Stress electrocardiography testing in coronary artery disease: Is it time for its swan song or to redefine its role in the modern era?

Stress electrocardiography (sECG) or treadmill stress testing is a well validated noninvasive diagnostic modality available to clinicians at low cost yet providing valuable functional data for coronary artery disease (CAD) diagnostic and prognostic evaluation. With the advances in cardiac imaging in both functional and anatomic fronts and the existing limitations of sECG testing, this modality appears less favored worldwide as reflected in some recent guideline updates. We review the past present and future of sECG to provide a viewpoint on where it stands in CAD evaluation and if it will remain relevant as a diagnostic modality or be retired going forward. We also provide our perspectives on how sECG can co-exist with other modalities such as calcium scoring and discuss the role of such testing in the Indian population

Coronary Risk Assessment and Management Options in Chronic Kidney Disease Patients Prior to Kidney Transplantation

Cardiovascular disease remains the most important cause of morbidity and mortality among kidney transplant recipients. Nearly half the deaths in transplanted patients are attributed to cardiac causes and almost 5% of these deaths occur within the first year after transplantation. The ideal strategies to screen for coronary artery disease (CAD) in chronic kidney disease patients who are evaluated for kidney transplantation (KT) remain controversial. The American Society of Transplantation recommends that patients with diabetes, prior history of ischemic heart disease or an abnormal ECG, or age ≥50 years should be considered as high-risk for CAD and referred for a cardiac stress test and only those with a positive stress test, for coronary angiography. Despite these recommendations, vast variations exist in the way these patients are screened for CAD at different transplant centers. The sensitivity and specificity of noninvasive cardiac tests in CKD patients is much lower than that in the general population. This has prompted the use of direct diagnostic cardiac catheterization in high-risk patients in several transplant centers despite the risks associated with this invasive procedure. No large randomized controlled trials exist to date that address these issues. In this article, we review the existing literature with regards to the available data on cardiovascular risk screening and management options in CKD patients presenting for kidney transplantation and outline a strategy for approach to these patients

Midventricular Hypertrophic Cardiomyopathy with Apical Aneurysm: Potential for Underdiagnosis and Value of Multimodality Imaging

We illustrate a case of midventricle obstructive HCM and apical aneurysm diagnosed with appropriate use of multimodality imaging. A 75-year-old African American woman presented with a 3-day history of chest pain and dyspnea with elevated troponins. Her electrocardiogram showed sinus rhythm, left atrial enlargement, left ventricular hypertrophy, prolonged QT, and occasional ectopy. After medical therapy optimization, she underwent coronary angiography for an initial diagnosis of non-ST segment elevation myocardial infarction. Her coronaries were unremarkable for significant disease but her left ventriculogram showed hyperdynamic contractility of the midportion of the ventricle along with a large dyskinetic aneurysmal apical sac. A subsequent transthoracic echocardiogram provided poor visualization of the apical region of the ventricle but contrast enhancement identified an aneurysmal pouch distal to the midventricular obstruction. To further clarify the diagnosis, cardiac magnetic resonance imaging with contrast was performed confirming the diagnosis of midventricular hypertrophic cardiomyopathy with apical aneurysm and fibrosis consistent with apical scar on delayed enhancement. The patient was medically treated and subsequently underwent elective implantable defibrillator placement in the ensuing months for recurrent nonsustained ventricular tachycardia and was initiated on prophylactic oral anticoagulation with warfarin for thromboembolic risk reduction

BACK TO THE BASICS: ALL THAT GLITTERS IS NOT SARCOIDOSIS

Background: 18-F-fluorodeoxyglucose positron emission tomography (FDG-PET) plays an important role in the diagnosis and management of cardiac sarcoidosis (CS). False positive study can be seen in conditions that increase myocardial FDG uptake or due to artifacts. Case: An 83-year-old male with mitral regurgitation who underwent Tendyne Transmitral Valve Implantation was referred for FDG-PET due to bilateral hilar lymphadenopathy on recent CT. FDG-PET showed moderate area of severely decreased perfusion involving the distal lateral wall and apical wall at rest. There was increased FDG uptake in the distal lateral and apical wall on the attenuation corrected images (AC) that was not present on the non-AC images. Decision-making: FDG accumulation in myocardial tissue is only indicative of increased cellular metabolic activity and is not specific for CS. Several reports of non-specific FDG uptake around prosthetic cardiac valves and devices have been reported. Although the uptake pattern in this case was consistent with active CS, it became apparent that this was an artifact due to the Tendyne prosthesis after the CT data of the Tendyne valve location was co-registered with the FDG data. Conclusion: FDG-PET is frequently used in diagnosing active CS and for disease monitoring. When interpreting the images, taking into consideration the clinical context, patient’s history and supporting data is vital to avoid misdiagnosis. Thus, going to basics of integrating all data cannot be over-emphasized