Imaging

Multimodality imaging is among the highlights of this year's American Society of Echocardiography meeting, which starts on June 30 at the National Harbor, Maryland.

The society is pushing forward the concept, looking at different diseases and integrating different kinds of imaging such as echo plus nuclear, cardiac CT, or cardiac MR, in order to get the best diagnoses, said Dr. Melissa Wood, co-director of Massachusetts General Hospital Heart Center Women's Heart Health Program, Boston, and the chair of ASE Public Relations Committee.

"This isn't just about echo, it's also about all the other imaging techniques that are out there and how we can work together and deliver the highest quality of care," said Dr. Wood in an interview. "It's also about what's superfluous, and what we don't need to do."

On the policy front, Accountable Care Organizations will be in the forefront during the meeting. Dr. Wood said that the speakers will address how "ACOs affect those of us who read echos and do them, and how they affect practices."

Echocardiography will also leave this planet for a bit during a symposium. ASE president Dr. James Thomas has long been actively involved in doing research with the space program and helping pick the right echo machine for use up there, said Dr. Wood. "There's substantial interest in microgravity and the heart, and how heart changes its function in space. It's something that's very unique, and there are lessons that can be learned from that, and that experience will be somehow useful in our clinical practices, whether it's specific type of research techniques or specific types of information that are gained in that environment."

Echocardiography is the second most commonly ordered test after ECG, according to Dr. Wood, and with the aging population, the use of the test is likely to increase. 

"I see echo take off more because of this concern about heart failure being an epidemic. Echo as a way to diagnose heart failure before it becomes profound," she said. And given the appropriate use criteria, "we're tying to moderate the reasons echos are ordered, so they'll continue to be fairly reimbursed by third parties and the Centers for Medicare and Medicaid Services," said Dr. Wood. 

You can find the meeting's program here. And be sure to check our coverage on ecardiologynews.com.

By Naseem S. Miller (@NaseemSMiller)

Multimodality imaging is among the highlights of this year's American Society of Echocardiography meeting, which starts on June 30 at the National Harbor, Maryland.

The society is pushing forward the concept, looking at different diseases and integrating different kinds of imaging such as echo plus nuclear, cardiac CT, or cardiac MR, in order to get the best diagnoses, said Dr. Melissa Wood, co-director of Massachusetts General Hospital Heart Center Women's Heart Health Program, Boston, and the chair of ASE Public Relations Committee.

"This isn't just about echo, it's also about all the other imaging techniques that are out there and how we can work together and deliver the highest quality of care," said Dr. Wood in an interview. "It's also about what's superfluous, and what we don't need to do."

On the policy front, Accountable Care Organizations will be in the forefront during the meeting. Dr. Wood said that the speakers will address how "ACOs affect those of us who read echos and do them, and how they affect practices."

Echocardiography will also leave this planet for a bit during a symposium. ASE president Dr. James Thomas has long been actively involved in doing research with the space program and helping pick the right echo machine for use up there, said Dr. Wood. "There's substantial interest in microgravity and the heart, and how heart changes its function in space. It's something that's very unique, and there are lessons that can be learned from that, and that experience will be somehow useful in our clinical practices, whether it's specific type of research techniques or specific types of information that are gained in that environment."

Echocardiography is the second most commonly ordered test after ECG, according to Dr. Wood, and with the aging population, the use of the test is likely to increase. 

"I see echo take off more because of this concern about heart failure being an epidemic. Echo as a way to diagnose heart failure before it becomes profound," she said. And given the appropriate use criteria, "we're tying to moderate the reasons echos are ordered, so they'll continue to be fairly reimbursed by third parties and the Centers for Medicare and Medicaid Services," said Dr. Wood. 

You can find the meeting's program here. And be sure to check our coverage on ecardiologynews.com.

By Naseem S. Miller (@NaseemSMiller)

Multimodality imaging is among the highlights of this year's American Society of Echocardiography meeting, which starts on June 30 at the National Harbor, Maryland.

The society is pushing forward the concept, looking at different diseases and integrating different kinds of imaging such as echo plus nuclear, cardiac CT, or cardiac MR, in order to get the best diagnoses, said Dr. Melissa Wood, co-director of Massachusetts General Hospital Heart Center Women's Heart Health Program, Boston, and the chair of ASE Public Relations Committee.

"This isn't just about echo, it's also about all the other imaging techniques that are out there and how we can work together and deliver the highest quality of care," said Dr. Wood in an interview. "It's also about what's superfluous, and what we don't need to do."

On the policy front, Accountable Care Organizations will be in the forefront during the meeting. Dr. Wood said that the speakers will address how "ACOs affect those of us who read echos and do them, and how they affect practices."

Echocardiography will also leave this planet for a bit during a symposium. ASE president Dr. James Thomas has long been actively involved in doing research with the space program and helping pick the right echo machine for use up there, said Dr. Wood. "There's substantial interest in microgravity and the heart, and how heart changes its function in space. It's something that's very unique, and there are lessons that can be learned from that, and that experience will be somehow useful in our clinical practices, whether it's specific type of research techniques or specific types of information that are gained in that environment."

Echocardiography is the second most commonly ordered test after ECG, according to Dr. Wood, and with the aging population, the use of the test is likely to increase. 

"I see echo take off more because of this concern about heart failure being an epidemic. Echo as a way to diagnose heart failure before it becomes profound," she said. And given the appropriate use criteria, "we're tying to moderate the reasons echos are ordered, so they'll continue to be fairly reimbursed by third parties and the Centers for Medicare and Medicaid Services," said Dr. Wood. 

You can find the meeting's program here. And be sure to check our coverage on ecardiologynews.com.

By Naseem S. Miller (@NaseemSMiller)

First, do no harm ... our creed, our command, our imperative. It’s easy to point out those times when a doctor does harm by commission of an act, but what about when we do harm by omission? After all, we get extraordinarily busy sometimes and, out of necessity, sometimes omit things deemed to be "not as important" as other things. If we are honest with ourselves, there are times we fail our patients, and fail miserably.

We are only human, right? How long can we go without sleep, food, or fluid, trying desperately to make it through the "next few patients" before we take a break and tend to our own needs? When we are hungry, thirsty, or just plain grumpy from stress on the job, and life’s events in general, how often do we opt to forgo opportunities to educate and protect our patients?

I think this happens more than any of us want to openly admit. Sometimes it just seems easier to order a test than to spend extra time determining whether there is a better alternative. And then there’s that ever-consuming lawsuit issue. On occasion, most physicians do order tests and procedures to avert a potential lawsuit, even though in our guts we feel the patients don’t really them.

Case in point: the glorious CT scan. Television would have our patients believe that CT scans can diagnose every condition under the sun. No wonder so many ask for them (and sometimes demand them) even for the simplest of symptoms.

Have you ever had a patient who has had 10 or 15 CAT scans in the recent past, all of which were normal, or nearly normal? I have. But after explaining that each scan carries a small but real risk of promoting cancer in the future, that CAT scan that was once so important became rather insignificant. Of course, clinically I did not feel the patient needed yet another scan and after learning about the risks involved, he didn’t either.

Many radiologists – who know the risks better than we do as hospitalists – sometimes feel uncomfortable about the number of CT scans performed. Says Dr. Peter Vandermeer, vice-chair of the department of radiology at Baltimore Washington Medical Center in Glen Burnie, Md.: "We are alternately frustrated and chastened by the fact that we cannot know everything that goes into decision making. It is hard to know if this is the real episode in which a CT will finally help. It will always remain a clinical decision based on immediate circumstances.

"Especially in young patients, we need to be aware that there are small but potentially serious consequences of CT scans. The other side of it is that as radiologists we are always willing to discuss alternate tests, such as ultrasound and MRI, that may be helpful in answering specific, directed questions. CT is great in giving a broad overview of the entire abdomen, but if all you really want to know is if there is hydronephrosis, renal ultrasound may be sufficient."

As a parent, I am particularly concerned about the risk in children. In an article published in The Lancet, researchers reported that 10 years after a first scan for children under the age of 10, there was one excess case of leukemia as well as one additional brain tumor per 10,000 head scans performed (Lancet 2012 June 7 [doi:10.1016/S0140-6736(12)60815-0]).

While a single CT scan does not seem problematic, for that 1 in 10,000 patients who does develop cancer, it is highly problematic. So let us make sure that each scan we order is truly worth the risk to out patients.

First, do no harm ... our creed, our command, our imperative. It’s easy to point out those times when a doctor does harm by commission of an act, but what about when we do harm by omission? After all, we get extraordinarily busy sometimes and, out of necessity, sometimes omit things deemed to be "not as important" as other things. If we are honest with ourselves, there are times we fail our patients, and fail miserably.

We are only human, right? How long can we go without sleep, food, or fluid, trying desperately to make it through the "next few patients" before we take a break and tend to our own needs? When we are hungry, thirsty, or just plain grumpy from stress on the job, and life’s events in general, how often do we opt to forgo opportunities to educate and protect our patients?

I think this happens more than any of us want to openly admit. Sometimes it just seems easier to order a test than to spend extra time determining whether there is a better alternative. And then there’s that ever-consuming lawsuit issue. On occasion, most physicians do order tests and procedures to avert a potential lawsuit, even though in our guts we feel the patients don’t really them.

Case in point: the glorious CT scan. Television would have our patients believe that CT scans can diagnose every condition under the sun. No wonder so many ask for them (and sometimes demand them) even for the simplest of symptoms.

Have you ever had a patient who has had 10 or 15 CAT scans in the recent past, all of which were normal, or nearly normal? I have. But after explaining that each scan carries a small but real risk of promoting cancer in the future, that CAT scan that was once so important became rather insignificant. Of course, clinically I did not feel the patient needed yet another scan and after learning about the risks involved, he didn’t either.

Many radiologists – who know the risks better than we do as hospitalists – sometimes feel uncomfortable about the number of CT scans performed. Says Dr. Peter Vandermeer, vice-chair of the department of radiology at Baltimore Washington Medical Center in Glen Burnie, Md.: "We are alternately frustrated and chastened by the fact that we cannot know everything that goes into decision making. It is hard to know if this is the real episode in which a CT will finally help. It will always remain a clinical decision based on immediate circumstances.

"Especially in young patients, we need to be aware that there are small but potentially serious consequences of CT scans. The other side of it is that as radiologists we are always willing to discuss alternate tests, such as ultrasound and MRI, that may be helpful in answering specific, directed questions. CT is great in giving a broad overview of the entire abdomen, but if all you really want to know is if there is hydronephrosis, renal ultrasound may be sufficient."

As a parent, I am particularly concerned about the risk in children. In an article published in The Lancet, researchers reported that 10 years after a first scan for children under the age of 10, there was one excess case of leukemia as well as one additional brain tumor per 10,000 head scans performed (Lancet 2012 June 7 [doi:10.1016/S0140-6736(12)60815-0]).

While a single CT scan does not seem problematic, for that 1 in 10,000 patients who does develop cancer, it is highly problematic. So let us make sure that each scan we order is truly worth the risk to out patients.

First, do no harm ... our creed, our command, our imperative. It’s easy to point out those times when a doctor does harm by commission of an act, but what about when we do harm by omission? After all, we get extraordinarily busy sometimes and, out of necessity, sometimes omit things deemed to be "not as important" as other things. If we are honest with ourselves, there are times we fail our patients, and fail miserably.

We are only human, right? How long can we go without sleep, food, or fluid, trying desperately to make it through the "next few patients" before we take a break and tend to our own needs? When we are hungry, thirsty, or just plain grumpy from stress on the job, and life’s events in general, how often do we opt to forgo opportunities to educate and protect our patients?

I think this happens more than any of us want to openly admit. Sometimes it just seems easier to order a test than to spend extra time determining whether there is a better alternative. And then there’s that ever-consuming lawsuit issue. On occasion, most physicians do order tests and procedures to avert a potential lawsuit, even though in our guts we feel the patients don’t really them.

Case in point: the glorious CT scan. Television would have our patients believe that CT scans can diagnose every condition under the sun. No wonder so many ask for them (and sometimes demand them) even for the simplest of symptoms.

Have you ever had a patient who has had 10 or 15 CAT scans in the recent past, all of which were normal, or nearly normal? I have. But after explaining that each scan carries a small but real risk of promoting cancer in the future, that CAT scan that was once so important became rather insignificant. Of course, clinically I did not feel the patient needed yet another scan and after learning about the risks involved, he didn’t either.

Many radiologists – who know the risks better than we do as hospitalists – sometimes feel uncomfortable about the number of CT scans performed. Says Dr. Peter Vandermeer, vice-chair of the department of radiology at Baltimore Washington Medical Center in Glen Burnie, Md.: "We are alternately frustrated and chastened by the fact that we cannot know everything that goes into decision making. It is hard to know if this is the real episode in which a CT will finally help. It will always remain a clinical decision based on immediate circumstances.

"Especially in young patients, we need to be aware that there are small but potentially serious consequences of CT scans. The other side of it is that as radiologists we are always willing to discuss alternate tests, such as ultrasound and MRI, that may be helpful in answering specific, directed questions. CT is great in giving a broad overview of the entire abdomen, but if all you really want to know is if there is hydronephrosis, renal ultrasound may be sufficient."

As a parent, I am particularly concerned about the risk in children. In an article published in The Lancet, researchers reported that 10 years after a first scan for children under the age of 10, there was one excess case of leukemia as well as one additional brain tumor per 10,000 head scans performed (Lancet 2012 June 7 [doi:10.1016/S0140-6736(12)60815-0]).

While a single CT scan does not seem problematic, for that 1 in 10,000 patients who does develop cancer, it is highly problematic. So let us make sure that each scan we order is truly worth the risk to out patients.

Longitudinal tracking of the deposition of beta-amyloid over a period of 2-3 years with the use of PET imaging radiotracers in patients with mild cognitive impairment can help predict progression to Alzheimer’s disease or reliably rule it out as a diagnosis.

Those results, reported in two studies of the investigational agents 11C-Pittsburgh compound B (PiB) and 18F-florbetaben at the annual meeting of the Society of Nuclear Medicine and Molecular Imaging in Miami, showed that the tracers could be used to predict progression to Alzheimer’s in 66%-75% of those with elevated binding of the agents to beta-amyloid plaques in the brains of individuals with mild cognitive impairment (MCI). In cases where an individual tested negative for elevated beta-amyloid binding, fewer than 20% progressed to another type of dementia.

Courtesy Dr. Marwan Sabbagh

Results such as these show that detecting beta-amyloid burden in the brain "can help lead to diagnosis of Alzheimer’s disease when a patient has mild symptoms rather than wait until they have established dementia as is the current clinical practice. This may have important benefits for the patient, for their family, and for society," said Dr. Christopher Rowe, the lead investigator on the PiB study and senior investigator on the florbetaben study.

The PiB study, called the Australian Imaging, Biomarkers, and Lifestyle Flagship Study of Ageing, included 92 patients with MCI. At baseline, Dr. Rowe and his colleagues detected high PiB binding in 65% of MCI patients. After 3 years, 66% of MCI patients who had a positive scan for high beta-amyloid burden at baseline had been diagnosed with Alzheimer’s, compared with only 7% of MCI patients with a negative scan.

Other studies of PiB out to 6 years of follow-up have shown that patients accrue beta-amyloid at "an incredibly slow" rate of about 2% per year. "If you have a negative scan, you can be reassured that you’re not going to have Alzheimer’s disease for at least the next 10 years," Dr. Rowe said at a press conference at the meeting.

Because the half-life of PiB is only 20 minutes, it is not suitable for clinical use. The 2-hour half-life of florbetaben and other 18F amyloid radiotracers make them much more cost effective for clinical use, noted Dr. Rowe, director of the department of nuclear medicine and the center for PET and a consultant neurologist to the memory disorders clinic at the Austin Hospital in Melbourne, Australia.

The florbetaben study involved 45 patients with MCI who received PET imaging with the compound. At baseline, 53% had a high level of neocortical binding, and binding increased 3% after 2 years in those with already high levels. Overall, 75% of patients with elevated florbetaben binding progressed to Alzheimer’s disease, whereas 19% of those with a low level of binding progressed to other kinds of dementias.

MR imaging in the same individuals indicated that 53% of patients with hippocampal atrophy at baseline had progressed to Alzheimer’s. When the combination of high florbetaben binding and hippocampal atrophy was present, 80% had progressed to Alzheimer’s after 2 years.

"We don’t say that everybody who’s got Alzheimer’s disease should have these scans because I don’t think that would be cost effective. But in selected scenarios, when they’ve seen a memory specialist, I think these can be very useful clinically," Dr. Rowe said.

He said amyloid imaging agents such as florbetaben have two potential uses:

• In patients with established dementia when there is uncertainty about whether the patient has Alzheimer’s disease or frontotemporal dementia. He noted that this has therapeutic implications because some of the medications used to treat Alzheimer’s, such as cholinesterase inhibitors, can make behavioral symptoms worse in frontotemporal dementia.

• In patients with MCI who have seen a specialist who is not sure what the cause of the symptoms might be and wants to see if it might be Alzheimer’s instead of waiting years for dementia to develop. Because about 40% with MCI do not go on to develop dementia, amyloid imaging studies would be reassuring to those patients, Dr. Rowe said.

Guidelines from the Alzheimer’s Association and the Society of Nuclear Medicine and Molecular Imaging (which recently changed its name from the Society of Nuclear Medicine) will soon be available on the appropriate use of the imaging agents, Dr. Rowe said in an interview.

He disclosed that he has served as an investigator on studies for many of the companies developing amyloid imaging products, including Avid Radiopharmaceuticals, Bayer Schering Pharma, GE Healthcare, and AstraZeneca. He has also received payments for consulting for Bayer and GE.

Longitudinal tracking of the deposition of beta-amyloid over a period of 2-3 years with the use of PET imaging radiotracers in patients with mild cognitive impairment can help predict progression to Alzheimer’s disease or reliably rule it out as a diagnosis.

Those results, reported in two studies of the investigational agents 11C-Pittsburgh compound B (PiB) and 18F-florbetaben at the annual meeting of the Society of Nuclear Medicine and Molecular Imaging in Miami, showed that the tracers could be used to predict progression to Alzheimer’s in 66%-75% of those with elevated binding of the agents to beta-amyloid plaques in the brains of individuals with mild cognitive impairment (MCI). In cases where an individual tested negative for elevated beta-amyloid binding, fewer than 20% progressed to another type of dementia.

Courtesy Dr. Marwan Sabbagh

Results such as these show that detecting beta-amyloid burden in the brain "can help lead to diagnosis of Alzheimer’s disease when a patient has mild symptoms rather than wait until they have established dementia as is the current clinical practice. This may have important benefits for the patient, for their family, and for society," said Dr. Christopher Rowe, the lead investigator on the PiB study and senior investigator on the florbetaben study.

The PiB study, called the Australian Imaging, Biomarkers, and Lifestyle Flagship Study of Ageing, included 92 patients with MCI. At baseline, Dr. Rowe and his colleagues detected high PiB binding in 65% of MCI patients. After 3 years, 66% of MCI patients who had a positive scan for high beta-amyloid burden at baseline had been diagnosed with Alzheimer’s, compared with only 7% of MCI patients with a negative scan.

Other studies of PiB out to 6 years of follow-up have shown that patients accrue beta-amyloid at "an incredibly slow" rate of about 2% per year. "If you have a negative scan, you can be reassured that you’re not going to have Alzheimer’s disease for at least the next 10 years," Dr. Rowe said at a press conference at the meeting.

Because the half-life of PiB is only 20 minutes, it is not suitable for clinical use. The 2-hour half-life of florbetaben and other 18F amyloid radiotracers make them much more cost effective for clinical use, noted Dr. Rowe, director of the department of nuclear medicine and the center for PET and a consultant neurologist to the memory disorders clinic at the Austin Hospital in Melbourne, Australia.

The florbetaben study involved 45 patients with MCI who received PET imaging with the compound. At baseline, 53% had a high level of neocortical binding, and binding increased 3% after 2 years in those with already high levels. Overall, 75% of patients with elevated florbetaben binding progressed to Alzheimer’s disease, whereas 19% of those with a low level of binding progressed to other kinds of dementias.

MR imaging in the same individuals indicated that 53% of patients with hippocampal atrophy at baseline had progressed to Alzheimer’s. When the combination of high florbetaben binding and hippocampal atrophy was present, 80% had progressed to Alzheimer’s after 2 years.

"We don’t say that everybody who’s got Alzheimer’s disease should have these scans because I don’t think that would be cost effective. But in selected scenarios, when they’ve seen a memory specialist, I think these can be very useful clinically," Dr. Rowe said.

He said amyloid imaging agents such as florbetaben have two potential uses:

• In patients with established dementia when there is uncertainty about whether the patient has Alzheimer’s disease or frontotemporal dementia. He noted that this has therapeutic implications because some of the medications used to treat Alzheimer’s, such as cholinesterase inhibitors, can make behavioral symptoms worse in frontotemporal dementia.

• In patients with MCI who have seen a specialist who is not sure what the cause of the symptoms might be and wants to see if it might be Alzheimer’s instead of waiting years for dementia to develop. Because about 40% with MCI do not go on to develop dementia, amyloid imaging studies would be reassuring to those patients, Dr. Rowe said.

Guidelines from the Alzheimer’s Association and the Society of Nuclear Medicine and Molecular Imaging (which recently changed its name from the Society of Nuclear Medicine) will soon be available on the appropriate use of the imaging agents, Dr. Rowe said in an interview.

He disclosed that he has served as an investigator on studies for many of the companies developing amyloid imaging products, including Avid Radiopharmaceuticals, Bayer Schering Pharma, GE Healthcare, and AstraZeneca. He has also received payments for consulting for Bayer and GE.

Longitudinal tracking of the deposition of beta-amyloid over a period of 2-3 years with the use of PET imaging radiotracers in patients with mild cognitive impairment can help predict progression to Alzheimer’s disease or reliably rule it out as a diagnosis.

Those results, reported in two studies of the investigational agents 11C-Pittsburgh compound B (PiB) and 18F-florbetaben at the annual meeting of the Society of Nuclear Medicine and Molecular Imaging in Miami, showed that the tracers could be used to predict progression to Alzheimer’s in 66%-75% of those with elevated binding of the agents to beta-amyloid plaques in the brains of individuals with mild cognitive impairment (MCI). In cases where an individual tested negative for elevated beta-amyloid binding, fewer than 20% progressed to another type of dementia.

Courtesy Dr. Marwan Sabbagh

Results such as these show that detecting beta-amyloid burden in the brain "can help lead to diagnosis of Alzheimer’s disease when a patient has mild symptoms rather than wait until they have established dementia as is the current clinical practice. This may have important benefits for the patient, for their family, and for society," said Dr. Christopher Rowe, the lead investigator on the PiB study and senior investigator on the florbetaben study.

The PiB study, called the Australian Imaging, Biomarkers, and Lifestyle Flagship Study of Ageing, included 92 patients with MCI. At baseline, Dr. Rowe and his colleagues detected high PiB binding in 65% of MCI patients. After 3 years, 66% of MCI patients who had a positive scan for high beta-amyloid burden at baseline had been diagnosed with Alzheimer’s, compared with only 7% of MCI patients with a negative scan.

Other studies of PiB out to 6 years of follow-up have shown that patients accrue beta-amyloid at "an incredibly slow" rate of about 2% per year. "If you have a negative scan, you can be reassured that you’re not going to have Alzheimer’s disease for at least the next 10 years," Dr. Rowe said at a press conference at the meeting.

Because the half-life of PiB is only 20 minutes, it is not suitable for clinical use. The 2-hour half-life of florbetaben and other 18F amyloid radiotracers make them much more cost effective for clinical use, noted Dr. Rowe, director of the department of nuclear medicine and the center for PET and a consultant neurologist to the memory disorders clinic at the Austin Hospital in Melbourne, Australia.

The florbetaben study involved 45 patients with MCI who received PET imaging with the compound. At baseline, 53% had a high level of neocortical binding, and binding increased 3% after 2 years in those with already high levels. Overall, 75% of patients with elevated florbetaben binding progressed to Alzheimer’s disease, whereas 19% of those with a low level of binding progressed to other kinds of dementias.

MR imaging in the same individuals indicated that 53% of patients with hippocampal atrophy at baseline had progressed to Alzheimer’s. When the combination of high florbetaben binding and hippocampal atrophy was present, 80% had progressed to Alzheimer’s after 2 years.

"We don’t say that everybody who’s got Alzheimer’s disease should have these scans because I don’t think that would be cost effective. But in selected scenarios, when they’ve seen a memory specialist, I think these can be very useful clinically," Dr. Rowe said.

He said amyloid imaging agents such as florbetaben have two potential uses:

• In patients with established dementia when there is uncertainty about whether the patient has Alzheimer’s disease or frontotemporal dementia. He noted that this has therapeutic implications because some of the medications used to treat Alzheimer’s, such as cholinesterase inhibitors, can make behavioral symptoms worse in frontotemporal dementia.

• In patients with MCI who have seen a specialist who is not sure what the cause of the symptoms might be and wants to see if it might be Alzheimer’s instead of waiting years for dementia to develop. Because about 40% with MCI do not go on to develop dementia, amyloid imaging studies would be reassuring to those patients, Dr. Rowe said.

Guidelines from the Alzheimer’s Association and the Society of Nuclear Medicine and Molecular Imaging (which recently changed its name from the Society of Nuclear Medicine) will soon be available on the appropriate use of the imaging agents, Dr. Rowe said in an interview.

He disclosed that he has served as an investigator on studies for many of the companies developing amyloid imaging products, including Avid Radiopharmaceuticals, Bayer Schering Pharma, GE Healthcare, and AstraZeneca. He has also received payments for consulting for Bayer and GE.

Advanced diagnostic imaging, with its much higher radiation doses than conventional radiography, is being used with increased frequency even within integrated health care delivery systems that are "clinically and fiscally accountable for their members’ outcomes" – in other words, even in the absence of financial incentives to overuse technologies, according to a report in the June 13 issue of JAMA.

The burgeoning use of diagnostic imaging has been well documented in Medicare and in fee-for-service insured populations, but until now no large, multicenter study has assessed time trends in imaging procedures within HMOs, which supposedly put greater limitations on questionable procedures, said Dr. Rebecca Smith-Bindman of the departments of radiology and biomedical imaging, epidemiology and biostatistics, and ob.gyn. and reproductive sciences, University of California, San Francisco, and her coinvestigators.

"Understanding imaging utilization and associated radiation exposure in these settings could help us determine how much of the increase in imaging may be independent of direct financial incentives," they noted (JAMA 307:2400-9).

The marked increase in advanced imaging is a concern because the higher radiation exposures have been linked with the development of radiation-induced cancers.

Dr. Smith-Bindman and her colleagues performed a retrospective population-based study of imaging trends between 1996 and 2010 among members of six geographically diverse U.S. health care delivery systems: Group Health Cooperative in Washington state; Kaiser Permanente in Colorado, Georgia, Hawaii, and Oregon; and Marshfield Clinic and Security Health Plan in Wisconsin.

Between 933,897 and 1,998,650 patients were included during each year of the study, and they underwent a total of 30.9 million imaging examinations. This averages out to 1.18 imaging studies per patient per year.

The investigators estimated the effective dose of ionizing radiation for each procedure, a measure that includes both the amount of radiation to which the patient is exposed and the biologic effect of that radiation on the exposed organs. They then used that data to calculate the total radiation dose each HMO member received each year, as well as the collective effective dose to the entire population.

The rates of conventional radiography and angiography/fluoroscopy remained relatively stable over the 15-year study period, rising just over 1% each year.

In marked contrast, the number of CT studies tripled, from 52 per 1,000 patients in 1996 to 149 per 1,000 in 2010. This represents an annual growth of nearly 8%.

The number of MRIs quadrupled, from 17 to 65 per 1,000 patients, an annual growth of 10%.

The number of ultrasound exams approximately doubled, from 134 to 230 per 1,000 patients, for an annual growth of 4%.

The rates of nuclear medicine exams decreased slightly, with one notable exception: During the last half of the study period, the number of PET scans skyrocketed from 0.24 per 1,000 patients in 2004 to 3.6 per 1,000 in 2010. This represents an annual growth of 57%.

Not surprisingly, the mean per capita effective radiation dose also rose significantly during the study period, effectively doubling from 1.2 mSv to 2.3 mSv. Among patients exposed to any radiation from medical imaging, the average effective dose climbed from 4.8 mSv in 1996 to 7.8 in 2010.

Of particular concern was the finding that the percentage of patients who received high (over 20-50 mSv) or very high (over 50 mSv) radiation exposure during a given year also approximately doubled. "By 2010, 2.5% of enrollees received a high annual dose of greater than 20-50 mSv, and 1.4% received a very high annual dose of greater than 50 mSv," the investigators wrote (JAMA 2012;307:2400-9).

Putting this exposure level in context, "the National Academy of Sciences’ National Research Council concluded, after a comprehensive review of the published literature, that patients who receive radiation exposures in the same range as a single CT – 10mSv – may be at increased risk for developing cancer," they said.

"The number of patients exposed to such levels highlights the need to consider this potential harm when ordering imaging tests and to track radiation exposures for individual patients so that this information is available to physicians who are ordering tests," Dr. Smith-Bindman and her associates said.

Older patients are at particular risk. The use of imaging, particularly of CT and nuclear medicine exams, increased steeply with patient age. "Among enrollees 45 years and older who underwent imaging, nearly 20% received high or very high radiation exposure annually," the researchers said.

Since the potential harm from such exposure may also increase with patient age, "it is particularly important to quantify the benefits of imaging in these patients," they noted.

The increase in the use of CT scanning accounted for much of the overall rise in radiation exposure. In 1996, 30% of patients’ exposure to ionizing radiation was attributed to CT studies; by 2010, 68% of exposure was attributed to CT studies.

"The increase in use of advanced diagnostic imaging has almost certainly contributed to both improved patient care processes and outcomes, but there are remarkably few data to quantify the benefits of imaging. Given the high costs of imaging – estimated at $100 billion annually – and the potential risks of cancer and other harms, these benefits should be quantified, and evidence-based guidelines for using imaging should be developed that clearly balance benefits against financial costs and health risk," Dr. Smith-Bindman and her colleagues said.

This study was funded by the National Cancer Institute and the National Institutes of Health. No financial conflicts of interest were reported by Dr. Smith-Bindman and her coinvestigators.

Advanced diagnostic imaging, with its much higher radiation doses than conventional radiography, is being used with increased frequency even within integrated health care delivery systems that are "clinically and fiscally accountable for their members’ outcomes" – in other words, even in the absence of financial incentives to overuse technologies, according to a report in the June 13 issue of JAMA.

The burgeoning use of diagnostic imaging has been well documented in Medicare and in fee-for-service insured populations, but until now no large, multicenter study has assessed time trends in imaging procedures within HMOs, which supposedly put greater limitations on questionable procedures, said Dr. Rebecca Smith-Bindman of the departments of radiology and biomedical imaging, epidemiology and biostatistics, and ob.gyn. and reproductive sciences, University of California, San Francisco, and her coinvestigators.

"Understanding imaging utilization and associated radiation exposure in these settings could help us determine how much of the increase in imaging may be independent of direct financial incentives," they noted (JAMA 307:2400-9).

The marked increase in advanced imaging is a concern because the higher radiation exposures have been linked with the development of radiation-induced cancers.

Dr. Smith-Bindman and her colleagues performed a retrospective population-based study of imaging trends between 1996 and 2010 among members of six geographically diverse U.S. health care delivery systems: Group Health Cooperative in Washington state; Kaiser Permanente in Colorado, Georgia, Hawaii, and Oregon; and Marshfield Clinic and Security Health Plan in Wisconsin.

Between 933,897 and 1,998,650 patients were included during each year of the study, and they underwent a total of 30.9 million imaging examinations. This averages out to 1.18 imaging studies per patient per year.

The investigators estimated the effective dose of ionizing radiation for each procedure, a measure that includes both the amount of radiation to which the patient is exposed and the biologic effect of that radiation on the exposed organs. They then used that data to calculate the total radiation dose each HMO member received each year, as well as the collective effective dose to the entire population.

The rates of conventional radiography and angiography/fluoroscopy remained relatively stable over the 15-year study period, rising just over 1% each year.

In marked contrast, the number of CT studies tripled, from 52 per 1,000 patients in 1996 to 149 per 1,000 in 2010. This represents an annual growth of nearly 8%.

The number of MRIs quadrupled, from 17 to 65 per 1,000 patients, an annual growth of 10%.

The number of ultrasound exams approximately doubled, from 134 to 230 per 1,000 patients, for an annual growth of 4%.

The rates of nuclear medicine exams decreased slightly, with one notable exception: During the last half of the study period, the number of PET scans skyrocketed from 0.24 per 1,000 patients in 2004 to 3.6 per 1,000 in 2010. This represents an annual growth of 57%.

Not surprisingly, the mean per capita effective radiation dose also rose significantly during the study period, effectively doubling from 1.2 mSv to 2.3 mSv. Among patients exposed to any radiation from medical imaging, the average effective dose climbed from 4.8 mSv in 1996 to 7.8 in 2010.

Of particular concern was the finding that the percentage of patients who received high (over 20-50 mSv) or very high (over 50 mSv) radiation exposure during a given year also approximately doubled. "By 2010, 2.5% of enrollees received a high annual dose of greater than 20-50 mSv, and 1.4% received a very high annual dose of greater than 50 mSv," the investigators wrote (JAMA 2012;307:2400-9).

Putting this exposure level in context, "the National Academy of Sciences’ National Research Council concluded, after a comprehensive review of the published literature, that patients who receive radiation exposures in the same range as a single CT – 10mSv – may be at increased risk for developing cancer," they said.

"The number of patients exposed to such levels highlights the need to consider this potential harm when ordering imaging tests and to track radiation exposures for individual patients so that this information is available to physicians who are ordering tests," Dr. Smith-Bindman and her associates said.

Older patients are at particular risk. The use of imaging, particularly of CT and nuclear medicine exams, increased steeply with patient age. "Among enrollees 45 years and older who underwent imaging, nearly 20% received high or very high radiation exposure annually," the researchers said.

Since the potential harm from such exposure may also increase with patient age, "it is particularly important to quantify the benefits of imaging in these patients," they noted.

The increase in the use of CT scanning accounted for much of the overall rise in radiation exposure. In 1996, 30% of patients’ exposure to ionizing radiation was attributed to CT studies; by 2010, 68% of exposure was attributed to CT studies.

"The increase in use of advanced diagnostic imaging has almost certainly contributed to both improved patient care processes and outcomes, but there are remarkably few data to quantify the benefits of imaging. Given the high costs of imaging – estimated at $100 billion annually – and the potential risks of cancer and other harms, these benefits should be quantified, and evidence-based guidelines for using imaging should be developed that clearly balance benefits against financial costs and health risk," Dr. Smith-Bindman and her colleagues said.

This study was funded by the National Cancer Institute and the National Institutes of Health. No financial conflicts of interest were reported by Dr. Smith-Bindman and her coinvestigators.

Advanced diagnostic imaging, with its much higher radiation doses than conventional radiography, is being used with increased frequency even within integrated health care delivery systems that are "clinically and fiscally accountable for their members’ outcomes" – in other words, even in the absence of financial incentives to overuse technologies, according to a report in the June 13 issue of JAMA.

The burgeoning use of diagnostic imaging has been well documented in Medicare and in fee-for-service insured populations, but until now no large, multicenter study has assessed time trends in imaging procedures within HMOs, which supposedly put greater limitations on questionable procedures, said Dr. Rebecca Smith-Bindman of the departments of radiology and biomedical imaging, epidemiology and biostatistics, and ob.gyn. and reproductive sciences, University of California, San Francisco, and her coinvestigators.

"Understanding imaging utilization and associated radiation exposure in these settings could help us determine how much of the increase in imaging may be independent of direct financial incentives," they noted (JAMA 307:2400-9).

The marked increase in advanced imaging is a concern because the higher radiation exposures have been linked with the development of radiation-induced cancers.

Dr. Smith-Bindman and her colleagues performed a retrospective population-based study of imaging trends between 1996 and 2010 among members of six geographically diverse U.S. health care delivery systems: Group Health Cooperative in Washington state; Kaiser Permanente in Colorado, Georgia, Hawaii, and Oregon; and Marshfield Clinic and Security Health Plan in Wisconsin.

Between 933,897 and 1,998,650 patients were included during each year of the study, and they underwent a total of 30.9 million imaging examinations. This averages out to 1.18 imaging studies per patient per year.

The investigators estimated the effective dose of ionizing radiation for each procedure, a measure that includes both the amount of radiation to which the patient is exposed and the biologic effect of that radiation on the exposed organs. They then used that data to calculate the total radiation dose each HMO member received each year, as well as the collective effective dose to the entire population.

The rates of conventional radiography and angiography/fluoroscopy remained relatively stable over the 15-year study period, rising just over 1% each year.

In marked contrast, the number of CT studies tripled, from 52 per 1,000 patients in 1996 to 149 per 1,000 in 2010. This represents an annual growth of nearly 8%.

The number of MRIs quadrupled, from 17 to 65 per 1,000 patients, an annual growth of 10%.

The number of ultrasound exams approximately doubled, from 134 to 230 per 1,000 patients, for an annual growth of 4%.

The rates of nuclear medicine exams decreased slightly, with one notable exception: During the last half of the study period, the number of PET scans skyrocketed from 0.24 per 1,000 patients in 2004 to 3.6 per 1,000 in 2010. This represents an annual growth of 57%.

Not surprisingly, the mean per capita effective radiation dose also rose significantly during the study period, effectively doubling from 1.2 mSv to 2.3 mSv. Among patients exposed to any radiation from medical imaging, the average effective dose climbed from 4.8 mSv in 1996 to 7.8 in 2010.

Of particular concern was the finding that the percentage of patients who received high (over 20-50 mSv) or very high (over 50 mSv) radiation exposure during a given year also approximately doubled. "By 2010, 2.5% of enrollees received a high annual dose of greater than 20-50 mSv, and 1.4% received a very high annual dose of greater than 50 mSv," the investigators wrote (JAMA 2012;307:2400-9).

Putting this exposure level in context, "the National Academy of Sciences’ National Research Council concluded, after a comprehensive review of the published literature, that patients who receive radiation exposures in the same range as a single CT – 10mSv – may be at increased risk for developing cancer," they said.

"The number of patients exposed to such levels highlights the need to consider this potential harm when ordering imaging tests and to track radiation exposures for individual patients so that this information is available to physicians who are ordering tests," Dr. Smith-Bindman and her associates said.

Older patients are at particular risk. The use of imaging, particularly of CT and nuclear medicine exams, increased steeply with patient age. "Among enrollees 45 years and older who underwent imaging, nearly 20% received high or very high radiation exposure annually," the researchers said.

Since the potential harm from such exposure may also increase with patient age, "it is particularly important to quantify the benefits of imaging in these patients," they noted.

The increase in the use of CT scanning accounted for much of the overall rise in radiation exposure. In 1996, 30% of patients’ exposure to ionizing radiation was attributed to CT studies; by 2010, 68% of exposure was attributed to CT studies.

"The increase in use of advanced diagnostic imaging has almost certainly contributed to both improved patient care processes and outcomes, but there are remarkably few data to quantify the benefits of imaging. Given the high costs of imaging – estimated at $100 billion annually – and the potential risks of cancer and other harms, these benefits should be quantified, and evidence-based guidelines for using imaging should be developed that clearly balance benefits against financial costs and health risk," Dr. Smith-Bindman and her colleagues said.

This study was funded by the National Cancer Institute and the National Institutes of Health. No financial conflicts of interest were reported by Dr. Smith-Bindman and her coinvestigators.

Routine exercise stress echocardiography may not be warranted in asymptomatic patients after coronary revascularization because even though it may identify those at high risk, this does not improve patient outcomes, according to a report published online May 14 in Archives of Internal Medicine.

"Given the very large population of post-PCI and post-CABG patients, careful consideration is warranted before the screening of asymptomatic patients is considered appropriate at any stage after revascularization," said Dr. Serge C. Harb and his associates at the Cleveland Clinic Heart and Vascular Institute.

Exercise stress echocardiography is useful in symptomatic patients after revascularization because it can identify the cause of the symptoms and allow further treatment to relieve them, which is usually highly effective. However, its role in asymptomatic patients is controversial because there is no evidence that identifying problems that cause no symptoms leads to better treatment, nor that treatment improves the course of the disease or patient outcomes.

Dr. Harb and his colleagues assessed the usefulness of exercise stress echocardiography in asymptomatic patients in an observational cohort study of 2,105 consecutive patients referred for such testing to their institute in 2000-2010. Patients were referred "solely at the discretion of individual physicians treating the patient, usually on the basis of concerns regarding risk factor status or incomplete revascularization," the researchers said.

Such testing is considered inappropriate when it is done too soon after the revascularization – less than 2 years after percutaneous coronary intervention (PCI) and less than 5 years after coronary artery bypass graft surgery (CABG). In this study, 1,143 study subjects had undergone PCI (709 referred for "early" and 434 for appropriate stress echocardiography) and 962 had undergone CABG (527 referred for "early" and 435 for appropriate stress echocardiography).

There were five major findings.

First, only 13% of the entire study population showed evidence of ischemia on stress echocardiography – a low yield of positive findings for this expensive procedure, the authors noted.

Second, abnormal results on stress echocardiography were associated with significantly higher risks of overall and cardiac mortality during a mean follow-up of 6 years. Mortality was 8.0% in patients who showed ischemia on stress testing, compared with only 4.1% in those who had no ischemia. However, identifying these high-risk patients made no difference in the eventual outcomes of the study cohort.

Interestingly, there was no distinction in the prognostic usefulness of stress echocardiography between patients who underwent "early" and those who underwent appropriate testing. This suggests that these cutoff times, which were based on expert opinion, are somewhat arbitrary and not useful for prognosis, the investigators said (Arch. Intern. Med. 2012 May 14 [doi:10.1001/archinternmed.2012.1355]).

Third, the main component of stress echocardiography that was found to be predictive was exercise capacity. This indicates that standard exercise testing rather than exercise echocardiography might be sufficient for risk evaluation.

Fourth, when exercise echocardiography did identify evidence of ischemia in a minority of patients, the findings were not acted upon in most cases. Only 33% of the 262 patients with positive results underwent further revascularization. Thus, the test results led to repeat revascularization in only 87 patients out of 2,105 who were tested. That’s because the decision to do repeat revascularization was based more on the development of symptoms after testing rather than on the results of the test.

Fifth, further revascularization procedures did not produce more favorable mortality outcomes.

"Our results suggest that from a prognostic standpoint, a combination of clinical and exercise data is effective in identifying patients at highest risk, even though they are unlikely to benefit from repeat revascularization," Dr. Harb and his associates said.

Dr. Rita F. Redberg, editor of Archives of Internal Medicine, noted that the recommendation "Do not perform serial stress cardiac imaging or advanced noninvasive imaging as part of routine follow-up in asymptomatic patients" is one of the Top 5 recommendationsfor the American College of Cardiology in the American Board of Internal Medicine Foundation’s "Choosing Wisely" campaign. Dr. Redberg, who is professor of medicine and director of Women’s Cardiovascular Services at the University of California, San Francisco, also gave the recommendation a "Less Is More" designation, which highlights areas of health care with no known benefit and definite risks.

Dr. Redberg has no relevant financial disclosures.

Routine exercise stress echocardiography may not be warranted in asymptomatic patients after coronary revascularization because even though it may identify those at high risk, this does not improve patient outcomes, according to a report published online May 14 in Archives of Internal Medicine.

"Given the very large population of post-PCI and post-CABG patients, careful consideration is warranted before the screening of asymptomatic patients is considered appropriate at any stage after revascularization," said Dr. Serge C. Harb and his associates at the Cleveland Clinic Heart and Vascular Institute.

Exercise stress echocardiography is useful in symptomatic patients after revascularization because it can identify the cause of the symptoms and allow further treatment to relieve them, which is usually highly effective. However, its role in asymptomatic patients is controversial because there is no evidence that identifying problems that cause no symptoms leads to better treatment, nor that treatment improves the course of the disease or patient outcomes.

Dr. Harb and his colleagues assessed the usefulness of exercise stress echocardiography in asymptomatic patients in an observational cohort study of 2,105 consecutive patients referred for such testing to their institute in 2000-2010. Patients were referred "solely at the discretion of individual physicians treating the patient, usually on the basis of concerns regarding risk factor status or incomplete revascularization," the researchers said.

Such testing is considered inappropriate when it is done too soon after the revascularization – less than 2 years after percutaneous coronary intervention (PCI) and less than 5 years after coronary artery bypass graft surgery (CABG). In this study, 1,143 study subjects had undergone PCI (709 referred for "early" and 434 for appropriate stress echocardiography) and 962 had undergone CABG (527 referred for "early" and 435 for appropriate stress echocardiography).

There were five major findings.

First, only 13% of the entire study population showed evidence of ischemia on stress echocardiography – a low yield of positive findings for this expensive procedure, the authors noted.

Second, abnormal results on stress echocardiography were associated with significantly higher risks of overall and cardiac mortality during a mean follow-up of 6 years. Mortality was 8.0% in patients who showed ischemia on stress testing, compared with only 4.1% in those who had no ischemia. However, identifying these high-risk patients made no difference in the eventual outcomes of the study cohort.

Interestingly, there was no distinction in the prognostic usefulness of stress echocardiography between patients who underwent "early" and those who underwent appropriate testing. This suggests that these cutoff times, which were based on expert opinion, are somewhat arbitrary and not useful for prognosis, the investigators said (Arch. Intern. Med. 2012 May 14 [doi:10.1001/archinternmed.2012.1355]).

Third, the main component of stress echocardiography that was found to be predictive was exercise capacity. This indicates that standard exercise testing rather than exercise echocardiography might be sufficient for risk evaluation.

Fourth, when exercise echocardiography did identify evidence of ischemia in a minority of patients, the findings were not acted upon in most cases. Only 33% of the 262 patients with positive results underwent further revascularization. Thus, the test results led to repeat revascularization in only 87 patients out of 2,105 who were tested. That’s because the decision to do repeat revascularization was based more on the development of symptoms after testing rather than on the results of the test.

Fifth, further revascularization procedures did not produce more favorable mortality outcomes.

"Our results suggest that from a prognostic standpoint, a combination of clinical and exercise data is effective in identifying patients at highest risk, even though they are unlikely to benefit from repeat revascularization," Dr. Harb and his associates said.

Dr. Rita F. Redberg, editor of Archives of Internal Medicine, noted that the recommendation "Do not perform serial stress cardiac imaging or advanced noninvasive imaging as part of routine follow-up in asymptomatic patients" is one of the Top 5 recommendationsfor the American College of Cardiology in the American Board of Internal Medicine Foundation’s "Choosing Wisely" campaign. Dr. Redberg, who is professor of medicine and director of Women’s Cardiovascular Services at the University of California, San Francisco, also gave the recommendation a "Less Is More" designation, which highlights areas of health care with no known benefit and definite risks.

Dr. Redberg has no relevant financial disclosures.

Routine exercise stress echocardiography may not be warranted in asymptomatic patients after coronary revascularization because even though it may identify those at high risk, this does not improve patient outcomes, according to a report published online May 14 in Archives of Internal Medicine.

"Given the very large population of post-PCI and post-CABG patients, careful consideration is warranted before the screening of asymptomatic patients is considered appropriate at any stage after revascularization," said Dr. Serge C. Harb and his associates at the Cleveland Clinic Heart and Vascular Institute.

Exercise stress echocardiography is useful in symptomatic patients after revascularization because it can identify the cause of the symptoms and allow further treatment to relieve them, which is usually highly effective. However, its role in asymptomatic patients is controversial because there is no evidence that identifying problems that cause no symptoms leads to better treatment, nor that treatment improves the course of the disease or patient outcomes.

Dr. Harb and his colleagues assessed the usefulness of exercise stress echocardiography in asymptomatic patients in an observational cohort study of 2,105 consecutive patients referred for such testing to their institute in 2000-2010. Patients were referred "solely at the discretion of individual physicians treating the patient, usually on the basis of concerns regarding risk factor status or incomplete revascularization," the researchers said.

Such testing is considered inappropriate when it is done too soon after the revascularization – less than 2 years after percutaneous coronary intervention (PCI) and less than 5 years after coronary artery bypass graft surgery (CABG). In this study, 1,143 study subjects had undergone PCI (709 referred for "early" and 434 for appropriate stress echocardiography) and 962 had undergone CABG (527 referred for "early" and 435 for appropriate stress echocardiography).

There were five major findings.

First, only 13% of the entire study population showed evidence of ischemia on stress echocardiography – a low yield of positive findings for this expensive procedure, the authors noted.

Second, abnormal results on stress echocardiography were associated with significantly higher risks of overall and cardiac mortality during a mean follow-up of 6 years. Mortality was 8.0% in patients who showed ischemia on stress testing, compared with only 4.1% in those who had no ischemia. However, identifying these high-risk patients made no difference in the eventual outcomes of the study cohort.

Interestingly, there was no distinction in the prognostic usefulness of stress echocardiography between patients who underwent "early" and those who underwent appropriate testing. This suggests that these cutoff times, which were based on expert opinion, are somewhat arbitrary and not useful for prognosis, the investigators said (Arch. Intern. Med. 2012 May 14 [doi:10.1001/archinternmed.2012.1355]).

Third, the main component of stress echocardiography that was found to be predictive was exercise capacity. This indicates that standard exercise testing rather than exercise echocardiography might be sufficient for risk evaluation.

Fourth, when exercise echocardiography did identify evidence of ischemia in a minority of patients, the findings were not acted upon in most cases. Only 33% of the 262 patients with positive results underwent further revascularization. Thus, the test results led to repeat revascularization in only 87 patients out of 2,105 who were tested. That’s because the decision to do repeat revascularization was based more on the development of symptoms after testing rather than on the results of the test.

Fifth, further revascularization procedures did not produce more favorable mortality outcomes.

"Our results suggest that from a prognostic standpoint, a combination of clinical and exercise data is effective in identifying patients at highest risk, even though they are unlikely to benefit from repeat revascularization," Dr. Harb and his associates said.

Dr. Rita F. Redberg, editor of Archives of Internal Medicine, noted that the recommendation "Do not perform serial stress cardiac imaging or advanced noninvasive imaging as part of routine follow-up in asymptomatic patients" is one of the Top 5 recommendationsfor the American College of Cardiology in the American Board of Internal Medicine Foundation’s "Choosing Wisely" campaign. Dr. Redberg, who is professor of medicine and director of Women’s Cardiovascular Services at the University of California, San Francisco, also gave the recommendation a "Less Is More" designation, which highlights areas of health care with no known benefit and definite risks.

Dr. Redberg has no relevant financial disclosures.

CHICAGO – Although clinical trials in rheumatoid arthritis have shown that treating to a target improves outcomes, uptake of the strategy in clinical practice continues to lag.

One of the greatest challenges is that although the treat-to-target recommendations say clinicians should change treatment based on objective outcome measures, no one has proved that doing so makes a difference in daily practice. Instead, the data on the strategy comes from prospective clinical trials, Dr. Sergio Schwartzman said at a symposium sponsored by the American College of Rheumatology (ACR).

Patrice Wendling/IMNG Medical Media

The treat-to-target strategy requires that clinicians choose a disease activity measure and measure consistently. But there are a myriad of outcome measures that clinicians can measure and a lack of consensus on which instrument to use. The American College of Rheumatology just published six recommended outcome measures for use in clinical practice based on systematic literature review (Arthritis Care Res. 2012;64:640-7). They are: the Clinical Disease Activity Index (CDAI); Disease Activity Score with 28-joint counts (erythrocyte sedimentation rate or C-reactive protein) (DAS28); Patient Activity Scale (PAS); PAS-II; Routine Assessment of Patient Index Data with three measures (RAPID-3); and the Simplified Disease Activity Index (SDAI).

Dr. Schwartzman, an associate attending rheumatologist from the Hospital for Special Surgery in New York City said the he uses the CDAI in his practice because it’s fast and immediate. Also, both the CDAI and SDAI are highly correlated with the DAS28 and ACR 20/50/70 response – two composite measures frequently used as outcomes in rheumatoid arthritis (RA) clinical trials.

"To do a 28-joint count takes about 90 seconds, and this has been published," he noted.

One limitation of composite measurement tools is that a tender joint count may be abnormal during a joint assessment but not necessarily reflective of active RA. The perfect example of this is the patient with inflammatory osteoarthritis and those with RA and fibromyalgia, Dr. Schwartzman said. Differentiating bony or fibrous swelling from joints truly swollen from synovitis can also be tricky. Composite measurement tools also frequently include comorbid symptoms such as back pain that have nothing to do with arthritis and have a floor effect once the patient has a disability, he added.

Ultrasound is increasingly being used in practice, with some evidence to suggest that the new German US 7 (G7) score is a viable option for following patients over time. The G7 uses a 3-point scale to score synovitis, peritendinitis /tenosynovitis, and erosions in seven joints in the clinically dominant hand and foot. A pilot study involving 120 RA patients in a daily rheumatology practice found that the G7 score significantly reflected response to disease-modifying antirheumatic drug and/or tumor necrosis factor (TNF)-alpha therapy at 6 months when compared with the DAS28 (Arthritis Rheum. 2009;61:1194-201).

The main drawback is that the G7 is relatively time consuming to perform at about 20-30 minutes in the hands of an experienced ultrasonographer, Dr. Schwartzman said. As with any outcome measure, there is also the time needed to review and document the outcome measures.

Inroads are being made with the use of biomarkers, but he argued that this approach is still in development. Crescendo Bioscience’s multi-protein Vectra DA biomarker blood test is approved in the United States to monitor disease activity, but reimbursement is by no means universal.

Dr. Schwartzman said that while many rheumatologists are measuring disease activity, they often fail to identify a therapeutic target and to utilize the measurement in a defined time frame.

"The weakness in the concept of treat-to-target is that many of us do the first, but don’t necessarily do the second and third pieces," he said.

Session moderator Dr. John Cush, medical director of Baylor Research Institute in Dallas, said: "I don’t think there is any evidence that anyone actually uses treat-to-target in practice other than a few crazies like myself."

He said most clinicians remain adverse to the treat-to-target strategy despite strong evidence from trials such as TICORA (Tight Control for Rheumatoid Arthritis) that it works (Lancet 2004;364:263-69), and asked Dr. Schwartman, "What is it going to take for people to do it, besides third-party payers mandating it?"

Dr. Schwartzman responded that third-party payers will indeed ultimately mandate outcome measures, and asked Dr. Cush whether he personalizes therapy or uses a protocol once an outcome is reached. Dr. Cush said he is "answerable to the numbers," but personalizes therapy for his patients. Just because he recommends a change in therapy, however, doesn’t mean patients will accept it, he added.

Dr. Schwartzman disclosed having financial relationships with Amgen, Abbott, Genentech, Janssen, Pfizer, Roche, and UCB. Dr. Cush reported financial relationships with Abbott, Celgene, Centocor, Genentech, Pfizer, Roche, UCB, and Wyeth/Amgen.

CHICAGO – Although clinical trials in rheumatoid arthritis have shown that treating to a target improves outcomes, uptake of the strategy in clinical practice continues to lag.

One of the greatest challenges is that although the treat-to-target recommendations say clinicians should change treatment based on objective outcome measures, no one has proved that doing so makes a difference in daily practice. Instead, the data on the strategy comes from prospective clinical trials, Dr. Sergio Schwartzman said at a symposium sponsored by the American College of Rheumatology (ACR).

Patrice Wendling/IMNG Medical Media

The treat-to-target strategy requires that clinicians choose a disease activity measure and measure consistently. But there are a myriad of outcome measures that clinicians can measure and a lack of consensus on which instrument to use. The American College of Rheumatology just published six recommended outcome measures for use in clinical practice based on systematic literature review (Arthritis Care Res. 2012;64:640-7). They are: the Clinical Disease Activity Index (CDAI); Disease Activity Score with 28-joint counts (erythrocyte sedimentation rate or C-reactive protein) (DAS28); Patient Activity Scale (PAS); PAS-II; Routine Assessment of Patient Index Data with three measures (RAPID-3); and the Simplified Disease Activity Index (SDAI).

Dr. Schwartzman, an associate attending rheumatologist from the Hospital for Special Surgery in New York City said the he uses the CDAI in his practice because it’s fast and immediate. Also, both the CDAI and SDAI are highly correlated with the DAS28 and ACR 20/50/70 response – two composite measures frequently used as outcomes in rheumatoid arthritis (RA) clinical trials.

"To do a 28-joint count takes about 90 seconds, and this has been published," he noted.

One limitation of composite measurement tools is that a tender joint count may be abnormal during a joint assessment but not necessarily reflective of active RA. The perfect example of this is the patient with inflammatory osteoarthritis and those with RA and fibromyalgia, Dr. Schwartzman said. Differentiating bony or fibrous swelling from joints truly swollen from synovitis can also be tricky. Composite measurement tools also frequently include comorbid symptoms such as back pain that have nothing to do with arthritis and have a floor effect once the patient has a disability, he added.

Ultrasound is increasingly being used in practice, with some evidence to suggest that the new German US 7 (G7) score is a viable option for following patients over time. The G7 uses a 3-point scale to score synovitis, peritendinitis /tenosynovitis, and erosions in seven joints in the clinically dominant hand and foot. A pilot study involving 120 RA patients in a daily rheumatology practice found that the G7 score significantly reflected response to disease-modifying antirheumatic drug and/or tumor necrosis factor (TNF)-alpha therapy at 6 months when compared with the DAS28 (Arthritis Rheum. 2009;61:1194-201).

The main drawback is that the G7 is relatively time consuming to perform at about 20-30 minutes in the hands of an experienced ultrasonographer, Dr. Schwartzman said. As with any outcome measure, there is also the time needed to review and document the outcome measures.

Inroads are being made with the use of biomarkers, but he argued that this approach is still in development. Crescendo Bioscience’s multi-protein Vectra DA biomarker blood test is approved in the United States to monitor disease activity, but reimbursement is by no means universal.

Dr. Schwartzman said that while many rheumatologists are measuring disease activity, they often fail to identify a therapeutic target and to utilize the measurement in a defined time frame.

"The weakness in the concept of treat-to-target is that many of us do the first, but don’t necessarily do the second and third pieces," he said.

Session moderator Dr. John Cush, medical director of Baylor Research Institute in Dallas, said: "I don’t think there is any evidence that anyone actually uses treat-to-target in practice other than a few crazies like myself."

He said most clinicians remain adverse to the treat-to-target strategy despite strong evidence from trials such as TICORA (Tight Control for Rheumatoid Arthritis) that it works (Lancet 2004;364:263-69), and asked Dr. Schwartman, "What is it going to take for people to do it, besides third-party payers mandating it?"

Dr. Schwartzman responded that third-party payers will indeed ultimately mandate outcome measures, and asked Dr. Cush whether he personalizes therapy or uses a protocol once an outcome is reached. Dr. Cush said he is "answerable to the numbers," but personalizes therapy for his patients. Just because he recommends a change in therapy, however, doesn’t mean patients will accept it, he added.

Dr. Schwartzman disclosed having financial relationships with Amgen, Abbott, Genentech, Janssen, Pfizer, Roche, and UCB. Dr. Cush reported financial relationships with Abbott, Celgene, Centocor, Genentech, Pfizer, Roche, UCB, and Wyeth/Amgen.

CHICAGO – Although clinical trials in rheumatoid arthritis have shown that treating to a target improves outcomes, uptake of the strategy in clinical practice continues to lag.

One of the greatest challenges is that although the treat-to-target recommendations say clinicians should change treatment based on objective outcome measures, no one has proved that doing so makes a difference in daily practice. Instead, the data on the strategy comes from prospective clinical trials, Dr. Sergio Schwartzman said at a symposium sponsored by the American College of Rheumatology (ACR).

Patrice Wendling/IMNG Medical Media

The treat-to-target strategy requires that clinicians choose a disease activity measure and measure consistently. But there are a myriad of outcome measures that clinicians can measure and a lack of consensus on which instrument to use. The American College of Rheumatology just published six recommended outcome measures for use in clinical practice based on systematic literature review (Arthritis Care Res. 2012;64:640-7). They are: the Clinical Disease Activity Index (CDAI); Disease Activity Score with 28-joint counts (erythrocyte sedimentation rate or C-reactive protein) (DAS28); Patient Activity Scale (PAS); PAS-II; Routine Assessment of Patient Index Data with three measures (RAPID-3); and the Simplified Disease Activity Index (SDAI).

Dr. Schwartzman, an associate attending rheumatologist from the Hospital for Special Surgery in New York City said the he uses the CDAI in his practice because it’s fast and immediate. Also, both the CDAI and SDAI are highly correlated with the DAS28 and ACR 20/50/70 response – two composite measures frequently used as outcomes in rheumatoid arthritis (RA) clinical trials.

"To do a 28-joint count takes about 90 seconds, and this has been published," he noted.

One limitation of composite measurement tools is that a tender joint count may be abnormal during a joint assessment but not necessarily reflective of active RA. The perfect example of this is the patient with inflammatory osteoarthritis and those with RA and fibromyalgia, Dr. Schwartzman said. Differentiating bony or fibrous swelling from joints truly swollen from synovitis can also be tricky. Composite measurement tools also frequently include comorbid symptoms such as back pain that have nothing to do with arthritis and have a floor effect once the patient has a disability, he added.

Ultrasound is increasingly being used in practice, with some evidence to suggest that the new German US 7 (G7) score is a viable option for following patients over time. The G7 uses a 3-point scale to score synovitis, peritendinitis /tenosynovitis, and erosions in seven joints in the clinically dominant hand and foot. A pilot study involving 120 RA patients in a daily rheumatology practice found that the G7 score significantly reflected response to disease-modifying antirheumatic drug and/or tumor necrosis factor (TNF)-alpha therapy at 6 months when compared with the DAS28 (Arthritis Rheum. 2009;61:1194-201).

The main drawback is that the G7 is relatively time consuming to perform at about 20-30 minutes in the hands of an experienced ultrasonographer, Dr. Schwartzman said. As with any outcome measure, there is also the time needed to review and document the outcome measures.

Inroads are being made with the use of biomarkers, but he argued that this approach is still in development. Crescendo Bioscience’s multi-protein Vectra DA biomarker blood test is approved in the United States to monitor disease activity, but reimbursement is by no means universal.

Dr. Schwartzman said that while many rheumatologists are measuring disease activity, they often fail to identify a therapeutic target and to utilize the measurement in a defined time frame.

"The weakness in the concept of treat-to-target is that many of us do the first, but don’t necessarily do the second and third pieces," he said.

Session moderator Dr. John Cush, medical director of Baylor Research Institute in Dallas, said: "I don’t think there is any evidence that anyone actually uses treat-to-target in practice other than a few crazies like myself."

He said most clinicians remain adverse to the treat-to-target strategy despite strong evidence from trials such as TICORA (Tight Control for Rheumatoid Arthritis) that it works (Lancet 2004;364:263-69), and asked Dr. Schwartman, "What is it going to take for people to do it, besides third-party payers mandating it?"

Dr. Schwartzman responded that third-party payers will indeed ultimately mandate outcome measures, and asked Dr. Cush whether he personalizes therapy or uses a protocol once an outcome is reached. Dr. Cush said he is "answerable to the numbers," but personalizes therapy for his patients. Just because he recommends a change in therapy, however, doesn’t mean patients will accept it, he added.

Dr. Schwartzman disclosed having financial relationships with Amgen, Abbott, Genentech, Janssen, Pfizer, Roche, and UCB. Dr. Cush reported financial relationships with Abbott, Celgene, Centocor, Genentech, Pfizer, Roche, UCB, and Wyeth/Amgen.