, Ziaee A, Kociolek L, Simon J, Herrmann S, Labovitz AJ. · Department of Internal Medicine/Cardiology, Saint Louis University School of Medicine, 3635 Vista Avenue, 14th Floor, Desloge Towers, St. Louis, MO 63110-2539, USA. · Eur J Echocardiogr. · Pubmed #16931162 links to  free full text

Abstract: BACKGROUND: Echocardiographic estimation of left ventricular ejection fraction aids in predicting adverse outcomes in coronary artery disease. However, in patients with impaired left ventricular function, further risk stratification is difficult. METHODS: A 2 year retrospective review was performed to identify patients with ejection fraction < or=30%. Echocardiographic measures of systolic and diastolic function were independently performed offline. Outcome information, which included MI, stroke, or death, was obtained. The patient cohort identified those with follow-up having 1) a single echocardiogram and a subset 2) with an initial echocardiogram and a second echocardiogram at greater than one year follow-up. RESULTS: This study included 110 patients, ages 20-94. Mean follow-up time was 29+/-9 months. Ejection fraction did not predict cardiovascular events. LV mass predicted of mortality (p=0.03). Diastolic indexes of mitral inflow E wave was a significant predictor of outcome (p=0.05). Impaired diastolic filling grade 2, 3, or 4 showed a 76% event rate. Decreases in ejection fraction at follow-up were seen in those who had an event, with an average decrease in ejection fraction of 17% versus those who lived with no event of 1%. Changes in mitral inflow E wave and changes in E/A ratio were both significant predictors of outcome. CONCLUSIONS: These data indicate that echocardiographic measures of both systolic and diastolic function aid in risk stratifying patients with decreased ejection fraction. The changed detected in serial echocardiographic information may be important in treatment and secondary prevention of future events.

Memisoglu E, Ropers D, Hobikoglu G, Tepe MS, Labovitz AJ. · Department of Radiology, St. Louis University Hospital, St. Louis, Missouri, USA. · Am J Cardiol. · Pubmed #16275198 No free full text.

Abstract: The ectopic origination of a coronary artery from the opposite sinus is a rare condition, often discovered as an incidental finding during invasive catheter angiography performed for the evaluation of atherosclerotic coronary artery disease. Although most patients lack hemodynamic significance, a small fraction of these anomalies have been associated with sudden cardiac death and ischemic complications. The exact anatomic definition of the anomalous coronary artery and its course, especially in relation to the ascending aorta and the pulmonary trunk, is therefore crucial for every imaging modality that attempts coronary artery visualization. To underline the potential of 3-dimensional electron-beam computed tomography as an important complement to invasive angiography in the delineation of anomalous coronary arteries, this study focused on the potentially malignant ectopic contralateral origination of a coronary artery.

Dolan MS, Riad K, El-Shafei A, Puri S, Tamirisa K, Bierig M, St Vrain J, McKinney L, Havens E, Habermehl K, Pyatt L, Kern M, Labovitz AJ. · Department of Internal Medicine, Division of Cardiology, Saint Louis University, St Louis, MO, USA. · Am Heart J. · Pubmed #11685180 No free full text.

Abstract: BACKGROUND: The study evaluates whether Optison used during dobutamine stress echocardiography (DSE) will improve endocardial border definition and whether this will translate to an improvement in sensitivity and specificity of the test in patients with poor echocardiographic windows. DSE is extremely valuable in the workup of patients with coronary artery disease. The test is limited in patients with suboptimal endocardial border visualization. Frequent studies have demonstrated improved endocardial border visualization with intravenous contrast agents at rest. METHODS AND RESULTS: We studied 229 patients: 112 had good rest echocardiography with no contrast and 117 had poor rest echocardiography with Optison injection during DSE. Percentage of endocardial border visualization, wall thickening, sensitivity, and specificity were compared in both groups, as was interobserver variability. Both groups were matched with respect to age, percentage of previous myocardial infarctions, resting wall motion abnormality, percentage of coronary stenosis, and number of diseased coronary arteries. Optison significantly improved endocardial border visualization, especially at peak stress. The ability to measure wall thickening was significantly higher in the contrast DSE group with suboptimal images versus the noncontrast group with optimal images (89% ability to measure wall thickening vs 71%, P =.01). This resulted in a comparable sensitivity (79% vs 71%, P = not significant [NS]), specificity (76% vs 82%, P = NS), and diagnostic accuracy (80% vs 76%, P = NS). Agreement on test interpretation was higher among 3 observers in contrast DSE versus noncontrast DSE groups (79% vs 69%, P =.01). CONCLUSIONS: In patients with poor echocardiographic windows, the use of Optison during DSE improves endocardial border visualization, which translates to a comparable sensitivity and specificity to noncontrast DSE tests in patients with good echocardiographic windows.