Coronary Artery Disease: Shaw LJ

Oudkerk M, Stillman AE, Halliburton SS, Kalender WA, Möhlenkamp S, McCollough CH, Vliegenthart R, Shaw LJ, Stanford W, Taylor AJ, van Ooijen PM, Wexler L, Raggi P, Anonymous00008, Anonymous00009. · Department of Radiology, Groningen University Hospital, Hanzeplein 1, 9700 RB, Groningen, The Netherlands. · Eur Radiol. · Pubmed #18651153 No free full text.

Abstract: Current guidelines and literature on screening for coronary artery calcium for cardiac risk assessment are reviewed for both general and special populations. It is shown that for both general and special populations a zero score excludes most clinically relevant coronary artery disease. The importance of standardization of coronary artery calcium measurements by multidetector CT is discussed.

Mieres JH, Shaw LJ, Arai A, Budoff MJ, Flamm SD, Hundley WG, Marwick TH, Mosca L, Patel AR, Quinones MA, Redberg RF, Taubert KA, Taylor AJ, Thomas GS, Wenger NK, Anonymous00198. · No affiliation provided · Circulation. · Pubmed #15687114 links to  free full text

Abstract: Cardiovascular disease is the leading cause of mortality for women in the United States. Coronary heart disease, which includes coronary atherosclerotic disease, myocardial infarction, acute coronary syndromes, and angina, is the largest subset of this mortality, with >240,000 women dying annually from the disease. Atherosclerotic coronary artery disease (CAD) is the focus of this consensus statement. Research continues to report underrecognition and underdiagnosis of CAD as contributory to high mortality rates in women. Timely and accurate diagnosis can significantly reduce CAD mortality for women; indeed, once the diagnosis is made, it does appear that current treatments are equally effective at reducing risk in both women and men. As such, noninvasive diagnostic and prognostic testing offers the potential to identify women at increased CAD risk as the basis for instituting preventive and therapeutic interventions. Nevertheless, the recent evidence-based practice program report from the Agency for Healthcare Research and Quality noted the paucity of women enrolled in diagnostic research studies. Consequently, much of the evidence supporting contemporary recommendations for noninvasive diagnostic studies in women is extrapolated from studies conducted predominantly in cohorts of middle-aged men. The majority of diagnostic and prognostic evidence in cardiac imaging in women and men has been derived from observational registries and referral populations that are affected by selection and other biases. Thus, a better understanding of the potential impact of sex differences on noninvasive cardiac testing in women may greatly improve clinical decision making. This consensus statement provides a synopsis of available evidence on the role of the exercise ECG and cardiac imaging modalities, both those in common use as well as developing technologies that may add clinical value to the diagnosis and risk assessment of the symptomatic and asymptomatic woman with suspected CAD.

Underwood SR, Anagnostopoulos C, Cerqueira M, Ell PJ, Flint EJ, Harbinson M, Kelion AD, Al-Mohammad A, Prvulovich EM, Shaw LJ, Tweddel AC, Anonymous00272, Anonymous00273, Anonymous00274, Anonymous00275, Anonymous00276. · Imperial College London, Royal Brompton Hospital, London, UK. · Eur J Nucl Med Mol Imaging. · Pubmed #15129710 links to  free full text

Abstract: This review summarises the evidence for the role of myocardial perfusion scintigraphy (MPS) in patients with known or suspected coronary artery disease. It is the product of a consensus conference organised by the British Cardiac Society, the British Nuclear Cardiology Society and the British Nuclear Medicine Society and is endorsed by the Royal College of Physicians of London and the Royal College of Radiologists. It was used to inform the UK National Institute of Clinical Excellence in their appraisal of MPS in patients with chest pain and myocardial infarction. MPS is a well-established, non-invasive imaging technique with a large body of evidence to support its effectiveness in the diagnosis and management of angina and myocardial infarction. It is more accurate than the exercise ECG in detecting myocardial ischaemia and it is the single most powerful technique for predicting future coronary events. The high diagnostic accuracy of MPS allows reliable risk stratification and guides the selection of patients for further interventions, such as revascularisation. This in turn allows more appropriate utilisation of resources, with the potential for both improved clinical outcomes and greater cost-effectiveness. Evidence from modelling and observational studies supports the enhanced cost-effectiveness associated with MPS use. In patients presenting with stable or acute chest pain, strategies of investigation involving MPS are more cost-effective than those not using the technique. MPS also has particular advantages over alternative techniques in the management of a number of patient subgroups, including women, the elderly and those with diabetes, and its use will have a favourable impact on cost-effectiveness in these groups. MPS is already an integral part of many clinical guidelines for the investigation and management of angina and myocardial infarction. However, the technique is underutilised in the UK, as judged by the inappropriately long waiting times and by comparison with the numbers of revascularisations and coronary angiograms performed. Furthermore, MPS activity levels in this country fall far short of those in comparable European countries, with about half as many scans being undertaken per year. Currently, the number of MPS studies performed annually in the UK is 1,200/million population/year. We estimate the real need to be 4,000/million/year. The current average waiting time is 20 weeks and we recommend that clinically appropriate upper limits of waiting time are 6 weeks for routine studies and 1 week for urgent studies.

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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Wann S, Shaw LJ. · No affiliation provided · J Cardiovasc Comput Tomogr. · Pubmed #19083873 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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Shaw LJ, Blumenthal RS, Raggi P. · No affiliation provided · J Nucl Cardiol. · Pubmed #15295406 No free full text.

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Shaw LJ, O'Rourke RA. · No affiliation provided · J Am Coll Cardiol. · Pubmed #11028481 No free full text.

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Klein P, Bax JJ, Shaw LJ, Feringa HH, Versteegh MI, Dion RA, Klautz RJ. · Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands. · Eur J Cardiothorac Surg. · Pubmed #18760619 No free full text.

Abstract: A systematic review of the literature was performed to determine early and late mortality associated with left ventricular (LV) reconstruction surgery and to assess the influence of different surgical techniques, concomitant surgical procedures, clinical and hemodynamic parameters on mortality. The MEDLINE database (January 1980-January 2005) was searched and from the pooled data, hospital mortality and survival were calculated. Summary estimates of relative risks (RR) were calculated for the techniques that were used and for concomitant coronary artery bypass grafting (CABG) and mitral valve surgery. The risk-adjusted relationships between mortality and clinical and hemodynamic parameters were assessed by meta-regression. A total of 62 studies (12,331 patients) were identified. Weighted average early mortality was 6.9%. Cumulative 1-year, 5-year and 10-year survival were 88.5%, 71.5% and 53.9%, respectively. Endoventricular reconstruction (EVR) showed a reduced risk for both early (RR=0.79, p<0.005) and late (RR=0.67, p<0.001) mortality compared to the linear repair (early: RR=1.38, p<0.001; late: RR=1.83, p<0.001). Early and late mortality were mainly cardiac in origin, with as predominant cause heart failure in respectively 49.7% and 34.5% of the cases. Ventricular arrhythmias caused 16.6% of early deaths and 17.2% of late deaths. Concomitant CABG significantly decreased late mortality (RR=0.28, p<0.001) without increasing early mortality (RR=1.018, p=0.858). Concomitant mitral valve surgery showed both an increased risk for early (RR=1.57, p=0.001) and late mortality (RR=4.28, p<0.001). No clinical or hemodynamic parameters were found to influence mortality. It is noteworthy that only one third of patients included in the current analysis were operated for heart failure (14 studies, 4135 patients). In this group we noted an early mortality of 11.0% with a late mortality (3-year) of 15.2%. This analysis of pooled literature data showed that LV reconstruction surgery is performed with acceptable mortality and EVR may be the preferred technique with a reduced risk for early and late mortality. Concomitant CABG improved outcome, whereas the need for mitral valve surgery appeared an index of gravity. No clinical or hemodynamic parameters were found to influence mortality; specifically LV ejection fraction and LV volumes both did not predict outcome.

Oudkerk M, Stillman AE, Halliburton SS, Kalender WA, Möhlenkamp S, McCollough CH, Vliegenthart R, Shaw LJ, Stanford W, Taylor AJ, van Ooijen PM, Wexler L, Raggi P. · Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands. · Int J Cardiovasc Imaging. · Pubmed #18504647 links to  free full text

Abstract: Current guidelines and literature on screening for coronary artery calcium for cardiac risk assessment are reviewed for both general and special populations. It is shown that for both general and special populations a zero score excludes most clinically relevant coronary artery disease. The importance of standardization of coronary artery calcium measurements by multi-detector CT is discussed.

Raggi P, Shaw LJ. · Division of Cardiology, Emory University School of Medicine, 1365 Clifton Road NE, AT-504, Atlanta, GA 30322, USA. · Curr Cardiol Rep. · Pubmed #18417003 No free full text.

Abstract: The importance of screening for subclinical coronary artery disease is reinforced by the detection gap existing between the currently used risk stratification tools and the persistently elevated rates of cardiovascular disease in Western countries. Medicare data clearly indicate the extremely high cost of caring for patients with end-stage diseases, and early detection may curb some of these expenses. Coronary artery calcium screening has become a widely used tool to estimate risk in a variety of categories in the general population and is discussed in this review.

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.

Makaryus AN, Shaw LJ, Mieres JH. · Department of Medicine, Division of Cardiology, North Shore University Hospital, Manhasset, New York, USA. · Cardiol Rev. · Pubmed #18090062 No free full text.

Abstract: Significant progress has been made toward increasing awareness of the risks of heart disease in women and in the area of sex-specific cardiovascular research. Yet, coronary artery disease remains the leading cause of death of women in the western world. Over the last decade, the increased research focus of women at risk for ischemic heart disease has helped in defining and delineating some of the sex-specific factors, which have adversely affected the accuracy of imaging techniques in women. A focused body of clinical research has been published over the last few years, and there now exists a growing body of evidence on the diagnostic and prognostic accuracy of contemporary cardiovascular imaging techniques in women. Recent publications specifically addressing this issue [namely the 2005 American Heart Association Statement on Cardiac Imaging in Women, and the 2006 Women's Ischemia Syndrome Evaluation (WISE) study] are now changing the existing paradigm of ischemic heart disease from one representing a "man's disease," to one including sex-specific algorithms. In this article we review the literature regarding the diagnostic and prognostic evaluation of coronary artery disease in women with respect to imaging.

Bellasi A, Raggi P, Merz CN, Shaw LJ. · Division of Cardiology, Department of Medicine, Emory University, Atlanta, GA 30306, USA. · Cleve Clin J Med. · Pubmed #17708130 links to  free full text

Abstract: Coronary artery disease is different in women than in men in its pathogenesis, symptoms, and prognosis. Needed is a strategy for detecting and assessing coronary disease specifically in women. This review highlights recent evidence on sex differences in coronary artery disease.

Miller DD, Shaw LJ. · Medical College of Georgia School of Medicine, Medical College of Georgia, Augusta, GA 30912, USA. · J Cardiovasc Nurs. · Pubmed #17293746 No free full text.

Abstract: Early and accurate diagnostic testing is a critical factor in the detection and optimal management of coronary artery disease (CAD); thus, noninvasive cardiac imaging has become a central tool for CAD evaluation. Currently, tests used for evaluating CAD include conventional resting and stress electrocardiogram, echocardiography, and myocardial perfusion imaging--the most widely used imaging test for evaluation of suspected myocardial ischemia. Emerging techniques for noninvasive assessment of myocardial perfusion and coronary angiography include cardiac computed tomography, cardiac magnetic resonance imaging, and positron emission tomography. The distinctive pathophysiology of atherosclerosis can be used together with imaging techniques to diagnose and assess risk for CAD. Imaging modalities for cardiac risk stratification include a diverse array of tools, such as noninvasive tests that visualize presymptomatic atherosclerosis to sophisticated radionuclide protocols that identify myocardial viability. Of the noninvasive imaging tests, gated SPECT is the most accurate method for risk stratification of CAD. Myocardial perfusion imaging with SPECT has improved accuracy and image quality such that a shift from diagnostic to prognostic use has occurred. Radionuclide myocardial perfusion imaging has played an important role in CAD evaluation since the introduction of thallium-201 (Tl-201) in the 1970s. Although Tl-201 has high sensitivity, specificity, and reproducibility, it also has physical properties that limit its use and affect image quality. Currently, Tc-99m tetrofosmin and sestamibi are the most commonly used agents for a variety of resting and stress protocols, both have similar diagnostic accuracy profiles. The field of nuclear cardiology has grown steadily over the past few decades, as more practitioners recognize its clinical applications and value in managing cardiovascular disease. There is abroad spectrum of noninvasive and invasive testing available for the diagnosis and management of patients with cardiovascular disease. Advances in computer technology have made sophisticated devices, such as the gated SPECT, a routine part of cardiology.

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.

Budoff MJ, Achenbach S, Blumenthal RS, Carr JJ, Goldin JG, Greenland P, Guerci AD, Lima JA, Rader DJ, Rubin GD, Shaw LJ, Wiegers SE, Anonymous00098, Anonymous00099, Anonymous00100. · No affiliation provided · Circulation. · Pubmed #17015792 links to  free full text

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Naghavi M, Falk E, Hecht HS, Jamieson MJ, Kaul S, Berman D, Fayad Z, Budoff MJ, Rumberger J, Naqvi TZ, Shaw LJ, Faergeman O, Cohn J, Bahr R, Koenig W, Demirovic J, Arking D, Herrera VL, Badimon J, Goldstein JA, Rudy Y, Airaksinen J, Schwartz RS, Riley WA, Mendes RA, Douglas P, Shah PK, Anonymous00340. · Association for Eradication of Heart Attack, Houston, Texas 77005, USA. · Am J Cardiol. · Pubmed #16843744 No free full text.

Abstract: Screening for early-stage asymptomatic cancers (eg, cancers of breast and colon) to prevent late-stage malignancies has been widely accepted. However, although atherosclerotic cardiovascular disease (eg, heart attack and stroke) accounts for more death and disability than all cancers combined, there are no national screening guidelines for asymptomatic (subclinical) atherosclerosis, and there is no government- or healthcare-sponsored reimbursement for atherosclerosis screening. Part I and Part II of this consensus statement elaborated on new discoveries in the field of atherosclerosis that led to the concept of the "vulnerable patient." These landmark discoveries, along with new diagnostic and therapeutic options, have set the stage for the next step: translation of this knowledge into a new practice of preventive cardiology. The identification and treatment of the vulnerable patient are the focuses of this consensus statement. In this report, the Screening for Heart Attack Prevention and Education (SHAPE) Task Force presents a new practice guideline for cardiovascular screening in the asymptomatic at-risk population. In summary, the SHAPE Guideline calls for noninvasive screening of all asymptomatic men 45-75 years of age and asymptomatic women 55-75 years of age (except those defined as very low risk) to detect and treat those with subclinical atherosclerosis. A variety of screening tests are available, and the cost-effectiveness of their use in a comprehensive strategy must be validated. Some of these screening tests, such as measurement of coronary artery calcification by computed tomography scanning and carotid artery intima-media thickness and plaque by ultrasonography, have been available longer than others and are capable of providing direct evidence for the presence and extent of atherosclerosis. Both of these imaging methods provide prognostic information of proven value regarding the future risk of heart attack and stroke. Careful and responsible implementation of these tests as part of a comprehensive risk assessment and reduction approach is warranted and outlined by this report. Other tests for the detection of atherosclerosis and abnormal arterial structure and function, such as magnetic resonance imaging of the great arteries, studies of small and large artery stiffness, and assessment of systemic endothelial dysfunction, are emerging and must be further validated. The screening results (severity of subclinical arterial disease) combined with risk factor assessment are used for risk stratification to identify the vulnerable patient and initiate appropriate therapy. The higher the risk, the more vulnerable an individual is to a near-term adverse event. Because <10% of the population who test positive for atherosclerosis will experience a near-term event, additional risk stratification based on reliable markers of disease activity is needed and is expected to further focus the search for the vulnerable patient in the future. All individuals with asymptomatic atherosclerosis should be counseled and treated to prevent progression to overt clinical disease. The aggressiveness of the treatment should be proportional to the level of risk. Individuals with no evidence of subclinical disease may be reassured of the low risk of a future near-term event, yet encouraged to adhere to a healthy lifestyle and maintain appropriate risk factor levels. Early heart attack care education is urged for all individuals with a positive test for atherosclerosis. The SHAPE Task Force reinforces existing guidelines for the screening and treatment of risk factors in younger populations. Cardiovascular healthcare professionals and policymakers are urged to adopt the SHAPE proposal and its attendant cost-effectiveness as a new strategy to contain the epidemic of atherosclerotic cardiovascular disease and the rising cost of therapies associated with this epidemic.

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.

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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Schuijf JD, Bax JJ, Shaw LJ, de Roos A, Lamb HJ, van der Wall EE, Wijns W. · Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands. · Am Heart J. · Pubmed #16442907 No free full text.

Abstract: BACKGROUND: Magnetic resonance imaging (MRI) and multislice computed tomography (MSCT) have emerged as potential noninvasive coronary imaging techniques. The objective of the present study was to clarify the current accuracy of both modalities in the detection of significant coronary artery lesions (compared to conventional angiography as the gold standard) by means of a comprehensive meta-analysis of the presently available literature. METHODS: A total of 51 studies on the detection of significant coronary artery stenoses (> or = 50% diameter stenosis) and comparing results with conventional angiography were identified by means of a MEDLINE search. Weighted sensitivities, specificities, and predictive values, all with 95% CIs, as well as summary odds ratios, were calculated for both techniques. In addition, the relationship between diagnostic specificity and disease prevalence was determined using metaregression analysis. RESULTS: A comparison of sensitivities and specificities revealed significantly higher values for MSCT (weighted average 85% [95% CI 86%-88%] and 95% [95% CI 95%]) as compared with MRI (weighted average 72%, 95% CI 69%-75% and 87%, 95% CI 86%-88%). A significantly higher odds ratio (16.9-fold) for the presence of significant stenosis was observed for MSCT as compared with MRI (6.4-fold) (P < .0001). Linear regression analysis revealed a better specificity for MSCT versus MRI in lower disease prevalence populations (P = .056). CONCLUSION: Meta-analysis of the available studies with MRI and MSCT for noninvasive coronary angiography indicates that MSCT has currently a significantly higher accuracy to detect or exclude significant coronary artery disease.

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.

Schuijf JD, Poldermans D, Shaw LJ, Jukema JW, Lamb HJ, de Roos A, Wijns W, van der Wall EE, Bax JJ. · Deparment of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands. · Eur J Nucl Med Mol Imaging. · Pubmed #16320016 No free full text.

Abstract: The role of non-invasive imaging techniques in the evaluation of patients with suspected or known coronary artery disease (CAD) has increased exponentially over the past decade. The traditionally available imaging modalities, including nuclear imaging, stress echocardiography and magnetic resonance imaging (MRI), have relied on detection of CAD by visualisation of its functional consequences (i.e. ischaemia). However, extensive research is being invested in the development of non-invasive anatomical imaging using computed tomography or MRI to allow detection of (significant) atherosclerosis, eventually at a preclinical stage. In addition to establishing the presence of or excluding CAD, identification of patients at high risk for cardiac events is of paramount importance to determine post-test management, and the majority of non-invasive imaging tests can also be used for this purpose. The aim of this review is to provide an overview of the available non-invasive imaging modalities and their merits for the diagnostic and prognostic work-up in patients with suspected or known CAD.

Raggi P, Taylor A, Fayad Z, O'Leary D, Nissen S, Rader D, Shaw LJ. · Section of Cardiology, Department of Internal Medicine, Tulane University School of Medicine, New Orleans, LA, USA. · Arch Intern Med. · Pubmed #16287763 links to  free full text

Abstract: Coronary artery disease imaging has traditionally been based on luminal angiography, but it has become evident that this tool, although extremely useful in diagnosing obstructive disease, is insufficient to define the presence and extent of atherosclerotic disease in the vessel wall. Progression of coronary artery disease was also initially evaluated using quantitative coronary angiography, and evidence soon accumulated that minor regression or nonprogression of luminal disease was associated with a favorable cardiovascular outcome. In recent years, however, several other techniques have been developed to image atherosclerosis and are emerging as useful tools in preventive cardiovascular medicine. These techniques provide new methods to assess the burden of atherosclerosis, gauge the risk of cardiovascular events, and offer a means to test the efficacy of therapeutic approaches to atherosclerosis. Furthermore, noninvasive coronary angiography can be performed with some of the new imaging modalities, potentially reducing the number of unnecessary invasive tests. This review focuses on techniques such as cardiac computed tomography, carotid artery intima-media thickness, cardiovascular magnetic resonance imaging, and intravascular ultrasonography as emerging tools in cardiovascular disease prevention.