Physiologic risk assessment in stable ischemic heart disease: still superior to the anatomic angiographic approach.

In patients with ischemic heart disease (IHD), a functional risk assessment based on non-invasive tests may conflict with a health care policy oriented toward cost containment and direct reperfusion delivery. In this respect, a survey of the European Society of Cardiology has shown that noninvasive tests are underutilized, with wide variability between different countries, so that several patients without significant IHD directly undergo invasive coronary angiography. On the other hand, coronary lesions detected by coronary angiography often are revascularized even without the evidence that myocardial blood supply or mechanical function is altered. This \u27\u27anatomically oriented\u27\u27 invasive approach may negatively impact patient management, with consequent suboptimal medical treatment, inappropriate revascularizations, additional risks, and increased health costs. To investigate the prognostic power of gated SPECT in current practice, we recently studied a cohort of 676 consecutive patients admitted for known or suspected IHD.3 Each patient underwent a complete diagnostic work-up that included clinical evaluation, laboratory tests, 12-lead electrocardiogram, two-dimensional echocardiography, stress/rest gated SPECT, and coronary angiography. During follow-up (median, 37 months), 24 patients died from cardiac causes and 19 had a nonfatal myocardial infarction (MI). Several variables were independent predictors of event-free survival (cardiac death and non-fatal MI) in the different phases of diagnostic work-up. When the above predictors were tested together, summed rest score (SRS), summed difference score (SDS), serumcreatinine, and LDL/HDL cholesterol were the only final independent predictors of event-free survival (Table 1). The results of this study lead us to make some considerations on risk stratification in stable IHD

Imágenes de inervación miocárdica: MIBG en práctica clínica

La 123I-metayodobencilguanidina (MIBG) es un análogo de norepinefrina radiomarcado que se puede usar para investigar la inervación simpática del miocardio. La gammagrafía con 123I-MIBG se ha investigado con interés en muchos contextos patológicos. En pacientes con insuficiencia cardiaca (IC) sistólica, la gammagrafía con 123I-MIBG puede detectar el deterioro funcional y la rarefacción de las terminales simpáticas (que se manifiestan como reducción de la relación corazón-mediastino [H/M] temprana y tardía en la gammagrafía planar) y aumento del flujo de salida simpático (que puede visualizarse como una alta tasa de lavado). Estos hallazgos se han asociado consistentemente con un peor resultado: más notablemente, un ensayo de fase 3, encontró que los pacientes con un H/M tardío 1.60, poseen una mayor incidencia de mortalidad cardiovascular y por todas las causas y arritmias potencialmente mortales durante un seguimiento de menos de 2 años. A pesar de estos hallazgos prometedores, la gammagrafía con 123I-MIBG aún no ha sido recomendada por las principales guías de IC como una herramienta para la estratificación del riesgo aditivo y nunca ha entrado en la etapa de adopción generalizada en la práctica clínica actual. La gammagrafía con 123I-MIBG también se ha evaluado en pacientes con infarto de miocardio, trastornos genéticos caracterizados por una mayor susceptibilidad a las arritmias ventriculares y varias otras condiciones caracterizadas por alteración de la inervación miocárdica simpática. En la presente revisión, se resumirá el estado del arte de la gammagrafía cardíaca con 123I-MIBG, los problemas actuales sin resolver y las posibles direcciones de la investigación futura.

Myocardial blood flow regulation in infarcted patients with stress-induced normalization of negative T waves

The correlation of stress-induced normalization of negative T waves (NTW) with regional myocardial blood flow (MBF) regulation and tissue viability remains still dented

CRT in Patients with Heart Failure: Time Course of Perfusion and Wall Motion Changes

In patients treated with CRT no data relative to the relationship between regional wall motion and perfusion and reverse remodelling of the left ventricle at short and medium term followup were available. To this aim, 36 heart failure patients were studied by G-SPECT before (T0), within 2 months (T1) and 6 months (T2) after CRT. A clinical followup was completed for 36 months. In 30/36 patients there was an improvement of NYHA Class at T1 that persisted at T2. G-SPECT showed significant improvement of perfusion at T1 in 92% of patients without further changes at T2. A reduction of LV volumes, an increase of EF and an improvement of regional wall motion and thickening were observed at T1 versus baseline, with only minor changes at T2. Moreover, baseline extension of perfusion defects was scarcely correlated with improvement after CRT. Finally, end diastolic volume, perfusion defect and diabetes mellitus were independent predictors of survival. The main effects of CRT on regional myocardial perfusion and wall motion are obtained within 2 months. Volume overload modulates recovery of ventricular function independently of reperfusion and, with extension of perfusion abnormalities and diabetes were independent predictors of survival during followup

A Review of Model Predictive Controls Applied to Advanced Driver-Assistance Systems

Advanced Driver-Assistance Systems (ADASs) are currently gaining particular attention in the automotive field, as enablers for vehicle energy consumption, safety, and comfort enhancement. Compelling evidence is in fact provided by the variety of related studies that are to be found in the literature. Moreover, considering the actual technology readiness, larger opportunities might stem from the combination of ADASs and vehicle connectivity. Nevertheless, the definition of a suitable control system is not often trivial, especially when dealing with multiple-objective problems and dynamics complexity. In this scenario, even though diverse strategies are possible (e.g., Equivalent Consumption Minimization Strategy, Rule-based strategy, etc.), the Model Predictive Control (MPC) turned out to be among the most effective ones in fulfilling the aforementioned tasks. Hence, the proposed study is meant to produce a comprehensive review of MPCs applied to scenarios where ADASs are exploited and aims at providing the guidelines to select the appropriate strategy. More precisely, particular attention is paid to the prediction phase, the objective function formulation and the constraints. Subsequently, the interest is shifted to the combination of ADASs and vehicle connectivity to assess for how such information is handled by the MPC. The main results from the literature are presented and discussed, along with the integration of MPC in the optimal management of higher level connection and automation. Current gaps and challenges are addressed to, so as to possibly provide hints on future developments

Tales from the future-nuclear cardio-oncology, from prediction to diagnosis and monitoring

Cancer and cardiovascular diseases (CVD) often share common risk factors, and patients with CVD who develop cancer are at high risk of experiencing major adverse cardiovascular events. Additionally, cancer treatment can induce short- and long-term adverse cardiovascular events. Given the improvement in oncological patients' prognosis, the burden in this vulnerable population is slowly shifting towards increased cardiovascular mortality. Consequently, the field of cardio-oncology is steadily expanding, prompting the need for new markers to stratify and monitor the cardiovascular risk in oncological patients before, during, and after the completion of treatment. Advanced non-invasive cardiac imaging has raised great interest in the early detection of CVD and cardiotoxicity in oncological patients. Nuclear medicine has long been a pivotal exam to robustly assess and monitor the cardiac function of patients undergoing potentially cardiotoxic chemotherapies. In addition, recent radiotracers have shown great interest in the early detection of cancer-treatment-related cardiotoxicity. In this review, we summarize the current and emerging nuclear cardiology tools that can help identify cardiotoxicity and assess the cardiovascular risk in patients undergoing cancer treatments and discuss the specific role of nuclear cardiology alongside other non-invasive imaging techniques

Association of Circulating Heme Oxygenase-1, Lipid Profile and Coronary Disease Phenotype in Patients with Chronic Coronary Syndrome

Background. The NF-E2-related factor 2 (Nrf2)/Heme Oxygenase-1 (HO-1) pathway has an emerging role in atherosclerosis. Activated by oxidative stress, it is deemed to exert athero-protective effects. We aimed at evaluating the relationships between plasma HO-1, clinical/molecular profiles and coronary disease patterns in patients with chronic coronary syndromes (CCS). Methods. HO-1 was measured in 526 patients (60 +/- 9 years, 318 males) with CCS. Coronary computed tomography angiography (CTA) and stress imaging were used to assess the disease phenotype (coronary atherosclerosis and myocardial ischemia) in a subgroup of 347 patients. Results. In the overall population, HO-1 median value (25-75 percentile) was 5.195 (1.75-8.25) ng/mL. Patients with higher HO-1 were more frequently male, had a higher BMI and lower LVEF%, but otherwise similar risk factors than the other patients. Their bio-humoral profile was characterized by higher markers of endothelial/myocardial dysfunction, but lower levels of cholesterol lipoproteins. Coronary artery disease was characterized by more diffuse atherosclerosis, with mainly non-obstructive and calcified plaques, and a higher prevalence of functional ischemia. Conclusion: In patients with CCS, higher plasma HO-1 levels are associated with lower cholesterol and a more diffuse but mainly non-obstructive coronary atherosclerosis, confirming a potential role for the Nrf2/HO-1 pathway as a protective feedback

Reporting nuclear cardiology: a joint position paper by the European Association of Nuclear Medicine (EANM) and the European Association of Cardiovascular Imaging (EACVI)

The report of an imaging procedure is a critical component of an examination, being the final and often the only communication from the interpreting physician to the referring or treating physician. Very limited evidence and few recommendations or guidelines on reporting imaging studies are available; therefore, an European position statement on how to report nuclear cardiology might be useful. The current paper combines the limited existing evidence with expert consensus, previously published recommendations as well as current clinical practices. For all the applications discussed in this paper (myocardial perfusion, viability, innervation, and function as acquired by single photon emission computed tomography and positron emission tomography or hybrid imaging), headings cover laboratory and patient demographics, clinical indication, tracer administration and image acquisition, findings, and conclusion of the report. The statement also discusses recommended terminology in nuclear cardiology, image display, and preliminary reports. It is hoped that this statement may lead to more attention to create well-written and standardized nuclear cardiology reports and eventually lead to improved clinical outcom