Trends of Increasing Medical Radiation Exposure in a Population Hospitalized for Cardiovascular Disease (1970-2009)

Abstract Background: High radiation doses employed in cardiac imaging may increase cancer frequency in exposed patients after decades. The aim of this study was to evaluate the relative trends in medical radiation exposure in a population hospitalized for cardiovascular disease. Methods and Results: An observational single-center study was conducted to examine 16,431 consecutive patients with heart disease admitted to the Italian National Research Council Institute of Clinical Physiology between January 1970 and December 2009. In all patients, the cumulative estimated effective dose was obtained from data mining of electronic records of hospital admissions, adopting the effective dose typical values of the American Heart Association 2009 statement and Mettler\u27s 2008 catalog of doses. Cumulative estimated effective dose per patient in the last 5 years was 22 (12-42) mSv (median, 25th-75th percentiles), with higher values in ischemic heart disease (IHD), 37 (20-59) vs non-IHD, 13 (8-22) mSv, p,0.001. Trends in radiation exposure showed a steady increase in IHD and a flat trend in non-IHD patients, with variation from 1970-74 to 2005-2009 of +155% for IHD (p,0.001) and 21% in non-IHD (NS). The relative contribution of different imaging techniques was remodeled over time, with nuclear cardiology dominating in 1970s (23% of individual exposure) and invasive fluoroscopy in the last decade (90% of individual exposure). Conclusion: A progressive increase in cumulative estimated effective dose is observed in hospitalized IHD patients. The growing medical radiation exposure may encourage a more careful justification policy regarding ionizing imaging in cardiology patients applying the two main principles of radiation protection: appropriate justification for ordering and performing each procedure, and careful optimization of the radiation dose used during each procedure

Interpretation of the "obesity paradox": A 30-year study in patients with cardiovascular disease

Background: Several epidemiological reports indicate that the body mass index (BMI) is inversely related with mortality, in spite of the notion that obesity is a recognized cardio-metabolic risk factor. The aim of the study was to evaluate the independent impact of overweight and obesity on long-term mortality in a large cohort of patients with heart disease (HD). Methods: The study included 10,446 patients hospitalized in the last three decades for ischemic (60%) or nonischemic HD and followed-up for 10 years. The relationship between BMI and total or cardiovascular mortality was analyzed in the whole cohort, and in age-stratified categories (≤65 and >65 years). Considering that survival in HD patients has improved after the introduction of revascularization, beta-blockers, ACE inhibitors, and statins, the relationship was re-examined separately in patients hospitalized before and after 1990. Results: Diabetes, hyperuricemia, hypertension, glycaemia, and triglyceridemia increased across BMI groups. During follow-up (73?59 months) there were 1707 all-cause deaths (47% cardiac). Any relationship between BMI and mortality was lost in the ≤65 age category and in patients hospitalized before 1990, but it persisted in old patients hospitalized after 1990. Most significant independent predictors of mortality in all groups were hyperuricemia, diabetes and impaired ejection fraction. Conclusions: No independent relationship was found between BMI and mortality in subjects ≤65 years of age. This neutral relationship seems to be partly counteracted by treatment, particularly in old patients. A different effect of obesity onset in old vs. young age cannot be ruled out

Electronic Medical Records Optimize Clinical Data Management in the Outpatient Cardiological Clinic

A system based on a relational database with administrative and clinical information and integrated with an Information System, where the system covers the role of a Functional Island, is routinely used in our Institution. To analyze how Electronic Medical Records (EMR) may help physicians in organizing and reducing time waste in a busy outpatient clinic, a sample of 1000 reports were evaluated for system performance. The time needed for building new clinical histories or modifying the already acquired ones, to create physical examination and biochemical and instrumental exams reports, was assessed. Cardio-pulmonary tests, basal, dynamic and effort EKG, chest X-ray, Echo Doppler studies, nuclear medicine procedures, invasive techniques, were collected. Clinical management was integrated with the administrative system (ADT), to correctly identify each patient. This system provided not only easy retrieving of stored data such as clinical history, physical examination, instrumental exams reports but also the results of new exams performed in the same day of patient visit with a time lapse of 1 to 20\u27. Graphical interface structure contained preformatted fields which allowed selection or modifications of data/text models without additional waste of time. EMR represents an important tool for organization and synergy of different Laboratories in a outpatient clinic, optimizing the time needed for data entry and leading to an overall better quality of care

Electronic medical record in cardiology: a 10-year Italian experience

SummaryObjectives:the aim of this study was to report a ten years experience in the electronic medical record (EMR) use. An estimated 80% of healthcare transactions are still paper-based.Methods:an EMR system was built at the end of 1998 in an Italian tertiary care center to achieve total integration among different human and instrumental sources, eliminating paper-based medical records. Physicians and nurses who used EMR system reported their opinions. In particular the hospital activity supported electronically, regarding 4,911 adult patients hospitalized in the 2004- 2008 period, was examined.Results:the final EMR product integrated multimedia document (text, images, signals). EMR presented for the most part advantages and was well adopted by the personnel. Appropriateness evaluation was also possible for some procedures. Some disadvantages were encountered, such as start-up costs, long time required to learn how to use the tool, little to no standardization between systems and the EMR technology.Conclusion:the EMR is a strategic goal for clinical system integration to allow a better health care quality. The advantages of the EMR overcome the disadvantages, yielding a positive return on investment to health care organization

Oxidative Stress as a predictor of cardiovascular events in coronari artery disease patients

Abstract Background: Enhanced oxidative stress has been associated with atherosclerosis and coronary artery disease (CAD). However, the predictive value of circulating oxidative stress biomarkers for cardiovascular events (CE) in patients with CAD has remained poorly understood. Aim: To assess the prognostic significance of reactive oxygen metabolites, estimated as index of oxidative stress in serum samples by means of a commercial kit (ROMs, Diacron, Italy) on the rate of mortality and major adverse CE (MACE) in CAD. Methods: A study of 93 consecutive patients with angiographically documented CAD (75 males, age: 68?10 years, mean?SD) was made during a mean follow-up of 66 months until the occurrence of one of the following CE: cardiac and all cause death, non-fatal myocardial infarction and coronary revascularization [percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG)]. Patient data were retrospectively collected from the Institute\u27s electronic databank that saves demographic, clinical, instrumental and follow-up data of all patients admitted to our department. Results: The Kaplan-Meier survival estimates showed a significantly worst outcome in patients presenting elevated ROM level (>75th percentile, corresponding to 481 AU) (log rank=11, 7.5, 5.1; p<0.001, p<0.01, p<0.05 for cardiac and all cause death and MACEs, respectively). In a multivariate Cox regression model, elevated oxidative stress remained a significant predictor of cardiac and all cause death [hazard ratio (HR) 3.9, 95% confidence interval, 95% (CI) 1.4-11.1, p=0.01; HR=2.6, 95% CI 1.1-6.2, p=0.02) and MACE (HR=1.8, 95% CI 1.1-3.1, p=0.03)]. Conclusions: The estimation of ROMs may represent an additional prognostic tool in the assessment of CE in CAD patients

Time Course of the Occurrences of Acute Cardiovascular Events in the Italian City of Brindisi

In a recent study on mortality on municipalities at high risk of environment crisis, significant excesses concerning all causes of death have been localized in the municipality of Brindisi. Focusing on cardiac pathology, we investigated the time course of the daily occurrences of acute cardiovascular events (OCE) leading to unscheduled hospitalization of subjects residents in Brindisi, during years 2001-2008. OCE series was analyzed by Detrended Fluctuation Analysis. The results indicate presence of long-term positive correlation, suggesting a role of atmospheric agents and air quality effects: increase/decrease of OCE following persistent high/low levels of air pollution

Variability of radiation doses of cardiac diagnostic imaging tests: the RADIO-EVINCI study (RADIationdOse subproject of the EVINCI study)

Background: Patients with coronary artery disease can accumulate significant radiation dose through repeated exposures to coronary computed tomographic angiography, myocardial perfusion imaging with single photon emission computed tomography or positron emission tomography, and to invasive coronary angiography. Aim of the study was to audit radiation doses of coronary computed tomographic angiography, single photon emission computed tomography, positron emission tomography and invasive coronary angiography in patients enrolled in the prospective, randomized, multi-centre European study-EVINCI (Evaluation of Integrated Cardiac Imaging for the Detection and Characterization of Ischemic Heart Disease).Methods: We reviewed 1070 tests (476 coronary computed tomographic angiographies, 85 positron emission tomographies, 310 single photon emission computed tomographies, 199 invasive coronary angiographies) performed in 476 patients (mean age 60 +/- 9 years, 60% males) enrolled in 12 centers of the EVINCI. The effective doses were calculated in milli-Sievert (mSv) as median, interquartile range (IQR) and coefficient of variation of the mean.Results: Coronary computed tomographic angiography (476 exams in 12 centers) median effective dose was 9. 6 mSv (IQR = 13.2 mSv); single photon emission computed tomography (310 exams in 9 centers) effective dose was 9.3 (IQR = 2.8); positron emission tomography (85 in 3 centers) effective dose 1.8 (IQR = 1.6) and invasive coronary angiography (199 in 9 centers) effective dose 7.4 (IQR = 7.3). Inter-institutional variability was highest for invasive coronary angiography (100%) and coronary computed tomographic angiography (54%) and lowest for single photon emission computed tomography (20%). Intra-institutional variability was highest for invasive coronary angiography (121%) and coronary computed tomographic angiography (115%) and lowest for single photon emission computed tomography (14%).Conclusion: Coronary computed tomographic angiography and invasive coronary angiography doses vary substantially between and within centers. The variability in nuclear medicine procedures is substantially lower. The findings highlight the need to audit doses, to track cumulative exposures and to standardize doses for imaging techniques

Variability of radiation doses of cardiac diagnostic imaging tests: the RADIO-EVINCI study (RADIationdOse subproject of the EVINCI study)

Background: Patients with coronary artery disease can accumulate significant radiation dose through repeated exposures to coronary computed tomographic angiography, myocardial perfusion imaging with single photon emission computed tomography or positron emission tomography, and to invasive coronary angiography. Aim of the study was to audit radiation doses of coronary computed tomographic angiography, single photon emission computed tomography, positron emission tomography and invasive coronary angiography in patients enrolled in the prospective, randomized, multi-centre European study–EVINCI (Evaluation of Integrated Cardiac Imaging for the Detection and Characterization of Ischemic Heart Disease).Methods: We reviewed 1070 tests (476 coronary computed tomographic angiographies, 85 positron emission tomographies, 310 single photon emission computed tomographies, 199 invasive coronary angiographies) performed in 476 patients (mean age 60 ± 9 years, 60% males) enrolled in 12 centers of the EVINCI. The effective doses were calculated in milli-Sievert (mSv) as median, interquartile range (IQR) and coefficient of variation of the mean.Results: Coronary computed tomographic angiography (476 exams in 12 centers) median effective dose was 9.6 mSv (IQR = 13.2 mSv); single photon emission computed tomography (310 exams in 9 centers) effective dose was 9.3 (IQR = 2.8); positron emission tomography (85 in 3 centers) effective dose 1.8 (IQR = 1.6) and invasive coronary angiography (199 in 9 centers) effective dose 7.4 (IQR = 7.3). Inter-institutional variability was highest for invasive coronary angiography (100%) and coronary computed tomographic angiography (54%) and lowest for single photon emission computed tomography (20%). Intra-institutional variability was highest for invasive coronary angiography (121%) and coronary computed tomographic angiography (115%) and lowest for single photon emission computed tomography (14%).Conclusion: Coronary computed tomographic angiography and invasive coronary angiography doses vary substantially between and within centers. The variability in nuclear medicine procedures is substantially lower. The findings highlight the need to audit doses, to track cumulative exposures and to standardize doses for imaging techniques.Trial registration: The study protocol is available at https://www.clinicaltrials.gov/ (ClinicalTrials.gov Identifier: NCT00979199). Information provided on September 16, 2009