Imaging

DENVER – Nuclear medicine specialists are feeling the brunt of increased public anxiety and regulatory concern regarding patient radiation exposures.

Nuclear cardiologists, in particular, find themselves in the crosshairs as a result of recent evidence of inappropriate overutilization of myocardial perfusion imaging. The profession has responded with a campaign aimed at defining appropriate use scenarios for practitioners and encouraging adoption of newer techniques that reduce radiation exposure while retaining high image quality.

"Based on these recommendations, we expect that for the population of patients referred for SPECT or PET myocardial perfusion imaging, on average a total radiation exposure of 9 mSv or less can be achieved in 50% of studies by 2014," Dr. Manuel D. Cerqueira said at the annual meeting of the American Society of Nuclear Cardiology.

Meeting that goal will require, for example, doing fewer separate-day, stress/rest technetium-99 myocardial perfusion imaging tests, which typically entail 13-16 mSv of radiation exposure. Also, the American Society of Nuclear Cardiology (ASNC) recommendations urge consideration of stress echocardiography as an alternative to nuclear imaging in younger patients because the diagnostic accuracy may be comparable and they can avoid radiation exposure altogether. In addition, the ASNC report discourages thallium-201–based imaging protocols, which involve 22-31 mSv of radiation exposure, noted Dr. Cerqueira, who was first author of the recommendations (J. Nucl. Cardiol. 2010;17:709-18), and is professor of radiology and medicine at Case Western Reserve University, Cleveland.

Something that has nuclear medicine specialists and interventional radiologists greatly concerned, according to Robert W. Atcher, Ph.D., is a proposed Nuclear Regulatory Commission (NRC) policy change that would lower the occupational radiation exposure limit from 5 to 2 rem (Roentgen equivalent man).

"The most affected groups in our field are technologists with a heavy PET [positron emission tomography] patient flow, cyclotron engineers, maintenance personnel, and radiochemists synthesizing PET tracers and therapeutic compounds. This is potentially devastating to us, because if we lower the limit then we have to double the number of people who are responsible for doing the same number of imaging studies, with no way to collect any more reimbursement to handle that task. In essence, they’re threatening to devastate our ability to do imaging," said Dr. Atcher, director of the National Isotope Development Center at the U.S. Department of Energy.

The NRC got an earful from concerned physicians and nonphysician scientists at hearings on the proposed changes held last year in Los Angeles, Houston, and Washington. The agency has not yet announced whether it plans to go ahead.

Another instance of what Dr. Atcher characterized as "regulatory overreacting" involves congressional interest in requiring hospitalization for patients who have received iodine-131. He and others have testified that there is no scientific evidence of risk to patients’ families or the general public if current guidelines for I-131 use are followed. Congressional representatives were also told that hospitalizing I-131 recipients would cost in excess of $600 million annually. In addition, critics of the idea pointed out that the risk of acquiring a serious methicillin-resistant Staphylococcus aureus infection during a hospital stay is quite real, said Dr. Atcher, a former president of the Society for Nuclear Medicine.

The new mantra at ASNC is "patient-centered imaging." The group’s recommendations for reducing radiation exposure from myocardial perfusion imaging emphasize appropriate patient selection, the use of standardized imaging protocols, radiotracers with shorter half-lives, weight-based dosing, and improved imaging systems.

Dr. E. Gordon DePuey highlighted the many new methods of optimizing image quality that have reached the market. These include resolution recovery and noise modeling software that provides superior image quality with shortened radiation exposure time. "All vendors now offer software that does this," he pointed out.

Also, hardware enhancements such as cardiofocal collimation are making a big difference. This particular technology allows half-time SPECT (single-photon emission computed tomography) with 100% myocardial radiation count density, explained Dr. DePuey of Columbia University, New York.

"All these new hardware and software methods out there are major advancements in nuclear cardiology. They need to be very seriously considered and incorporated in your practice, because they are really the keys to allowing you to decrease the radiation dose to your patients," he said.

Dr. Cerqueira drew attention to a large study that concluded myocardial perfusion imaging accounts for 22% of the total effective radiation dose accumulated from all nuclear medicine imaging procedures. Abdominal CT was the second biggest contributor, at 18% (N. Engl. J. Med. 2009;361:849-57).

Also concerning was a recent study using the very large UnitedHealthcare patient database. It showed that myocardial perfusion imaging accounted for 80% of the cumulative effective radiation dose from all cardiac imaging procedures in women age 18-34 years (J. Am. Coll. Cardiol. 2010;56:702-11).

"That’s a young population of women of childbearing age where you really wouldn’t expect a great many of these myocardial perfusion imaging studies to be done," Dr. Cerqueira commented.

He noted that the ASNC recommendations urge reserving myocardial perfusion imaging for patients in whom it has the greatest clinical utility: those at intermediate risk of coronary artery disease, patients requiring prognostic or management information, and those with persistent unexplained symptoms.

Dr. DePuey disclosed that he serves as an adviser to UltraSPECT and Dogwood Pharmaceuticals. The other speakers declared having no relevant financial interests.

DENVER – Nuclear medicine specialists are feeling the brunt of increased public anxiety and regulatory concern regarding patient radiation exposures.

Nuclear cardiologists, in particular, find themselves in the crosshairs as a result of recent evidence of inappropriate overutilization of myocardial perfusion imaging. The profession has responded with a campaign aimed at defining appropriate use scenarios for practitioners and encouraging adoption of newer techniques that reduce radiation exposure while retaining high image quality.

"Based on these recommendations, we expect that for the population of patients referred for SPECT or PET myocardial perfusion imaging, on average a total radiation exposure of 9 mSv or less can be achieved in 50% of studies by 2014," Dr. Manuel D. Cerqueira said at the annual meeting of the American Society of Nuclear Cardiology.

Meeting that goal will require, for example, doing fewer separate-day, stress/rest technetium-99 myocardial perfusion imaging tests, which typically entail 13-16 mSv of radiation exposure. Also, the American Society of Nuclear Cardiology (ASNC) recommendations urge consideration of stress echocardiography as an alternative to nuclear imaging in younger patients because the diagnostic accuracy may be comparable and they can avoid radiation exposure altogether. In addition, the ASNC report discourages thallium-201–based imaging protocols, which involve 22-31 mSv of radiation exposure, noted Dr. Cerqueira, who was first author of the recommendations (J. Nucl. Cardiol. 2010;17:709-18), and is professor of radiology and medicine at Case Western Reserve University, Cleveland.

Something that has nuclear medicine specialists and interventional radiologists greatly concerned, according to Robert W. Atcher, Ph.D., is a proposed Nuclear Regulatory Commission (NRC) policy change that would lower the occupational radiation exposure limit from 5 to 2 rem (Roentgen equivalent man).

"The most affected groups in our field are technologists with a heavy PET [positron emission tomography] patient flow, cyclotron engineers, maintenance personnel, and radiochemists synthesizing PET tracers and therapeutic compounds. This is potentially devastating to us, because if we lower the limit then we have to double the number of people who are responsible for doing the same number of imaging studies, with no way to collect any more reimbursement to handle that task. In essence, they’re threatening to devastate our ability to do imaging," said Dr. Atcher, director of the National Isotope Development Center at the U.S. Department of Energy.

The NRC got an earful from concerned physicians and nonphysician scientists at hearings on the proposed changes held last year in Los Angeles, Houston, and Washington. The agency has not yet announced whether it plans to go ahead.

Another instance of what Dr. Atcher characterized as "regulatory overreacting" involves congressional interest in requiring hospitalization for patients who have received iodine-131. He and others have testified that there is no scientific evidence of risk to patients’ families or the general public if current guidelines for I-131 use are followed. Congressional representatives were also told that hospitalizing I-131 recipients would cost in excess of $600 million annually. In addition, critics of the idea pointed out that the risk of acquiring a serious methicillin-resistant Staphylococcus aureus infection during a hospital stay is quite real, said Dr. Atcher, a former president of the Society for Nuclear Medicine.

The new mantra at ASNC is "patient-centered imaging." The group’s recommendations for reducing radiation exposure from myocardial perfusion imaging emphasize appropriate patient selection, the use of standardized imaging protocols, radiotracers with shorter half-lives, weight-based dosing, and improved imaging systems.

Dr. E. Gordon DePuey highlighted the many new methods of optimizing image quality that have reached the market. These include resolution recovery and noise modeling software that provides superior image quality with shortened radiation exposure time. "All vendors now offer software that does this," he pointed out.

Also, hardware enhancements such as cardiofocal collimation are making a big difference. This particular technology allows half-time SPECT (single-photon emission computed tomography) with 100% myocardial radiation count density, explained Dr. DePuey of Columbia University, New York.

"All these new hardware and software methods out there are major advancements in nuclear cardiology. They need to be very seriously considered and incorporated in your practice, because they are really the keys to allowing you to decrease the radiation dose to your patients," he said.

Dr. Cerqueira drew attention to a large study that concluded myocardial perfusion imaging accounts for 22% of the total effective radiation dose accumulated from all nuclear medicine imaging procedures. Abdominal CT was the second biggest contributor, at 18% (N. Engl. J. Med. 2009;361:849-57).

Also concerning was a recent study using the very large UnitedHealthcare patient database. It showed that myocardial perfusion imaging accounted for 80% of the cumulative effective radiation dose from all cardiac imaging procedures in women age 18-34 years (J. Am. Coll. Cardiol. 2010;56:702-11).

"That’s a young population of women of childbearing age where you really wouldn’t expect a great many of these myocardial perfusion imaging studies to be done," Dr. Cerqueira commented.

He noted that the ASNC recommendations urge reserving myocardial perfusion imaging for patients in whom it has the greatest clinical utility: those at intermediate risk of coronary artery disease, patients requiring prognostic or management information, and those with persistent unexplained symptoms.

Dr. DePuey disclosed that he serves as an adviser to UltraSPECT and Dogwood Pharmaceuticals. The other speakers declared having no relevant financial interests.

DENVER – Nuclear medicine specialists are feeling the brunt of increased public anxiety and regulatory concern regarding patient radiation exposures.

Nuclear cardiologists, in particular, find themselves in the crosshairs as a result of recent evidence of inappropriate overutilization of myocardial perfusion imaging. The profession has responded with a campaign aimed at defining appropriate use scenarios for practitioners and encouraging adoption of newer techniques that reduce radiation exposure while retaining high image quality.

"Based on these recommendations, we expect that for the population of patients referred for SPECT or PET myocardial perfusion imaging, on average a total radiation exposure of 9 mSv or less can be achieved in 50% of studies by 2014," Dr. Manuel D. Cerqueira said at the annual meeting of the American Society of Nuclear Cardiology.

Meeting that goal will require, for example, doing fewer separate-day, stress/rest technetium-99 myocardial perfusion imaging tests, which typically entail 13-16 mSv of radiation exposure. Also, the American Society of Nuclear Cardiology (ASNC) recommendations urge consideration of stress echocardiography as an alternative to nuclear imaging in younger patients because the diagnostic accuracy may be comparable and they can avoid radiation exposure altogether. In addition, the ASNC report discourages thallium-201–based imaging protocols, which involve 22-31 mSv of radiation exposure, noted Dr. Cerqueira, who was first author of the recommendations (J. Nucl. Cardiol. 2010;17:709-18), and is professor of radiology and medicine at Case Western Reserve University, Cleveland.

Something that has nuclear medicine specialists and interventional radiologists greatly concerned, according to Robert W. Atcher, Ph.D., is a proposed Nuclear Regulatory Commission (NRC) policy change that would lower the occupational radiation exposure limit from 5 to 2 rem (Roentgen equivalent man).

"The most affected groups in our field are technologists with a heavy PET [positron emission tomography] patient flow, cyclotron engineers, maintenance personnel, and radiochemists synthesizing PET tracers and therapeutic compounds. This is potentially devastating to us, because if we lower the limit then we have to double the number of people who are responsible for doing the same number of imaging studies, with no way to collect any more reimbursement to handle that task. In essence, they’re threatening to devastate our ability to do imaging," said Dr. Atcher, director of the National Isotope Development Center at the U.S. Department of Energy.

The NRC got an earful from concerned physicians and nonphysician scientists at hearings on the proposed changes held last year in Los Angeles, Houston, and Washington. The agency has not yet announced whether it plans to go ahead.

Another instance of what Dr. Atcher characterized as "regulatory overreacting" involves congressional interest in requiring hospitalization for patients who have received iodine-131. He and others have testified that there is no scientific evidence of risk to patients’ families or the general public if current guidelines for I-131 use are followed. Congressional representatives were also told that hospitalizing I-131 recipients would cost in excess of $600 million annually. In addition, critics of the idea pointed out that the risk of acquiring a serious methicillin-resistant Staphylococcus aureus infection during a hospital stay is quite real, said Dr. Atcher, a former president of the Society for Nuclear Medicine.

The new mantra at ASNC is "patient-centered imaging." The group’s recommendations for reducing radiation exposure from myocardial perfusion imaging emphasize appropriate patient selection, the use of standardized imaging protocols, radiotracers with shorter half-lives, weight-based dosing, and improved imaging systems.

Dr. E. Gordon DePuey highlighted the many new methods of optimizing image quality that have reached the market. These include resolution recovery and noise modeling software that provides superior image quality with shortened radiation exposure time. "All vendors now offer software that does this," he pointed out.

Also, hardware enhancements such as cardiofocal collimation are making a big difference. This particular technology allows half-time SPECT (single-photon emission computed tomography) with 100% myocardial radiation count density, explained Dr. DePuey of Columbia University, New York.

"All these new hardware and software methods out there are major advancements in nuclear cardiology. They need to be very seriously considered and incorporated in your practice, because they are really the keys to allowing you to decrease the radiation dose to your patients," he said.

Dr. Cerqueira drew attention to a large study that concluded myocardial perfusion imaging accounts for 22% of the total effective radiation dose accumulated from all nuclear medicine imaging procedures. Abdominal CT was the second biggest contributor, at 18% (N. Engl. J. Med. 2009;361:849-57).

Also concerning was a recent study using the very large UnitedHealthcare patient database. It showed that myocardial perfusion imaging accounted for 80% of the cumulative effective radiation dose from all cardiac imaging procedures in women age 18-34 years (J. Am. Coll. Cardiol. 2010;56:702-11).

"That’s a young population of women of childbearing age where you really wouldn’t expect a great many of these myocardial perfusion imaging studies to be done," Dr. Cerqueira commented.

He noted that the ASNC recommendations urge reserving myocardial perfusion imaging for patients in whom it has the greatest clinical utility: those at intermediate risk of coronary artery disease, patients requiring prognostic or management information, and those with persistent unexplained symptoms.

Dr. DePuey disclosed that he serves as an adviser to UltraSPECT and Dogwood Pharmaceuticals. The other speakers declared having no relevant financial interests.

SAN DIEGO – What if 3-6 million Americans had an asymptomatic condition that was easily, but coincidentally, detected on CT and MRI scans?

What if a number of excellent, but expensive, options existed to treat this condition, potentially preventing a catastrophic event in 0%-53% of cases, depending on the size, location, and duration of the problematic entity?

Obviously, you would look to well-designed, prospective, randomized, controlled trials intended to determine which patients should be referred for treatment, which patients should be watched, and which should be reassured.

But such trials don’t exist.

This real-life scenario describes asymptomatic, saccular, unruptured intracranial aneurysms (UIAs), which pose a management conundrum for virtually every neurologist in practice today.

"These are extremely common. About 2% of the population has a UIA," including perhaps 14 of the 700 attendees of the annual meeting of the American Neurological Association, noted Dr. Robert D. Brown during a symposium at the meeting.

"Not to fret," Dr. Brown assured the audience after personalizing his statistics. "That doesn’t necessary mean [14 attendees possess] a ticking time bomb."

Aneurysmal subarachnoid hemorrhages affect 6-10 per 100,000 U.S. population annually, with a case fatality rate of 30%-40%.

Still, "most aneurysms do not rupture," said Dr. Brown, chair of neurology at the Mayo Clinic in Rochester, Minn.

The predominance of natural history studies point to size as being of critical importance in the assessment of rupture risk, "no matter where the location or what the age of the patient," he said.

Secondarily, location and age matter, with posterior aneurysms and those in older patients being at seemingly greater risk of rupture.

But with smaller and smaller aneurysms becoming increasingly easy to see on scans, "we’re in the situation right now where the question is not ‘Can we do anything [with incidentally discovered aneurysms in younger patients],’ but should we?" he remarked.

Beyond patient age and aneurysm size and position, the hypothesized risk factors for rupture include smoking, hypertension, alcohol consumption (with risk associated with no alcohol or high alcohol use), and perhaps family history, as well as morphological characteristics and growth of the aneurysm itself over time.

Epidemiologic cohort studies can help to direct management in the absence of a well-designed, randomized trial, Dr. Brown said.

For example, data on unoperated patients who were enrolled in the 5,500-patient ISUIA (International Study of Unruptured Intracranial Aneurysms) suggest that smaller aneurysms located in the anterior circulation of the circle of Willis and the cavernous segment of the internal carotid artery are quite unlikely to hemorrhage when they are followed conservatively for 5 years.

Available data from the trial also suggest that even very small (less than 7 mm) aneurysms have a potential for hemorrhage that is "noteworthy and certainly far from zero" if they are located in the posterior communicating artery or posterior circulation.

Current and future research is exploring whether more precise analysis of the features of such aneurysms – including their undulation and elliptical indices and nonspherical shape – may be more predictive of rupture risk.

Computational fluid dynamics, drawn from engineering principles, may also provide better guidance, Dr. Brown said.

In the meantime, he cited a "huge variation" in clinical practice when it comes to management of smaller, unruptured aneurysms, with some centers opting to treat 90% with coils or clips and others treating fewer than 10% of such cases.

His own practice, guided by the literature, is to advise treatment in the following situations:

• In younger patients in otherwise good health whose aneurysms measure 7 mm or greater.

• In younger patients in otherwise good health whose aneurysms measure less than 7 mm but are in the posterior circulation.

• Possibly, in older patients with aneurysms measuring 7-12 mm in the posterior circulation.

• In older patients with aneurysms greater than 12 mm in which a reasonable treatment option exists.

Dr. Brown advised aggressive treatment of hypertension and smoking-cessation management in all patients with unruptured aneurysms, as well as careful, imaging-based follow-up of conservatively managed patients based on limited data showing growth in moderate and large lesions over time.

Even 1 in 12 small (measuring less than 8 mm) aneurysms demonstrated "clear, definitive growth" over 4 years in a study of 165 patients (Stroke 2009;40:406-11), he noted.

Aspirin therapy may be beneficial, based on soon-to-be-released data from the ISUIA study showing a "strong and significant" trend toward lower rupture risk in patients taking the highest aspirin doses, he said.

Dr. Brown disclosed no conflicts of interest relative to his talk.

SAN DIEGO – What if 3-6 million Americans had an asymptomatic condition that was easily, but coincidentally, detected on CT and MRI scans?

What if a number of excellent, but expensive, options existed to treat this condition, potentially preventing a catastrophic event in 0%-53% of cases, depending on the size, location, and duration of the problematic entity?

Obviously, you would look to well-designed, prospective, randomized, controlled trials intended to determine which patients should be referred for treatment, which patients should be watched, and which should be reassured.

But such trials don’t exist.

This real-life scenario describes asymptomatic, saccular, unruptured intracranial aneurysms (UIAs), which pose a management conundrum for virtually every neurologist in practice today.

"These are extremely common. About 2% of the population has a UIA," including perhaps 14 of the 700 attendees of the annual meeting of the American Neurological Association, noted Dr. Robert D. Brown during a symposium at the meeting.

"Not to fret," Dr. Brown assured the audience after personalizing his statistics. "That doesn’t necessary mean [14 attendees possess] a ticking time bomb."

Aneurysmal subarachnoid hemorrhages affect 6-10 per 100,000 U.S. population annually, with a case fatality rate of 30%-40%.

Still, "most aneurysms do not rupture," said Dr. Brown, chair of neurology at the Mayo Clinic in Rochester, Minn.

The predominance of natural history studies point to size as being of critical importance in the assessment of rupture risk, "no matter where the location or what the age of the patient," he said.

Secondarily, location and age matter, with posterior aneurysms and those in older patients being at seemingly greater risk of rupture.

But with smaller and smaller aneurysms becoming increasingly easy to see on scans, "we’re in the situation right now where the question is not ‘Can we do anything [with incidentally discovered aneurysms in younger patients],’ but should we?" he remarked.

Beyond patient age and aneurysm size and position, the hypothesized risk factors for rupture include smoking, hypertension, alcohol consumption (with risk associated with no alcohol or high alcohol use), and perhaps family history, as well as morphological characteristics and growth of the aneurysm itself over time.

Epidemiologic cohort studies can help to direct management in the absence of a well-designed, randomized trial, Dr. Brown said.

For example, data on unoperated patients who were enrolled in the 5,500-patient ISUIA (International Study of Unruptured Intracranial Aneurysms) suggest that smaller aneurysms located in the anterior circulation of the circle of Willis and the cavernous segment of the internal carotid artery are quite unlikely to hemorrhage when they are followed conservatively for 5 years.

Available data from the trial also suggest that even very small (less than 7 mm) aneurysms have a potential for hemorrhage that is "noteworthy and certainly far from zero" if they are located in the posterior communicating artery or posterior circulation.

Current and future research is exploring whether more precise analysis of the features of such aneurysms – including their undulation and elliptical indices and nonspherical shape – may be more predictive of rupture risk.

Computational fluid dynamics, drawn from engineering principles, may also provide better guidance, Dr. Brown said.

In the meantime, he cited a "huge variation" in clinical practice when it comes to management of smaller, unruptured aneurysms, with some centers opting to treat 90% with coils or clips and others treating fewer than 10% of such cases.

His own practice, guided by the literature, is to advise treatment in the following situations:

• In younger patients in otherwise good health whose aneurysms measure 7 mm or greater.

• In younger patients in otherwise good health whose aneurysms measure less than 7 mm but are in the posterior circulation.

• Possibly, in older patients with aneurysms measuring 7-12 mm in the posterior circulation.

• In older patients with aneurysms greater than 12 mm in which a reasonable treatment option exists.

Dr. Brown advised aggressive treatment of hypertension and smoking-cessation management in all patients with unruptured aneurysms, as well as careful, imaging-based follow-up of conservatively managed patients based on limited data showing growth in moderate and large lesions over time.

Even 1 in 12 small (measuring less than 8 mm) aneurysms demonstrated "clear, definitive growth" over 4 years in a study of 165 patients (Stroke 2009;40:406-11), he noted.

Aspirin therapy may be beneficial, based on soon-to-be-released data from the ISUIA study showing a "strong and significant" trend toward lower rupture risk in patients taking the highest aspirin doses, he said.

Dr. Brown disclosed no conflicts of interest relative to his talk.

SAN DIEGO – What if 3-6 million Americans had an asymptomatic condition that was easily, but coincidentally, detected on CT and MRI scans?

What if a number of excellent, but expensive, options existed to treat this condition, potentially preventing a catastrophic event in 0%-53% of cases, depending on the size, location, and duration of the problematic entity?

Obviously, you would look to well-designed, prospective, randomized, controlled trials intended to determine which patients should be referred for treatment, which patients should be watched, and which should be reassured.

But such trials don’t exist.

This real-life scenario describes asymptomatic, saccular, unruptured intracranial aneurysms (UIAs), which pose a management conundrum for virtually every neurologist in practice today.

"These are extremely common. About 2% of the population has a UIA," including perhaps 14 of the 700 attendees of the annual meeting of the American Neurological Association, noted Dr. Robert D. Brown during a symposium at the meeting.

"Not to fret," Dr. Brown assured the audience after personalizing his statistics. "That doesn’t necessary mean [14 attendees possess] a ticking time bomb."

Aneurysmal subarachnoid hemorrhages affect 6-10 per 100,000 U.S. population annually, with a case fatality rate of 30%-40%.

Still, "most aneurysms do not rupture," said Dr. Brown, chair of neurology at the Mayo Clinic in Rochester, Minn.

The predominance of natural history studies point to size as being of critical importance in the assessment of rupture risk, "no matter where the location or what the age of the patient," he said.

Secondarily, location and age matter, with posterior aneurysms and those in older patients being at seemingly greater risk of rupture.

But with smaller and smaller aneurysms becoming increasingly easy to see on scans, "we’re in the situation right now where the question is not ‘Can we do anything [with incidentally discovered aneurysms in younger patients],’ but should we?" he remarked.

Beyond patient age and aneurysm size and position, the hypothesized risk factors for rupture include smoking, hypertension, alcohol consumption (with risk associated with no alcohol or high alcohol use), and perhaps family history, as well as morphological characteristics and growth of the aneurysm itself over time.

Epidemiologic cohort studies can help to direct management in the absence of a well-designed, randomized trial, Dr. Brown said.

For example, data on unoperated patients who were enrolled in the 5,500-patient ISUIA (International Study of Unruptured Intracranial Aneurysms) suggest that smaller aneurysms located in the anterior circulation of the circle of Willis and the cavernous segment of the internal carotid artery are quite unlikely to hemorrhage when they are followed conservatively for 5 years.

Available data from the trial also suggest that even very small (less than 7 mm) aneurysms have a potential for hemorrhage that is "noteworthy and certainly far from zero" if they are located in the posterior communicating artery or posterior circulation.

Current and future research is exploring whether more precise analysis of the features of such aneurysms – including their undulation and elliptical indices and nonspherical shape – may be more predictive of rupture risk.

Computational fluid dynamics, drawn from engineering principles, may also provide better guidance, Dr. Brown said.

In the meantime, he cited a "huge variation" in clinical practice when it comes to management of smaller, unruptured aneurysms, with some centers opting to treat 90% with coils or clips and others treating fewer than 10% of such cases.

His own practice, guided by the literature, is to advise treatment in the following situations:

• In younger patients in otherwise good health whose aneurysms measure 7 mm or greater.

• In younger patients in otherwise good health whose aneurysms measure less than 7 mm but are in the posterior circulation.

• Possibly, in older patients with aneurysms measuring 7-12 mm in the posterior circulation.

• In older patients with aneurysms greater than 12 mm in which a reasonable treatment option exists.

Dr. Brown advised aggressive treatment of hypertension and smoking-cessation management in all patients with unruptured aneurysms, as well as careful, imaging-based follow-up of conservatively managed patients based on limited data showing growth in moderate and large lesions over time.

Even 1 in 12 small (measuring less than 8 mm) aneurysms demonstrated "clear, definitive growth" over 4 years in a study of 165 patients (Stroke 2009;40:406-11), he noted.

Aspirin therapy may be beneficial, based on soon-to-be-released data from the ISUIA study showing a "strong and significant" trend toward lower rupture risk in patients taking the highest aspirin doses, he said.

Dr. Brown disclosed no conflicts of interest relative to his talk.

DENVER – Physicians making referrals for cardiac stress testing often underestimate their patients’ ability to exercise to target heart rate, according to Dr. Michael Ross.

Here’s what can happen as a result: In a prospective series of 120 consecutive patients referred for pharmacologic myocardial perfusion imaging stress testing by primary care physicians, surgeons, and cardiologists, 60% of the patients were able to mount the treadmill and exercise to 85% of their estimated maximum heart rate, he reported at the annual meeting of American Society of Nuclear Cardiology.

Primary care physicians were significantly more likely than were cardiologists or surgeons to order a pharmacologic stress test in patients who did not need one because they were able to complete the less costly exercise stress test.

Is that because primary care physicians don’t know their patients and their physical capacities as well as other physicians do? Highly unlikely. Instead, it appears they are more concerned that if they order an exercise stress test and a patient can’t complete it, they’ll have to reorder the test – this time using pharmacologic stress – with the attendant inconvenience and delay, according to Dr. Ross of Northwestern University, Chicago.

In a multivariate logistic regression analysis, the only independent predictors of failure to reach target heart rate were being on a beta-blocker and having diabetes.

Dr. Ross said he had no relevant financial disclosures.

DENVER – Physicians making referrals for cardiac stress testing often underestimate their patients’ ability to exercise to target heart rate, according to Dr. Michael Ross.

Here’s what can happen as a result: In a prospective series of 120 consecutive patients referred for pharmacologic myocardial perfusion imaging stress testing by primary care physicians, surgeons, and cardiologists, 60% of the patients were able to mount the treadmill and exercise to 85% of their estimated maximum heart rate, he reported at the annual meeting of American Society of Nuclear Cardiology.

Primary care physicians were significantly more likely than were cardiologists or surgeons to order a pharmacologic stress test in patients who did not need one because they were able to complete the less costly exercise stress test.

Is that because primary care physicians don’t know their patients and their physical capacities as well as other physicians do? Highly unlikely. Instead, it appears they are more concerned that if they order an exercise stress test and a patient can’t complete it, they’ll have to reorder the test – this time using pharmacologic stress – with the attendant inconvenience and delay, according to Dr. Ross of Northwestern University, Chicago.

In a multivariate logistic regression analysis, the only independent predictors of failure to reach target heart rate were being on a beta-blocker and having diabetes.

Dr. Ross said he had no relevant financial disclosures.

DENVER – Physicians making referrals for cardiac stress testing often underestimate their patients’ ability to exercise to target heart rate, according to Dr. Michael Ross.

Here’s what can happen as a result: In a prospective series of 120 consecutive patients referred for pharmacologic myocardial perfusion imaging stress testing by primary care physicians, surgeons, and cardiologists, 60% of the patients were able to mount the treadmill and exercise to 85% of their estimated maximum heart rate, he reported at the annual meeting of American Society of Nuclear Cardiology.

Primary care physicians were significantly more likely than were cardiologists or surgeons to order a pharmacologic stress test in patients who did not need one because they were able to complete the less costly exercise stress test.

Is that because primary care physicians don’t know their patients and their physical capacities as well as other physicians do? Highly unlikely. Instead, it appears they are more concerned that if they order an exercise stress test and a patient can’t complete it, they’ll have to reorder the test – this time using pharmacologic stress – with the attendant inconvenience and delay, according to Dr. Ross of Northwestern University, Chicago.

In a multivariate logistic regression analysis, the only independent predictors of failure to reach target heart rate were being on a beta-blocker and having diabetes.

Dr. Ross said he had no relevant financial disclosures.

Major Finding: Exercise ECG stress test showed a sensitivity of 39% for myocardial ischemia in patients with LAFB on their resting ECG, compared with 70% in the patients without LAFB.

Data Source: Retrospective study of 1,403 patients who underwent both maximal treadmill exercise stress ECG test and SPECT myocardial perfusion imaging in search of inducible myocardial ischemia.

Disclosures: Dr. Mousa declared having no financial conflicts.

DENVER – The presence of left anterior fascicular block on a resting ECG indicates an ECG exercise stress test will have significantly diminished diagnostic accuracy, according to a retrospective study.

Thus, this finding on the resting ECG warrants giving serious consideration to adding an imaging modality such as single-photon emission computed tomography (SPECT) myocardial perfusion imaging to the patient's exercise stress test, Dr. Tarek M. Mousa said at the meeting.

He presented a retrospective study of 1,403 patients who underwent both a maximal treadmill exercise stress ECG test and SPECT myocardial perfusion imaging in search of inducible myocardial ischemia. In all, 62 patients (4.4%) had left anterior fascicular block (LAFB) on their resting ECG, including 24 who had both LAFB and right bundle branch block.

The exercise ECG stress test showed greatly reduced sensitivity for myocardial ischemia in patients with LAFB on their resting ECG: 39% as compared with 70% in the 1,341 patients without LAFB.

On the other hand, a finding of greater than 1 mm of exercise-induced ST-segment depression in at least two contiguous leads had significantly greater specificity as an indicator of inducible myocardial ischemia when it occurred in the setting of LAFB: 96% as compared with 79% in controls, added Dr. Mousa of New York Hospital Queens in Flushing.

The presence or absence of right bundle branch block in patients with LAFB on their resting ECG did not affect the diagnostic accuracy of their ECG exercise stress test.

Major Finding: Exercise ECG stress test showed a sensitivity of 39% for myocardial ischemia in patients with LAFB on their resting ECG, compared with 70% in the patients without LAFB.

Data Source: Retrospective study of 1,403 patients who underwent both maximal treadmill exercise stress ECG test and SPECT myocardial perfusion imaging in search of inducible myocardial ischemia.

Disclosures: Dr. Mousa declared having no financial conflicts.

DENVER – The presence of left anterior fascicular block on a resting ECG indicates an ECG exercise stress test will have significantly diminished diagnostic accuracy, according to a retrospective study.

Thus, this finding on the resting ECG warrants giving serious consideration to adding an imaging modality such as single-photon emission computed tomography (SPECT) myocardial perfusion imaging to the patient's exercise stress test, Dr. Tarek M. Mousa said at the meeting.

He presented a retrospective study of 1,403 patients who underwent both a maximal treadmill exercise stress ECG test and SPECT myocardial perfusion imaging in search of inducible myocardial ischemia. In all, 62 patients (4.4%) had left anterior fascicular block (LAFB) on their resting ECG, including 24 who had both LAFB and right bundle branch block.

The exercise ECG stress test showed greatly reduced sensitivity for myocardial ischemia in patients with LAFB on their resting ECG: 39% as compared with 70% in the 1,341 patients without LAFB.

On the other hand, a finding of greater than 1 mm of exercise-induced ST-segment depression in at least two contiguous leads had significantly greater specificity as an indicator of inducible myocardial ischemia when it occurred in the setting of LAFB: 96% as compared with 79% in controls, added Dr. Mousa of New York Hospital Queens in Flushing.

The presence or absence of right bundle branch block in patients with LAFB on their resting ECG did not affect the diagnostic accuracy of their ECG exercise stress test.

Major Finding: Exercise ECG stress test showed a sensitivity of 39% for myocardial ischemia in patients with LAFB on their resting ECG, compared with 70% in the patients without LAFB.

Data Source: Retrospective study of 1,403 patients who underwent both maximal treadmill exercise stress ECG test and SPECT myocardial perfusion imaging in search of inducible myocardial ischemia.

Disclosures: Dr. Mousa declared having no financial conflicts.

DENVER – The presence of left anterior fascicular block on a resting ECG indicates an ECG exercise stress test will have significantly diminished diagnostic accuracy, according to a retrospective study.

Thus, this finding on the resting ECG warrants giving serious consideration to adding an imaging modality such as single-photon emission computed tomography (SPECT) myocardial perfusion imaging to the patient's exercise stress test, Dr. Tarek M. Mousa said at the meeting.

He presented a retrospective study of 1,403 patients who underwent both a maximal treadmill exercise stress ECG test and SPECT myocardial perfusion imaging in search of inducible myocardial ischemia. In all, 62 patients (4.4%) had left anterior fascicular block (LAFB) on their resting ECG, including 24 who had both LAFB and right bundle branch block.

The exercise ECG stress test showed greatly reduced sensitivity for myocardial ischemia in patients with LAFB on their resting ECG: 39% as compared with 70% in the 1,341 patients without LAFB.

On the other hand, a finding of greater than 1 mm of exercise-induced ST-segment depression in at least two contiguous leads had significantly greater specificity as an indicator of inducible myocardial ischemia when it occurred in the setting of LAFB: 96% as compared with 79% in controls, added Dr. Mousa of New York Hospital Queens in Flushing.

The presence or absence of right bundle branch block in patients with LAFB on their resting ECG did not affect the diagnostic accuracy of their ECG exercise stress test.

DENVER – The majority of nuclear cardiology labs are not utilizing the American College of Cardiology appropriate use criteria for myocardial perfusion imaging, according to the preliminary results of an American Society of Nuclear Cardiology membership survey.

The revelation that only 48% of nuclear cardiology imaging labs employ the ACC appropriate use criteria is disturbing. It comes at a time when nuclear cardiologists are already drawing heat from payers, clinicians, patients, and Congress for perceived overutilization of testing and a casual attitude toward patient exposure to radiation.

The ACC's appropriate use criteria (AUC) program is a high-profile quality improvement initiative. The myocardial perfusion imaging AUC were developed jointly by the ACC, ASNC, and other key specialty societies. Myocardial perfusion imaging (MPI) was the first topic selected for the program, which has since gone on to develop AUC for other common cardiovascular tests and procedures. MPI was selected to go first because of concerns raised by the explosive growth and substantial regional variation in the procedures. The initial version of the MPI AUC was published in 2005, with an updated rendition appearing 2 years ago (J. Am. Coll. Cardiol. 2009;53:2201-9).

ASNC President Leslee J. Shaw, Ph.D., presented the preliminary membership survey results during her presidential address. She also took that occasion to unveil an ambitious new multifaceted ASNC campaign called “Excellence in Imaging.” The program is designed to improve the practice of nuclear cardiology through education and advocacy, and by fostering high-quality research that demonstrates nuclear imaging's clinical value. ASNC members who take the Excellence in Imaging pledge commit themselves to following the AUC.

“By taking a proactive stance on defining quality in nuclear cardiology and demonstrating our members' commitment to these defined quality measures, ASNC will lead the discussion about appropriate use and set the standards by which our patients receive optimal care,” promised Dr. Shaw, professor of medicine at Emory University, Atlanta.

“What the survey results say to me is that we need to do a better job of providing you with tools where you can see the value in improving your process of care, and how the AUC can be utilized to actually identify appropriate patient referral patterns and track your success. This is increasingly going to be a performance metric. Your rating for appropriate test candidates is going to be used as a quality metric,” she explained.

The educational portion of the Excellence in Imaging campaign will include continuing medical education that is designed to raise the quality of imaging by ASNC members, and webinars for referring physicians aimed at fostering appropriate referral patterns. Clinical decision support tools are being developed for smart phones to assist referring physicians in selecting the optimal test for a given patient, rather than leaving the testing decision to be made downstream when the patient arrives at the nuclear cardiology clinic. There will also be public education efforts to dispel widespread misconceptions about radiation safety.

Dr. Manuel D. Cerqueira later observed that shifting the timing of appropriate test decision making to the point when testing is ordered by referring physicians is “easy to say, hard to do.”

No matter how many conversations he has with emergency department physicians at outlying hospitals about not sending him low-risk, inappropriate candidates for imaging procedures involving ionizing radiation exposure when there are better nonradioactive tests available, they continue to do so.

“They're worried about liability, they're worried about their 1-year contract that gets reviewed by the hospital, and they're worried about the pressure the hospital puts on them to do more procedures that are lucrative for the hospital,” said Dr. Cerqueira, professor of radiology and medicine at the Cleveland Clinic Foundation.

In a separate presentation, Dr. Robert C. Hendel, who chaired the writing group for the updated MPI AUC, said a dozen studies presented in the past 5 years show that 10%-15% of all MPIs are inappropriate, as defined by the AUC.

“Basically, if it's an inappropriate indication, by definition the risks exceed the benefits. The best radiation safety we can do is not to perform the test – not to expose the patient – when it's not necessary,” explained Dr. Hendel, professor of medicine and radiology at the University of Miami.

He led a six-center study called SPECT-MPI involving roughly 6,000 consecutive patients who underwent single photon emission CT. Overall, inappropriate use of the procedure occurred in 14.4% of patients, with rates ranging from 4% to 22% among the practices.

The SPECT-MPI study identified the major problem areas for inappropriate utilization. Topping the list was the use of MPI to detect CAD in asymptomatic patients at low risk for coronary heart disease; this accounted for 45% of all inappropriate tests and 6% of total testing.

The five most common inappropriate-use indications accounted for 92% of all inappropriate tests. (See graphic.) If all testing done for these five inappropriate reasons were to be eliminated, total imaging volume would be reduced by 12.4% (J. Am. Coll. Cardiol. 2010;55:156-62).

“Imaging in Focus” is an ACC-sponsored national quality improvement initiative aimed at helping cardiovascular physicians to reduce inappropriate imaging in a collaborative, nonconfrontational way through the use of webinars, blogs, and other tools. It's designed as a learning community whose stated goal is to achieve a 50% reduction in inappropriate imaging in 3 years. Dr. Hendel announced that the program has already resoundingly surpassed that target. In its first year of operation, imaging centers participating in Imaging in Focus reduced their inappropriate imaging by 50% from a baseline rate of 10%.

None of the speakers has relevant financial interests.

'Your rating for appropriate test candidates is going to be used as a quality metric.'

Source DR. SHAW

Source Elsevier Global Medical News

DENVER – The majority of nuclear cardiology labs are not utilizing the American College of Cardiology appropriate use criteria for myocardial perfusion imaging, according to the preliminary results of an American Society of Nuclear Cardiology membership survey.

The revelation that only 48% of nuclear cardiology imaging labs employ the ACC appropriate use criteria is disturbing. It comes at a time when nuclear cardiologists are already drawing heat from payers, clinicians, patients, and Congress for perceived overutilization of testing and a casual attitude toward patient exposure to radiation.

The ACC's appropriate use criteria (AUC) program is a high-profile quality improvement initiative. The myocardial perfusion imaging AUC were developed jointly by the ACC, ASNC, and other key specialty societies. Myocardial perfusion imaging (MPI) was the first topic selected for the program, which has since gone on to develop AUC for other common cardiovascular tests and procedures. MPI was selected to go first because of concerns raised by the explosive growth and substantial regional variation in the procedures. The initial version of the MPI AUC was published in 2005, with an updated rendition appearing 2 years ago (J. Am. Coll. Cardiol. 2009;53:2201-9).

ASNC President Leslee J. Shaw, Ph.D., presented the preliminary membership survey results during her presidential address. She also took that occasion to unveil an ambitious new multifaceted ASNC campaign called “Excellence in Imaging.” The program is designed to improve the practice of nuclear cardiology through education and advocacy, and by fostering high-quality research that demonstrates nuclear imaging's clinical value. ASNC members who take the Excellence in Imaging pledge commit themselves to following the AUC.

“By taking a proactive stance on defining quality in nuclear cardiology and demonstrating our members' commitment to these defined quality measures, ASNC will lead the discussion about appropriate use and set the standards by which our patients receive optimal care,” promised Dr. Shaw, professor of medicine at Emory University, Atlanta.

“What the survey results say to me is that we need to do a better job of providing you with tools where you can see the value in improving your process of care, and how the AUC can be utilized to actually identify appropriate patient referral patterns and track your success. This is increasingly going to be a performance metric. Your rating for appropriate test candidates is going to be used as a quality metric,” she explained.

The educational portion of the Excellence in Imaging campaign will include continuing medical education that is designed to raise the quality of imaging by ASNC members, and webinars for referring physicians aimed at fostering appropriate referral patterns. Clinical decision support tools are being developed for smart phones to assist referring physicians in selecting the optimal test for a given patient, rather than leaving the testing decision to be made downstream when the patient arrives at the nuclear cardiology clinic. There will also be public education efforts to dispel widespread misconceptions about radiation safety.

Dr. Manuel D. Cerqueira later observed that shifting the timing of appropriate test decision making to the point when testing is ordered by referring physicians is “easy to say, hard to do.”

No matter how many conversations he has with emergency department physicians at outlying hospitals about not sending him low-risk, inappropriate candidates for imaging procedures involving ionizing radiation exposure when there are better nonradioactive tests available, they continue to do so.

“They're worried about liability, they're worried about their 1-year contract that gets reviewed by the hospital, and they're worried about the pressure the hospital puts on them to do more procedures that are lucrative for the hospital,” said Dr. Cerqueira, professor of radiology and medicine at the Cleveland Clinic Foundation.

In a separate presentation, Dr. Robert C. Hendel, who chaired the writing group for the updated MPI AUC, said a dozen studies presented in the past 5 years show that 10%-15% of all MPIs are inappropriate, as defined by the AUC.

“Basically, if it's an inappropriate indication, by definition the risks exceed the benefits. The best radiation safety we can do is not to perform the test – not to expose the patient – when it's not necessary,” explained Dr. Hendel, professor of medicine and radiology at the University of Miami.

He led a six-center study called SPECT-MPI involving roughly 6,000 consecutive patients who underwent single photon emission CT. Overall, inappropriate use of the procedure occurred in 14.4% of patients, with rates ranging from 4% to 22% among the practices.

The SPECT-MPI study identified the major problem areas for inappropriate utilization. Topping the list was the use of MPI to detect CAD in asymptomatic patients at low risk for coronary heart disease; this accounted for 45% of all inappropriate tests and 6% of total testing.

The five most common inappropriate-use indications accounted for 92% of all inappropriate tests. (See graphic.) If all testing done for these five inappropriate reasons were to be eliminated, total imaging volume would be reduced by 12.4% (J. Am. Coll. Cardiol. 2010;55:156-62).

“Imaging in Focus” is an ACC-sponsored national quality improvement initiative aimed at helping cardiovascular physicians to reduce inappropriate imaging in a collaborative, nonconfrontational way through the use of webinars, blogs, and other tools. It's designed as a learning community whose stated goal is to achieve a 50% reduction in inappropriate imaging in 3 years. Dr. Hendel announced that the program has already resoundingly surpassed that target. In its first year of operation, imaging centers participating in Imaging in Focus reduced their inappropriate imaging by 50% from a baseline rate of 10%.

None of the speakers has relevant financial interests.

'Your rating for appropriate test candidates is going to be used as a quality metric.'

Source DR. SHAW

Source Elsevier Global Medical News

DENVER – The majority of nuclear cardiology labs are not utilizing the American College of Cardiology appropriate use criteria for myocardial perfusion imaging, according to the preliminary results of an American Society of Nuclear Cardiology membership survey.

The revelation that only 48% of nuclear cardiology imaging labs employ the ACC appropriate use criteria is disturbing. It comes at a time when nuclear cardiologists are already drawing heat from payers, clinicians, patients, and Congress for perceived overutilization of testing and a casual attitude toward patient exposure to radiation.

The ACC's appropriate use criteria (AUC) program is a high-profile quality improvement initiative. The myocardial perfusion imaging AUC were developed jointly by the ACC, ASNC, and other key specialty societies. Myocardial perfusion imaging (MPI) was the first topic selected for the program, which has since gone on to develop AUC for other common cardiovascular tests and procedures. MPI was selected to go first because of concerns raised by the explosive growth and substantial regional variation in the procedures. The initial version of the MPI AUC was published in 2005, with an updated rendition appearing 2 years ago (J. Am. Coll. Cardiol. 2009;53:2201-9).

ASNC President Leslee J. Shaw, Ph.D., presented the preliminary membership survey results during her presidential address. She also took that occasion to unveil an ambitious new multifaceted ASNC campaign called “Excellence in Imaging.” The program is designed to improve the practice of nuclear cardiology through education and advocacy, and by fostering high-quality research that demonstrates nuclear imaging's clinical value. ASNC members who take the Excellence in Imaging pledge commit themselves to following the AUC.

“By taking a proactive stance on defining quality in nuclear cardiology and demonstrating our members' commitment to these defined quality measures, ASNC will lead the discussion about appropriate use and set the standards by which our patients receive optimal care,” promised Dr. Shaw, professor of medicine at Emory University, Atlanta.

“What the survey results say to me is that we need to do a better job of providing you with tools where you can see the value in improving your process of care, and how the AUC can be utilized to actually identify appropriate patient referral patterns and track your success. This is increasingly going to be a performance metric. Your rating for appropriate test candidates is going to be used as a quality metric,” she explained.

The educational portion of the Excellence in Imaging campaign will include continuing medical education that is designed to raise the quality of imaging by ASNC members, and webinars for referring physicians aimed at fostering appropriate referral patterns. Clinical decision support tools are being developed for smart phones to assist referring physicians in selecting the optimal test for a given patient, rather than leaving the testing decision to be made downstream when the patient arrives at the nuclear cardiology clinic. There will also be public education efforts to dispel widespread misconceptions about radiation safety.

Dr. Manuel D. Cerqueira later observed that shifting the timing of appropriate test decision making to the point when testing is ordered by referring physicians is “easy to say, hard to do.”

No matter how many conversations he has with emergency department physicians at outlying hospitals about not sending him low-risk, inappropriate candidates for imaging procedures involving ionizing radiation exposure when there are better nonradioactive tests available, they continue to do so.

“They're worried about liability, they're worried about their 1-year contract that gets reviewed by the hospital, and they're worried about the pressure the hospital puts on them to do more procedures that are lucrative for the hospital,” said Dr. Cerqueira, professor of radiology and medicine at the Cleveland Clinic Foundation.

In a separate presentation, Dr. Robert C. Hendel, who chaired the writing group for the updated MPI AUC, said a dozen studies presented in the past 5 years show that 10%-15% of all MPIs are inappropriate, as defined by the AUC.

“Basically, if it's an inappropriate indication, by definition the risks exceed the benefits. The best radiation safety we can do is not to perform the test – not to expose the patient – when it's not necessary,” explained Dr. Hendel, professor of medicine and radiology at the University of Miami.

He led a six-center study called SPECT-MPI involving roughly 6,000 consecutive patients who underwent single photon emission CT. Overall, inappropriate use of the procedure occurred in 14.4% of patients, with rates ranging from 4% to 22% among the practices.

The SPECT-MPI study identified the major problem areas for inappropriate utilization. Topping the list was the use of MPI to detect CAD in asymptomatic patients at low risk for coronary heart disease; this accounted for 45% of all inappropriate tests and 6% of total testing.

The five most common inappropriate-use indications accounted for 92% of all inappropriate tests. (See graphic.) If all testing done for these five inappropriate reasons were to be eliminated, total imaging volume would be reduced by 12.4% (J. Am. Coll. Cardiol. 2010;55:156-62).

“Imaging in Focus” is an ACC-sponsored national quality improvement initiative aimed at helping cardiovascular physicians to reduce inappropriate imaging in a collaborative, nonconfrontational way through the use of webinars, blogs, and other tools. It's designed as a learning community whose stated goal is to achieve a 50% reduction in inappropriate imaging in 3 years. Dr. Hendel announced that the program has already resoundingly surpassed that target. In its first year of operation, imaging centers participating in Imaging in Focus reduced their inappropriate imaging by 50% from a baseline rate of 10%.

None of the speakers has relevant financial interests.

'Your rating for appropriate test candidates is going to be used as a quality metric.'

Source DR. SHAW

Source Elsevier Global Medical News

DENVER – The majority of nuclear cardiology labs are not utilizing the American College of Cardiology appropriate use criteria for myocardial perfusion imaging, according to the preliminary results of an American Society of Nuclear Cardiology membership survey.

The revelation that only 48% of nuclear cardiology imaging labs employ the ACC appropriate use criteria is disturbing. It comes at a time when nuclear cardiologists are already drawing heat from payers, clinicians, patients, and Congress for perceived overutilization of testing and a casual attitude toward patient exposure to radiation.

The ACC’s appropriate use criteria (AUC) program is a high-profile quality improvement initiative. The myocardial perfusion imaging AUC were developed jointly by the ACC, ASNC, and other key specialty societies. Myocardial perfusion imaging (MPI) was the first topic selected for the program, which has since gone on to develop AUC for other common cardiovascular tests and procedures. MPI was selected to go first because of concerns raised by the explosive growth and substantial regional variation in the procedures. The initial version of the MPI AUC was published in 2005, with an updated rendition appearing 2 years ago (J. Am. Coll. Cardiol. 2009;53:2201-9).

ASNC President Leslee J. Shaw, Ph.D., presented the preliminary membership survey results during her presidential address at the annual meeting of the American Society of Nuclear Cardiology. She also took that occasion to unveil an ambitious new multifaceted ASNC campaign called "Excellence in Imaging." The program is designed to improve the practice of nuclear cardiology through education and advocacy, and by fostering high-quality research that demonstrates nuclear imaging’s clinical value. ASNC members who take the Excellence in Imaging pledge commit themselves to following the AUC.

"By taking a proactive stance on defining quality in nuclear cardiology and demonstrating our members’ commitment to these defined quality measures, ASNC will lead the discussion about appropriate use and set the standards by which our patients receive optimal care," promised Dr. Shaw, professor of medicine at Emory University, Atlanta.

"What the survey results say to me is that we need to do a better job of providing you with tools where you can see the value in improving your process of care, and how the AUC can be utilized to actually identify appropriate patient referral patterns and track your success. This is increasingly going to be a performance metric. Your rating for appropriate test candidates is going to be used as a quality metric," she explained.

The educational portion of the Excellence in Imaging campaign will not only include continuing medical education that is designed to raise the quality of imaging by ASNC members, but also webinars for referring physicians aimed at fostering appropriate referral patterns. Clinical decision support tools are being developed that can be embedded in smart phones to assist referring physicians in selecting the optimal test for a given patient, rather than leaving the testing decision to be made downstream when the patient arrives at the nuclear cardiology clinic. There will also be public education efforts to dispel widespread misconceptions about radiation safety.

Later, Dr. Manuel D. Cerqueira observed that shifting the timing of appropriate test decision making to the point when testing is ordered by referring physicians is "easy to say, hard to do."

No matter how many conversations he has with emergency department physicians at outlying hospitals about not sending him low-risk, inappropriate candidates for imaging procedures involving ionizing radiation exposure when there are better nonradioactive tests available, they continue to do so.

"They’re worried about liability, they’re worried about their 1-year contract that gets reviewed by the hospital, and they’re worried about the pressure the hospital puts on them to do more procedures that are lucrative for the hospital," said Dr. Cerqueira, professor of radiology and medicine and chairman of the nuclear medicine imaging institute at the Cleveland Clinic Foundation.

In a separate presentation, Dr. Robert C. Hendel, who chaired the writing group for the updated MPI AUC, said a dozen studies presented in the past 5 years demonstrate that 10%-15% of all MPIs are inappropriate, as defined by the AUC.

"Basically, if it’s an inappropriate indication, by definition the risks exceed the benefits. The best radiation safety we can do is not to perform the test – not to expose the patient – when it’s not necessary," explained Dr. Hendel, professor of medicine and radiology and director of cardiac imaging and outpatient services at the University of Miami.

He led a six-center study called SPECT-MPI involving roughly 6,000 consecutive patients who underwent single photon emission CT. Overall, inappropriate use of the procedure occurred in 14.4% of patients, with rates ranging from 4% to 22% among the practices.

The SPECT-MPI study identified the major problem areas for inappropriate utilization. Topping the list was the use of MPI to detect CAD in asymptomatic patients at low risk for coronary heart disease; this accounted for 45% of all inappropriate tests and 6% of total testing.

The five most common inappropriate-use indications accounted for 92% of all inappropriate tests. If all testing done for these five inappropriate reasons were to be eliminated, total imaging volume would be reduced by 12.4% (J. Am. Coll. Cardiol. 2010;55:156-62).

"Imaging in Focus" is an ACC-sponsored national quality improvement initiative aimed at helping cardiovascular physicians to reduce inappropriate imaging in a collaborative, nonconfrontational way through the use of webinars, blogs, and other tools. It’s designed as a learning community whose stated goal is to achieve a 50% reduction in inappropriate cardiovascular imaging in 3 years. Dr. Hendel announced some good news: The program has already resoundingly surpassed that target. In just its first year of operation, imaging centers participating in Imaging in Focus reduced their inappropriate imaging by 50% from a baseline rate of 10%.

"This is very exciting," he said.

None of the speakers had relevant financial interests.

DENVER – The majority of nuclear cardiology labs are not utilizing the American College of Cardiology appropriate use criteria for myocardial perfusion imaging, according to the preliminary results of an American Society of Nuclear Cardiology membership survey.

The revelation that only 48% of nuclear cardiology imaging labs employ the ACC appropriate use criteria is disturbing. It comes at a time when nuclear cardiologists are already drawing heat from payers, clinicians, patients, and Congress for perceived overutilization of testing and a casual attitude toward patient exposure to radiation.

The ACC’s appropriate use criteria (AUC) program is a high-profile quality improvement initiative. The myocardial perfusion imaging AUC were developed jointly by the ACC, ASNC, and other key specialty societies. Myocardial perfusion imaging (MPI) was the first topic selected for the program, which has since gone on to develop AUC for other common cardiovascular tests and procedures. MPI was selected to go first because of concerns raised by the explosive growth and substantial regional variation in the procedures. The initial version of the MPI AUC was published in 2005, with an updated rendition appearing 2 years ago (J. Am. Coll. Cardiol. 2009;53:2201-9).

ASNC President Leslee J. Shaw, Ph.D., presented the preliminary membership survey results during her presidential address at the annual meeting of the American Society of Nuclear Cardiology. She also took that occasion to unveil an ambitious new multifaceted ASNC campaign called "Excellence in Imaging." The program is designed to improve the practice of nuclear cardiology through education and advocacy, and by fostering high-quality research that demonstrates nuclear imaging’s clinical value. ASNC members who take the Excellence in Imaging pledge commit themselves to following the AUC.

"By taking a proactive stance on defining quality in nuclear cardiology and demonstrating our members’ commitment to these defined quality measures, ASNC will lead the discussion about appropriate use and set the standards by which our patients receive optimal care," promised Dr. Shaw, professor of medicine at Emory University, Atlanta.

"What the survey results say to me is that we need to do a better job of providing you with tools where you can see the value in improving your process of care, and how the AUC can be utilized to actually identify appropriate patient referral patterns and track your success. This is increasingly going to be a performance metric. Your rating for appropriate test candidates is going to be used as a quality metric," she explained.

The educational portion of the Excellence in Imaging campaign will not only include continuing medical education that is designed to raise the quality of imaging by ASNC members, but also webinars for referring physicians aimed at fostering appropriate referral patterns. Clinical decision support tools are being developed that can be embedded in smart phones to assist referring physicians in selecting the optimal test for a given patient, rather than leaving the testing decision to be made downstream when the patient arrives at the nuclear cardiology clinic. There will also be public education efforts to dispel widespread misconceptions about radiation safety.

Later, Dr. Manuel D. Cerqueira observed that shifting the timing of appropriate test decision making to the point when testing is ordered by referring physicians is "easy to say, hard to do."

No matter how many conversations he has with emergency department physicians at outlying hospitals about not sending him low-risk, inappropriate candidates for imaging procedures involving ionizing radiation exposure when there are better nonradioactive tests available, they continue to do so.

"They’re worried about liability, they’re worried about their 1-year contract that gets reviewed by the hospital, and they’re worried about the pressure the hospital puts on them to do more procedures that are lucrative for the hospital," said Dr. Cerqueira, professor of radiology and medicine and chairman of the nuclear medicine imaging institute at the Cleveland Clinic Foundation.

In a separate presentation, Dr. Robert C. Hendel, who chaired the writing group for the updated MPI AUC, said a dozen studies presented in the past 5 years demonstrate that 10%-15% of all MPIs are inappropriate, as defined by the AUC.

"Basically, if it’s an inappropriate indication, by definition the risks exceed the benefits. The best radiation safety we can do is not to perform the test – not to expose the patient – when it’s not necessary," explained Dr. Hendel, professor of medicine and radiology and director of cardiac imaging and outpatient services at the University of Miami.

He led a six-center study called SPECT-MPI involving roughly 6,000 consecutive patients who underwent single photon emission CT. Overall, inappropriate use of the procedure occurred in 14.4% of patients, with rates ranging from 4% to 22% among the practices.

The SPECT-MPI study identified the major problem areas for inappropriate utilization. Topping the list was the use of MPI to detect CAD in asymptomatic patients at low risk for coronary heart disease; this accounted for 45% of all inappropriate tests and 6% of total testing.

The five most common inappropriate-use indications accounted for 92% of all inappropriate tests. If all testing done for these five inappropriate reasons were to be eliminated, total imaging volume would be reduced by 12.4% (J. Am. Coll. Cardiol. 2010;55:156-62).

"Imaging in Focus" is an ACC-sponsored national quality improvement initiative aimed at helping cardiovascular physicians to reduce inappropriate imaging in a collaborative, nonconfrontational way through the use of webinars, blogs, and other tools. It’s designed as a learning community whose stated goal is to achieve a 50% reduction in inappropriate cardiovascular imaging in 3 years. Dr. Hendel announced some good news: The program has already resoundingly surpassed that target. In just its first year of operation, imaging centers participating in Imaging in Focus reduced their inappropriate imaging by 50% from a baseline rate of 10%.

"This is very exciting," he said.

None of the speakers had relevant financial interests.

DENVER – The majority of nuclear cardiology labs are not utilizing the American College of Cardiology appropriate use criteria for myocardial perfusion imaging, according to the preliminary results of an American Society of Nuclear Cardiology membership survey.

The revelation that only 48% of nuclear cardiology imaging labs employ the ACC appropriate use criteria is disturbing. It comes at a time when nuclear cardiologists are already drawing heat from payers, clinicians, patients, and Congress for perceived overutilization of testing and a casual attitude toward patient exposure to radiation.

The ACC’s appropriate use criteria (AUC) program is a high-profile quality improvement initiative. The myocardial perfusion imaging AUC were developed jointly by the ACC, ASNC, and other key specialty societies. Myocardial perfusion imaging (MPI) was the first topic selected for the program, which has since gone on to develop AUC for other common cardiovascular tests and procedures. MPI was selected to go first because of concerns raised by the explosive growth and substantial regional variation in the procedures. The initial version of the MPI AUC was published in 2005, with an updated rendition appearing 2 years ago (J. Am. Coll. Cardiol. 2009;53:2201-9).

ASNC President Leslee J. Shaw, Ph.D., presented the preliminary membership survey results during her presidential address at the annual meeting of the American Society of Nuclear Cardiology. She also took that occasion to unveil an ambitious new multifaceted ASNC campaign called "Excellence in Imaging." The program is designed to improve the practice of nuclear cardiology through education and advocacy, and by fostering high-quality research that demonstrates nuclear imaging’s clinical value. ASNC members who take the Excellence in Imaging pledge commit themselves to following the AUC.

"By taking a proactive stance on defining quality in nuclear cardiology and demonstrating our members’ commitment to these defined quality measures, ASNC will lead the discussion about appropriate use and set the standards by which our patients receive optimal care," promised Dr. Shaw, professor of medicine at Emory University, Atlanta.

"What the survey results say to me is that we need to do a better job of providing you with tools where you can see the value in improving your process of care, and how the AUC can be utilized to actually identify appropriate patient referral patterns and track your success. This is increasingly going to be a performance metric. Your rating for appropriate test candidates is going to be used as a quality metric," she explained.

The educational portion of the Excellence in Imaging campaign will not only include continuing medical education that is designed to raise the quality of imaging by ASNC members, but also webinars for referring physicians aimed at fostering appropriate referral patterns. Clinical decision support tools are being developed that can be embedded in smart phones to assist referring physicians in selecting the optimal test for a given patient, rather than leaving the testing decision to be made downstream when the patient arrives at the nuclear cardiology clinic. There will also be public education efforts to dispel widespread misconceptions about radiation safety.

Later, Dr. Manuel D. Cerqueira observed that shifting the timing of appropriate test decision making to the point when testing is ordered by referring physicians is "easy to say, hard to do."

No matter how many conversations he has with emergency department physicians at outlying hospitals about not sending him low-risk, inappropriate candidates for imaging procedures involving ionizing radiation exposure when there are better nonradioactive tests available, they continue to do so.

"They’re worried about liability, they’re worried about their 1-year contract that gets reviewed by the hospital, and they’re worried about the pressure the hospital puts on them to do more procedures that are lucrative for the hospital," said Dr. Cerqueira, professor of radiology and medicine and chairman of the nuclear medicine imaging institute at the Cleveland Clinic Foundation.

In a separate presentation, Dr. Robert C. Hendel, who chaired the writing group for the updated MPI AUC, said a dozen studies presented in the past 5 years demonstrate that 10%-15% of all MPIs are inappropriate, as defined by the AUC.

"Basically, if it’s an inappropriate indication, by definition the risks exceed the benefits. The best radiation safety we can do is not to perform the test – not to expose the patient – when it’s not necessary," explained Dr. Hendel, professor of medicine and radiology and director of cardiac imaging and outpatient services at the University of Miami.

He led a six-center study called SPECT-MPI involving roughly 6,000 consecutive patients who underwent single photon emission CT. Overall, inappropriate use of the procedure occurred in 14.4% of patients, with rates ranging from 4% to 22% among the practices.

The SPECT-MPI study identified the major problem areas for inappropriate utilization. Topping the list was the use of MPI to detect CAD in asymptomatic patients at low risk for coronary heart disease; this accounted for 45% of all inappropriate tests and 6% of total testing.

The five most common inappropriate-use indications accounted for 92% of all inappropriate tests. If all testing done for these five inappropriate reasons were to be eliminated, total imaging volume would be reduced by 12.4% (J. Am. Coll. Cardiol. 2010;55:156-62).

"Imaging in Focus" is an ACC-sponsored national quality improvement initiative aimed at helping cardiovascular physicians to reduce inappropriate imaging in a collaborative, nonconfrontational way through the use of webinars, blogs, and other tools. It’s designed as a learning community whose stated goal is to achieve a 50% reduction in inappropriate cardiovascular imaging in 3 years. Dr. Hendel announced some good news: The program has already resoundingly surpassed that target. In just its first year of operation, imaging centers participating in Imaging in Focus reduced their inappropriate imaging by 50% from a baseline rate of 10%.

"This is very exciting," he said.

None of the speakers had relevant financial interests.

DENVER – The presence of left anterior fascicular block on a resting ECG indicates an ECG exercise stress test will have significantly diminished diagnostic accuracy, according to a retrospective study.

Thus, this finding on the resting ECG warrants giving serious consideration to adding an imaging modality such as single-photon emission computed tomography (SPECT) myocardial perfusion imaging to the patient’s exercise stress test, Dr. Tarek M. Mousa said at the annual meeting of the American Society of Nuclear Cardiology.

He presented a retrospective study of 1,403 patients who underwent both a maximal treadmill exercise stress ECG test and SPECT myocardial perfusion imaging in search of inducible myocardial ischemia. In all, 62 patients (4.4%) had left anterior fascicular block (LAFB) on their resting ECG, including 24 who had both LAFB and right bundle branch block.

The exercise ECG stress test showed greatly reduced sensitivity for myocardial ischemia in patients with LAFB on their resting ECG: 39% as compared with 70% in the 1,341 patients without LAFB.

On the other hand, a finding of greater than 1 mm of exercise-induced ST-segment depression in at least two contiguous leads had significantly greater specificity as an indicator of inducible myocardial ischemia when it occurred in the setting of LAFB: 96% as compared with 79% in controls, added Dr. Mousa of New York Hospital Queens in Flushing.

The presence or absence of right bundle branch block in patients with LAFB on their resting ECG did not affect the diagnostic accuracy of their ECG exercise stress test.

Dr. Mousa declared having no financial conflicts.

DENVER – The presence of left anterior fascicular block on a resting ECG indicates an ECG exercise stress test will have significantly diminished diagnostic accuracy, according to a retrospective study.

Thus, this finding on the resting ECG warrants giving serious consideration to adding an imaging modality such as single-photon emission computed tomography (SPECT) myocardial perfusion imaging to the patient’s exercise stress test, Dr. Tarek M. Mousa said at the annual meeting of the American Society of Nuclear Cardiology.

He presented a retrospective study of 1,403 patients who underwent both a maximal treadmill exercise stress ECG test and SPECT myocardial perfusion imaging in search of inducible myocardial ischemia. In all, 62 patients (4.4%) had left anterior fascicular block (LAFB) on their resting ECG, including 24 who had both LAFB and right bundle branch block.

The exercise ECG stress test showed greatly reduced sensitivity for myocardial ischemia in patients with LAFB on their resting ECG: 39% as compared with 70% in the 1,341 patients without LAFB.

On the other hand, a finding of greater than 1 mm of exercise-induced ST-segment depression in at least two contiguous leads had significantly greater specificity as an indicator of inducible myocardial ischemia when it occurred in the setting of LAFB: 96% as compared with 79% in controls, added Dr. Mousa of New York Hospital Queens in Flushing.

The presence or absence of right bundle branch block in patients with LAFB on their resting ECG did not affect the diagnostic accuracy of their ECG exercise stress test.

Dr. Mousa declared having no financial conflicts.

DENVER – The presence of left anterior fascicular block on a resting ECG indicates an ECG exercise stress test will have significantly diminished diagnostic accuracy, according to a retrospective study.

Thus, this finding on the resting ECG warrants giving serious consideration to adding an imaging modality such as single-photon emission computed tomography (SPECT) myocardial perfusion imaging to the patient’s exercise stress test, Dr. Tarek M. Mousa said at the annual meeting of the American Society of Nuclear Cardiology.

He presented a retrospective study of 1,403 patients who underwent both a maximal treadmill exercise stress ECG test and SPECT myocardial perfusion imaging in search of inducible myocardial ischemia. In all, 62 patients (4.4%) had left anterior fascicular block (LAFB) on their resting ECG, including 24 who had both LAFB and right bundle branch block.

The exercise ECG stress test showed greatly reduced sensitivity for myocardial ischemia in patients with LAFB on their resting ECG: 39% as compared with 70% in the 1,341 patients without LAFB.

On the other hand, a finding of greater than 1 mm of exercise-induced ST-segment depression in at least two contiguous leads had significantly greater specificity as an indicator of inducible myocardial ischemia when it occurred in the setting of LAFB: 96% as compared with 79% in controls, added Dr. Mousa of New York Hospital Queens in Flushing.

The presence or absence of right bundle branch block in patients with LAFB on their resting ECG did not affect the diagnostic accuracy of their ECG exercise stress test.

Dr. Mousa declared having no financial conflicts.