Important parameters in the detection of left main trunk disease using stress myocardial perfusion imaging

SummaryObjectivesWe sought noninvasively to diagnose left main trunk (LMT) disease using myocardial perfusion imaging (MPI).MethodsFive hundred and eight patients with suspected coronary artery disease (CAD) underwent both stress MPI and coronary angiography. The extent and severity of perfusion abnormalities were assessed using a 20-segment model. In addition, perfusion defects in both left anterior descending and left circumflex arterial territories were defined as a left main (LM) pattern defect, and those in 3-coronary arterial territories as a 3-vessel pattern defect.ResultsIn 42 patients with LMT disease, a summed stress score (19.4±10.0 vs. 13.5±10.0; p<0.0001) and a summed rest score (12.1±9.7 vs. 7.0±7.8; p=0.002) were greater than in 466 patients without LMT disease, while a summed difference score was similar (7.3±7.7 vs. 6.5±6.1; p=NS). The prevalence of an LM-pattern defect was low in both groups (12% vs. 8%; p=NS). However, a 3-vessel pattern defect (33% vs. 7%; p<0.0001), lung uptake of radiotracers (38% vs. 11%; p<0.0001), and transient ischemic dilation (31% vs. 13%; p=0.003) were more frequently observed in patients with LMT disease than in those without. Logistic regression analysis showed that a 3-vessel pattern defect (OR=3.5, 95% CI=1.4–8.8; p=0.007), lung uptake of radiotracers (OR=2.5, 95% CI=1.1–5.7; p=0.03), and previous myocardial infarction (MI) (OR=2.4, 95% CI=1.0–5.7; p=0.05) were the most important parameters to detect LMT disease. After excluding 163 patients with previous MI, a repeat analysis revealed that lung uptake of radiotracers (OR=8.2, 95% CI=2.3–29.2; p=0.001) and an LM-pattern defect (OR=6.3, 95% CI=1.4–27.2; p<0.02) were independent predictors for LMT disease.ConclusionIn the identification of LMT disease, lung uptake of radiotracers was a single best parameter, which was independent of the presence or absence of previous MI

Blood Pressure and Arterial Stiffness

Background—The difference in the predictive ability of the brachial-ankle pulse wave velocity (baPWV) and its stiffness index β-transformed value (β-baPWV, ie, baPWV adjusted for the pulse pressure) for the development of pathophysiological abnormalities related to cardiovascular disease or future occurrence of cardiovascular disease was examined. Methods and Results—In study 1, a 7-year prospective observational study in cohorts of 3274 men and 3490 men, the area under the curve in the receiver operator characteristic curve analysis was higher for baPWV than for β-baPWV for predicting the development of hypertension (0.73, 95% CI=0.70 to 0.75 versus 0.59, 95% CI=0.56 to 0.62; P<0.01) and/or the development of retinopathy (0.78, 95% CI=0.73 to 0.82 versus 0.66, 95% CI=0.60 to 0.71; P<0.01) by the end of the study period. During study 2, a 3-year observation period on 511 patients with coronary artery disease, 72 cardiovascular events were confirmed. The C statistics of both markers for predicting the development of cardiovascular events were similar. Conclusions—Stiffness index β transformation of the baPWV may attenuate the significance of the baPWV as a risk marker for development of pathophysiological abnormalities related to cardiovascular disease in male subjects

Updated Japanese Ministry of Health, Labour and Welfare Reimbursement Policy for Cardiac Positron Emission Tomography and Coronary Interventio

The Japanese Ministry of Health, Labour and Welfare (JMHLW) approved 13N-ammonia (13N-NH3) for detecting coronary artery disease (CAD) and 18F-fluorodeoxyglucose (18F-FDG) for cardiac sarcoidosis in 2012. These 2012 PET approvals shifted cardiac PET from research PET to clinical PET in Japan. Since the 2012 approvals, the nuclear cardiology community has realized the challenges of applying 13N-NH3 PET in clinical practice given the limited reimbursement through the health insurance system. Similar to the case with cardiac sarcoidosis, Japanese cardiologists have put great effort into treating patients with great arteritis such as Takayasu arteritis and have also shown the diagnostic utility of 18F-FDG PET/CT. Considering these issues, the Japanese Society of Nuclear Medicine (JSNM) and Japanese Circulation Society (JCS) worked together with JMHLW to update health insurance policy regarding PET. In addition, physiology-based coronary intervention has played an important role in the management of patients with CAD. Based on these recent developments and discussions with major societies, JMHLW released its updated reimbursement policy on March 5, 2018. This rapid communication will address the key issues of this policy update related to cardiovascular PET and coronary intervention