Imaging

MONTREAL — Patients with type 2 diabetes had abnormally elevated pulmonary capillary wedge pressure and reduced myocardial perfusion indexes during exercise testing in a small pilot study.

This inverse correlation was present even in the absence of obstructive coronary artery disease or diastolic dysfunction, Dr. Marcus Chen and colleagues reported in a poster at the annual meeting of the American Society of Nuclear Cardiology.

People with type 2 diabetes and no known cardiovascular disease are known to have a reduced ability to exercise, but the mechanism of impairment is not well established. One possibility is that exercise capacity is impaired due to relative cardiac underperfusion, Dr. Chen, a cardiology fellow at the University of Colorado at Denver and Health Sciences Center, said in an interview.

The study included seven women with uncomplicated type 2 diabetes for an average of 3 years, and seven nondiabetic women matched for age (42 years vs. 43 years); weight (body mass index of 28 kg/m

Myocardial perfusion index (MPI) was determined from stress and rest mean pixel counts in 17 cardiac segments using 4D-SPECT software corrected for dose, decay, and time of imaging. On a separate day, subjects had an internal jugular pulmonary artery catheter placed, and hemodynamics were continuously monitored during graded bicycle maximal exercise stress testing.

Mean pulmonary capillary wedge pressure (PCWP) rose significantly more steeply and to a greater level with exercise in the diabetic patients than in the controls. At maximal exercise, PCWP was 22.3 mm Hg in those with diabetes, compared with 18.1 mm Hg in controls, the authors reported. No subjects in either group had visual myocardial perfusion defects.

Stress counts normalized to myocardial mass were significantly lower in the diabetic group than in controls (4.28 vs. 6.60).

Total MPI as an absolute number did not differ between groups. But when total MPI was normalized to myocardial mass, BMI, and peak exercise double product, it was significantly lower in the diabetes group, compared with controls (11.0 vs. 17.5). Peak exercise double product is a measure of stress workload, derived by multiplying the heart rate by the systolic blood pressure.

The inverse correlation between elevated wedge pressure and decreased normalized MPI was statistically significant. The findings suggest the presence of cardiac dysfunction during exercise in subjects with type 2 diabetes, the authors concluded.

The investigators acknowledged that the study was small and included only women, but reported that women were chosen because it's been suggested that diabetic women have worse exercise impairments than diabetic men relative to their nondiabetic counterparts. Future studies will expand the cohort, they said.

The findings suggest the presence of cardiac dysfunction during exercise in patients with type 2 diabetes. DR. CHEN

MONTREAL — Patients with type 2 diabetes had abnormally elevated pulmonary capillary wedge pressure and reduced myocardial perfusion indexes during exercise testing in a small pilot study.

This inverse correlation was present even in the absence of obstructive coronary artery disease or diastolic dysfunction, Dr. Marcus Chen and colleagues reported in a poster at the annual meeting of the American Society of Nuclear Cardiology.

People with type 2 diabetes and no known cardiovascular disease are known to have a reduced ability to exercise, but the mechanism of impairment is not well established. One possibility is that exercise capacity is impaired due to relative cardiac underperfusion, Dr. Chen, a cardiology fellow at the University of Colorado at Denver and Health Sciences Center, said in an interview.

The study included seven women with uncomplicated type 2 diabetes for an average of 3 years, and seven nondiabetic women matched for age (42 years vs. 43 years); weight (body mass index of 28 kg/m

Myocardial perfusion index (MPI) was determined from stress and rest mean pixel counts in 17 cardiac segments using 4D-SPECT software corrected for dose, decay, and time of imaging. On a separate day, subjects had an internal jugular pulmonary artery catheter placed, and hemodynamics were continuously monitored during graded bicycle maximal exercise stress testing.

Mean pulmonary capillary wedge pressure (PCWP) rose significantly more steeply and to a greater level with exercise in the diabetic patients than in the controls. At maximal exercise, PCWP was 22.3 mm Hg in those with diabetes, compared with 18.1 mm Hg in controls, the authors reported. No subjects in either group had visual myocardial perfusion defects.

Stress counts normalized to myocardial mass were significantly lower in the diabetic group than in controls (4.28 vs. 6.60).

Total MPI as an absolute number did not differ between groups. But when total MPI was normalized to myocardial mass, BMI, and peak exercise double product, it was significantly lower in the diabetes group, compared with controls (11.0 vs. 17.5). Peak exercise double product is a measure of stress workload, derived by multiplying the heart rate by the systolic blood pressure.

The inverse correlation between elevated wedge pressure and decreased normalized MPI was statistically significant. The findings suggest the presence of cardiac dysfunction during exercise in subjects with type 2 diabetes, the authors concluded.

The investigators acknowledged that the study was small and included only women, but reported that women were chosen because it's been suggested that diabetic women have worse exercise impairments than diabetic men relative to their nondiabetic counterparts. Future studies will expand the cohort, they said.

The findings suggest the presence of cardiac dysfunction during exercise in patients with type 2 diabetes. DR. CHEN

MONTREAL — Patients with type 2 diabetes had abnormally elevated pulmonary capillary wedge pressure and reduced myocardial perfusion indexes during exercise testing in a small pilot study.

This inverse correlation was present even in the absence of obstructive coronary artery disease or diastolic dysfunction, Dr. Marcus Chen and colleagues reported in a poster at the annual meeting of the American Society of Nuclear Cardiology.

People with type 2 diabetes and no known cardiovascular disease are known to have a reduced ability to exercise, but the mechanism of impairment is not well established. One possibility is that exercise capacity is impaired due to relative cardiac underperfusion, Dr. Chen, a cardiology fellow at the University of Colorado at Denver and Health Sciences Center, said in an interview.

The study included seven women with uncomplicated type 2 diabetes for an average of 3 years, and seven nondiabetic women matched for age (42 years vs. 43 years); weight (body mass index of 28 kg/m

Myocardial perfusion index (MPI) was determined from stress and rest mean pixel counts in 17 cardiac segments using 4D-SPECT software corrected for dose, decay, and time of imaging. On a separate day, subjects had an internal jugular pulmonary artery catheter placed, and hemodynamics were continuously monitored during graded bicycle maximal exercise stress testing.

Mean pulmonary capillary wedge pressure (PCWP) rose significantly more steeply and to a greater level with exercise in the diabetic patients than in the controls. At maximal exercise, PCWP was 22.3 mm Hg in those with diabetes, compared with 18.1 mm Hg in controls, the authors reported. No subjects in either group had visual myocardial perfusion defects.

Stress counts normalized to myocardial mass were significantly lower in the diabetic group than in controls (4.28 vs. 6.60).

Total MPI as an absolute number did not differ between groups. But when total MPI was normalized to myocardial mass, BMI, and peak exercise double product, it was significantly lower in the diabetes group, compared with controls (11.0 vs. 17.5). Peak exercise double product is a measure of stress workload, derived by multiplying the heart rate by the systolic blood pressure.

The inverse correlation between elevated wedge pressure and decreased normalized MPI was statistically significant. The findings suggest the presence of cardiac dysfunction during exercise in subjects with type 2 diabetes, the authors concluded.

The investigators acknowledged that the study was small and included only women, but reported that women were chosen because it's been suggested that diabetic women have worse exercise impairments than diabetic men relative to their nondiabetic counterparts. Future studies will expand the cohort, they said.

The findings suggest the presence of cardiac dysfunction during exercise in patients with type 2 diabetes. DR. CHEN

MONTREAL — Adenosine stress testing with supplemental arm pumping exercise had the same diagnostic accuracy as exercise stress testing in detecting significant coronary artery disease in a study of 302 patients.

The results validate a long-standing practice at Massachusetts General Hospital, Boston, where supplemental arm exercise with light weights—not arm exercise with squeeze balls and not a treadmill walk—has been used to prevent adenosine-related side effects during myocardial perfusion imaging (MPI). Arm-pumping exercise is utilized in all patients who are unable to safely negotiate a treadmill, Dr. Arash Kardan, of the hospital, said in an interview at the annual meeting of the American Society of Nuclear Cardiology.

Supplemental exercise is thought to mitigate adenosine-related bradycardia and hypotension via a neurocirculatory response, he said. “It really works; it's not just a distraction for the patient.”

The study included 302 patients referred for clinically indicated rest-stress MPI with technetium 99m sestamibi. Patients underwent either exercise stress testing using the standard Bruce protocol achieving 85% of maximum predicted heart rate, or received an adenosine infusion of 0.14 mg/kg per minute for 4–5 minutes in one arm and pumped a 2.5-pound weight with their opposite arm.

All patients underwent coronary angiography within 2 months of MPI. Positive MPI was defined as showing a reversible defect; positive angiography was defined as the presence of any lesion with greater than 50% stenosis. One-third of patients had prior reported coronary artery disease.

In the 158 patients in the exercise stress group, with a mean age of 63 years, the sensitivity was 91% and specificity 100%, the authors reported.

In the 144 patients in the arm exercise group, with a mean age of 68 years, sensitivity was 84% and specificity 81%. The differences from the exercise stress group were nonsignificant. No adenosine arm tests required termination because of side effects. All exercise treadmill tests were completed as well, he said.

The hospital has performedmore than 10,000 adenosine tests using the arm-pumping exercises, and less than 1% of tests have been terminated, said Dr. Kardan.

MONTREAL — Adenosine stress testing with supplemental arm pumping exercise had the same diagnostic accuracy as exercise stress testing in detecting significant coronary artery disease in a study of 302 patients.

The results validate a long-standing practice at Massachusetts General Hospital, Boston, where supplemental arm exercise with light weights—not arm exercise with squeeze balls and not a treadmill walk—has been used to prevent adenosine-related side effects during myocardial perfusion imaging (MPI). Arm-pumping exercise is utilized in all patients who are unable to safely negotiate a treadmill, Dr. Arash Kardan, of the hospital, said in an interview at the annual meeting of the American Society of Nuclear Cardiology.

Supplemental exercise is thought to mitigate adenosine-related bradycardia and hypotension via a neurocirculatory response, he said. “It really works; it's not just a distraction for the patient.”

The study included 302 patients referred for clinically indicated rest-stress MPI with technetium 99m sestamibi. Patients underwent either exercise stress testing using the standard Bruce protocol achieving 85% of maximum predicted heart rate, or received an adenosine infusion of 0.14 mg/kg per minute for 4–5 minutes in one arm and pumped a 2.5-pound weight with their opposite arm.

All patients underwent coronary angiography within 2 months of MPI. Positive MPI was defined as showing a reversible defect; positive angiography was defined as the presence of any lesion with greater than 50% stenosis. One-third of patients had prior reported coronary artery disease.

In the 158 patients in the exercise stress group, with a mean age of 63 years, the sensitivity was 91% and specificity 100%, the authors reported.

In the 144 patients in the arm exercise group, with a mean age of 68 years, sensitivity was 84% and specificity 81%. The differences from the exercise stress group were nonsignificant. No adenosine arm tests required termination because of side effects. All exercise treadmill tests were completed as well, he said.

The hospital has performedmore than 10,000 adenosine tests using the arm-pumping exercises, and less than 1% of tests have been terminated, said Dr. Kardan.

MONTREAL — Adenosine stress testing with supplemental arm pumping exercise had the same diagnostic accuracy as exercise stress testing in detecting significant coronary artery disease in a study of 302 patients.

The results validate a long-standing practice at Massachusetts General Hospital, Boston, where supplemental arm exercise with light weights—not arm exercise with squeeze balls and not a treadmill walk—has been used to prevent adenosine-related side effects during myocardial perfusion imaging (MPI). Arm-pumping exercise is utilized in all patients who are unable to safely negotiate a treadmill, Dr. Arash Kardan, of the hospital, said in an interview at the annual meeting of the American Society of Nuclear Cardiology.

Supplemental exercise is thought to mitigate adenosine-related bradycardia and hypotension via a neurocirculatory response, he said. “It really works; it's not just a distraction for the patient.”

The study included 302 patients referred for clinically indicated rest-stress MPI with technetium 99m sestamibi. Patients underwent either exercise stress testing using the standard Bruce protocol achieving 85% of maximum predicted heart rate, or received an adenosine infusion of 0.14 mg/kg per minute for 4–5 minutes in one arm and pumped a 2.5-pound weight with their opposite arm.

All patients underwent coronary angiography within 2 months of MPI. Positive MPI was defined as showing a reversible defect; positive angiography was defined as the presence of any lesion with greater than 50% stenosis. One-third of patients had prior reported coronary artery disease.

In the 158 patients in the exercise stress group, with a mean age of 63 years, the sensitivity was 91% and specificity 100%, the authors reported.

In the 144 patients in the arm exercise group, with a mean age of 68 years, sensitivity was 84% and specificity 81%. The differences from the exercise stress group were nonsignificant. No adenosine arm tests required termination because of side effects. All exercise treadmill tests were completed as well, he said.

The hospital has performedmore than 10,000 adenosine tests using the arm-pumping exercises, and less than 1% of tests have been terminated, said Dr. Kardan.

MONTREAL — Patients with systemic lupus erythematosus demonstrated significantly more perfusion abnormalities on gated scintigraphy scans, compared with well-matched controls, in a small pilot study.

The observed differences may represent early manifestations of cardiomyopathy or silent diffuse myocardial ischemia, Dr. Scott Yoder and colleagues at the University of Rochester (N.Y.) Medical Center reported in a poster at the annual meeting of the American Society of Nuclear Cardiology.

Although several studies have highlighted the utility of gated single photon emission CT (SPECT) scans for the diagnosis of coronary artery disease (CAD) in SLE patients, no specific recommendations have been formulated. Dr. Yoder advocates routine cardiac screening of all lupus patients, and repeat scans roughly every 6 months for any patient with identified CAD to track the progression and severity of the heart disease, as well as disease modification for SLE and treatment of underlying heart disease.

“Especially if they have evidence of heart disease on their initial screening, then every time they have an active flare of their SLE you should probably look to see if they have any worsening of their heart disease,” he said.

Lupus is associated with a two- to fourfold increased risk for coronary artery disease (CAD), and is typically difficult to diagnose because patients don't have classic symptoms and tend to present late with heart failure or some other myocardial injury, Dr. Yoder said in an interview.

The study included 15 SLE patients and 15 controls who were randomly selected from the center's patient database, and matched for age (55 years), gender (90% female), and coronary risk factors such as hypercholesterolemia (80%), hypertension (80%), tobacco use (33%), and family history of CAD (80%). All patients underwent gated SPECT scans, plus either exercise using the Bruce or modified Bruce protocols, or pharmacologic stress testing using dobutamine or adenosine.

Patients with SLE had significantly worse end-systolic volume indices (45 mL/m

Nonsignificant differences also were noted in end-diastolic volume indices (84 mL/m

The study was prompted by a case in which gated-SPECT imaging was used to risk-stratify a 35-year-old male who came to the clinic with active lupus and chest pain, and was found to have significant stress and resting perfusion defects and inducible ischemia in the anterior wall. Aggressive treatment for SLE and cardiac risk factors with prednisone, mycophenolate, aspirin, and atorvastatin resulted in significant regression of the ischemia at 1 year. His ejection fraction recovered from 23% to 47%, and stress-induced cavity dilation of the left ventricle improved from 1.68 to 1.25.

SPECT imaging shows below normal perfusion at rest (top left) and stress-induced ischemia (top right) in an SLE patient with chest pain. SLE and CAD treatment improved resting perfusion (lower left) with no evidence of stress-induced ischemia (lower right). Photos courtesy Dr. Scott Yoder

MONTREAL — Patients with systemic lupus erythematosus demonstrated significantly more perfusion abnormalities on gated scintigraphy scans, compared with well-matched controls, in a small pilot study.

The observed differences may represent early manifestations of cardiomyopathy or silent diffuse myocardial ischemia, Dr. Scott Yoder and colleagues at the University of Rochester (N.Y.) Medical Center reported in a poster at the annual meeting of the American Society of Nuclear Cardiology.

Although several studies have highlighted the utility of gated single photon emission CT (SPECT) scans for the diagnosis of coronary artery disease (CAD) in SLE patients, no specific recommendations have been formulated. Dr. Yoder advocates routine cardiac screening of all lupus patients, and repeat scans roughly every 6 months for any patient with identified CAD to track the progression and severity of the heart disease, as well as disease modification for SLE and treatment of underlying heart disease.

“Especially if they have evidence of heart disease on their initial screening, then every time they have an active flare of their SLE you should probably look to see if they have any worsening of their heart disease,” he said.

Lupus is associated with a two- to fourfold increased risk for coronary artery disease (CAD), and is typically difficult to diagnose because patients don't have classic symptoms and tend to present late with heart failure or some other myocardial injury, Dr. Yoder said in an interview.

The study included 15 SLE patients and 15 controls who were randomly selected from the center's patient database, and matched for age (55 years), gender (90% female), and coronary risk factors such as hypercholesterolemia (80%), hypertension (80%), tobacco use (33%), and family history of CAD (80%). All patients underwent gated SPECT scans, plus either exercise using the Bruce or modified Bruce protocols, or pharmacologic stress testing using dobutamine or adenosine.

Patients with SLE had significantly worse end-systolic volume indices (45 mL/m

Nonsignificant differences also were noted in end-diastolic volume indices (84 mL/m

The study was prompted by a case in which gated-SPECT imaging was used to risk-stratify a 35-year-old male who came to the clinic with active lupus and chest pain, and was found to have significant stress and resting perfusion defects and inducible ischemia in the anterior wall. Aggressive treatment for SLE and cardiac risk factors with prednisone, mycophenolate, aspirin, and atorvastatin resulted in significant regression of the ischemia at 1 year. His ejection fraction recovered from 23% to 47%, and stress-induced cavity dilation of the left ventricle improved from 1.68 to 1.25.

SPECT imaging shows below normal perfusion at rest (top left) and stress-induced ischemia (top right) in an SLE patient with chest pain. SLE and CAD treatment improved resting perfusion (lower left) with no evidence of stress-induced ischemia (lower right). Photos courtesy Dr. Scott Yoder

MONTREAL — Patients with systemic lupus erythematosus demonstrated significantly more perfusion abnormalities on gated scintigraphy scans, compared with well-matched controls, in a small pilot study.

The observed differences may represent early manifestations of cardiomyopathy or silent diffuse myocardial ischemia, Dr. Scott Yoder and colleagues at the University of Rochester (N.Y.) Medical Center reported in a poster at the annual meeting of the American Society of Nuclear Cardiology.

Although several studies have highlighted the utility of gated single photon emission CT (SPECT) scans for the diagnosis of coronary artery disease (CAD) in SLE patients, no specific recommendations have been formulated. Dr. Yoder advocates routine cardiac screening of all lupus patients, and repeat scans roughly every 6 months for any patient with identified CAD to track the progression and severity of the heart disease, as well as disease modification for SLE and treatment of underlying heart disease.

“Especially if they have evidence of heart disease on their initial screening, then every time they have an active flare of their SLE you should probably look to see if they have any worsening of their heart disease,” he said.

Lupus is associated with a two- to fourfold increased risk for coronary artery disease (CAD), and is typically difficult to diagnose because patients don't have classic symptoms and tend to present late with heart failure or some other myocardial injury, Dr. Yoder said in an interview.

The study included 15 SLE patients and 15 controls who were randomly selected from the center's patient database, and matched for age (55 years), gender (90% female), and coronary risk factors such as hypercholesterolemia (80%), hypertension (80%), tobacco use (33%), and family history of CAD (80%). All patients underwent gated SPECT scans, plus either exercise using the Bruce or modified Bruce protocols, or pharmacologic stress testing using dobutamine or adenosine.

Patients with SLE had significantly worse end-systolic volume indices (45 mL/m

Nonsignificant differences also were noted in end-diastolic volume indices (84 mL/m

The study was prompted by a case in which gated-SPECT imaging was used to risk-stratify a 35-year-old male who came to the clinic with active lupus and chest pain, and was found to have significant stress and resting perfusion defects and inducible ischemia in the anterior wall. Aggressive treatment for SLE and cardiac risk factors with prednisone, mycophenolate, aspirin, and atorvastatin resulted in significant regression of the ischemia at 1 year. His ejection fraction recovered from 23% to 47%, and stress-induced cavity dilation of the left ventricle improved from 1.68 to 1.25.

SPECT imaging shows below normal perfusion at rest (top left) and stress-induced ischemia (top right) in an SLE patient with chest pain. SLE and CAD treatment improved resting perfusion (lower left) with no evidence of stress-induced ischemia (lower right). Photos courtesy Dr. Scott Yoder

Multislice CT had greater sensitivity, specificity, and negative predictive value, with equivalent positive predictive value, than did MRI for angiographic diagnosis of 108 patients.

Multislice CT also had less than half the rate of noninterpretable results.

Dr. Marc Dewey of Humboldt University's Charité Medical School, Berlin, and colleagues assessed patients referred to their center for conventional coronary angiography for suspected coronary artery disease (CAD). Patients were a mean of 64 years old and in sinus rhythm (Ann. Intern. Med. 2006;145:407–15).

After undergoing conventional angiography, each patient within 1 day underwent multislice CT and MRI; readers assessed the results without knowing the results of conventional angiography or other clinical data.

Multislice CT had a sensitivity of 92%, versus 74% for MRI. For specificity, CT rendered 79%, versus MRI's 75%. Negative predictive value was 90% and 84%, respectively, and positive predictive value was 95% for both instruments. Only 7% of CT results were noninterpretable, versus 18% of those produced by MRI. However, for both machines, the only findings that reached statistical significance were sensitivity and the percentage of noninterpretable images.

These findings led the investigators to conclude that in their study, CT was superior to MRI in detecting coronary artery stenoses, and its high negative predictive value “makes it potentially useful as a diagnostic tool for ruling out coronary disease in a population with a low to intermediate pretest likelihood.”

Multislice CT had greater sensitivity, specificity, and negative predictive value, with equivalent positive predictive value, than did MRI for angiographic diagnosis of 108 patients.

Multislice CT also had less than half the rate of noninterpretable results.

Dr. Marc Dewey of Humboldt University's Charité Medical School, Berlin, and colleagues assessed patients referred to their center for conventional coronary angiography for suspected coronary artery disease (CAD). Patients were a mean of 64 years old and in sinus rhythm (Ann. Intern. Med. 2006;145:407–15).

After undergoing conventional angiography, each patient within 1 day underwent multislice CT and MRI; readers assessed the results without knowing the results of conventional angiography or other clinical data.

Multislice CT had a sensitivity of 92%, versus 74% for MRI. For specificity, CT rendered 79%, versus MRI's 75%. Negative predictive value was 90% and 84%, respectively, and positive predictive value was 95% for both instruments. Only 7% of CT results were noninterpretable, versus 18% of those produced by MRI. However, for both machines, the only findings that reached statistical significance were sensitivity and the percentage of noninterpretable images.

These findings led the investigators to conclude that in their study, CT was superior to MRI in detecting coronary artery stenoses, and its high negative predictive value “makes it potentially useful as a diagnostic tool for ruling out coronary disease in a population with a low to intermediate pretest likelihood.”

Multislice CT had greater sensitivity, specificity, and negative predictive value, with equivalent positive predictive value, than did MRI for angiographic diagnosis of 108 patients.

Multislice CT also had less than half the rate of noninterpretable results.

Dr. Marc Dewey of Humboldt University's Charité Medical School, Berlin, and colleagues assessed patients referred to their center for conventional coronary angiography for suspected coronary artery disease (CAD). Patients were a mean of 64 years old and in sinus rhythm (Ann. Intern. Med. 2006;145:407–15).

After undergoing conventional angiography, each patient within 1 day underwent multislice CT and MRI; readers assessed the results without knowing the results of conventional angiography or other clinical data.

Multislice CT had a sensitivity of 92%, versus 74% for MRI. For specificity, CT rendered 79%, versus MRI's 75%. Negative predictive value was 90% and 84%, respectively, and positive predictive value was 95% for both instruments. Only 7% of CT results were noninterpretable, versus 18% of those produced by MRI. However, for both machines, the only findings that reached statistical significance were sensitivity and the percentage of noninterpretable images.

These findings led the investigators to conclude that in their study, CT was superior to MRI in detecting coronary artery stenoses, and its high negative predictive value “makes it potentially useful as a diagnostic tool for ruling out coronary disease in a population with a low to intermediate pretest likelihood.”

MONTREAL — Suboptimal glycemic control, elevated plasma osteoprotegerin, and presence of serum interleukin-6 were risk factors for progression of coronary artery calcification in a prospective study of asymptomatic patients with type 2 diabetes.

Despite having no known coronary artery disease, a significant proportion (30%) of the 398 patients followed in the study had atherosclerosis progression, Dr. Avijit Lahiri said at the annual meeting of the American Society of Nuclear Cardiology.

The study provides insight into the risk factors for progression of coronary calcification and establishes the role of combining cardiac CT for coronary artery calcium (CAC) imaging with simultaneous single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) in uncomplicated, stable, asymptomatic patients with type 2 diabetes, Dr. Lahiri said.

CAC can be used to identify patients with increased atherosclerotic burden, but it does not identify obstructive coronary artery disease, explained Dr. Lahiri, director of cardiac imaging and research at Wellington Hospital in London. Therefore, there is a need to use combined MPI to detect silent ischemia. “Interestingly, these tests had a synergistic value on prognosis,” he said in an interview. “Thus, it would be cost effective to exclude those without CAC for further testing.”

The original study included 510 patients, of whom 20 went on to have cardiac events, and 402 were willing to participate in the follow-up study. Four scans were technically inadequate, resulting in a cohort of 398 patients. Their mean age was 53 years; 61% were male; and their average serum glycosylated hemoglobin (HbA_1c) was 8%.

All patients underwent CAC imaging, as well as a clinical evaluation—at baseline and about 2.5 years later—that measured HbA_1c; serum interleukin-6 and C-reactive protein; and plasma osteoprotegerin. Those with a CAC score of more than 100 Agatston units at baseline also underwent MPI using a 2-day stress-rest protocol with technetium-99m sestamibi and dipyridamole and maximum treadmill exercise.

At baseline, 211 (53%) of the 398 patients had coronary artery calcification. At follow-up, atherosclerosis progression was observed in 118 (30%) patients, including 22 (5.5%) who had no calcification at baseline, Dr. Lahiri said. Regression was noted in 3 (0.8%), and there was no change in 277 (70%).

At baseline, 24 patients had an abnormal perfusion scan. Progression of ischemia was seen in 14 patients, regression in 8, and no change in 2.

In a univariate analysis, age, male gender, presence of hypertension, and baseline HbA_1c were predictors of atherosclerosis progression. There was no significant association between calcium scores and serum levels of C-reactive protein or IL-6. Surprisingly, statin use was a negative predictor, Dr. Lahiri said.

In a multivariate logistic regression model, serum HbA_1c was a most important factor influencing progression. Poor glycemic control raised the risk of progression 10.5-fold; the risk increased 2.5-fold for elevated plasma osteoprotegerin and 2.1-fold for IL-6.

Age, male gender, presence of hypertension, and baseline HbA_1c were predictors of atherosclerosis progression. DR. LAHIRI

SPECT images show progression of atherosclerosis in the right coronary and left circumflex arteries (arrows) of a diabetic patient over 1.7 years. Photos courtesy Dr. Avijit Lahiri

MONTREAL — Suboptimal glycemic control, elevated plasma osteoprotegerin, and presence of serum interleukin-6 were risk factors for progression of coronary artery calcification in a prospective study of asymptomatic patients with type 2 diabetes.

Despite having no known coronary artery disease, a significant proportion (30%) of the 398 patients followed in the study had atherosclerosis progression, Dr. Avijit Lahiri said at the annual meeting of the American Society of Nuclear Cardiology.

The study provides insight into the risk factors for progression of coronary calcification and establishes the role of combining cardiac CT for coronary artery calcium (CAC) imaging with simultaneous single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) in uncomplicated, stable, asymptomatic patients with type 2 diabetes, Dr. Lahiri said.

CAC can be used to identify patients with increased atherosclerotic burden, but it does not identify obstructive coronary artery disease, explained Dr. Lahiri, director of cardiac imaging and research at Wellington Hospital in London. Therefore, there is a need to use combined MPI to detect silent ischemia. “Interestingly, these tests had a synergistic value on prognosis,” he said in an interview. “Thus, it would be cost effective to exclude those without CAC for further testing.”

The original study included 510 patients, of whom 20 went on to have cardiac events, and 402 were willing to participate in the follow-up study. Four scans were technically inadequate, resulting in a cohort of 398 patients. Their mean age was 53 years; 61% were male; and their average serum glycosylated hemoglobin (HbA_1c) was 8%.

All patients underwent CAC imaging, as well as a clinical evaluation—at baseline and about 2.5 years later—that measured HbA_1c; serum interleukin-6 and C-reactive protein; and plasma osteoprotegerin. Those with a CAC score of more than 100 Agatston units at baseline also underwent MPI using a 2-day stress-rest protocol with technetium-99m sestamibi and dipyridamole and maximum treadmill exercise.

At baseline, 211 (53%) of the 398 patients had coronary artery calcification. At follow-up, atherosclerosis progression was observed in 118 (30%) patients, including 22 (5.5%) who had no calcification at baseline, Dr. Lahiri said. Regression was noted in 3 (0.8%), and there was no change in 277 (70%).

At baseline, 24 patients had an abnormal perfusion scan. Progression of ischemia was seen in 14 patients, regression in 8, and no change in 2.

In a univariate analysis, age, male gender, presence of hypertension, and baseline HbA_1c were predictors of atherosclerosis progression. There was no significant association between calcium scores and serum levels of C-reactive protein or IL-6. Surprisingly, statin use was a negative predictor, Dr. Lahiri said.

In a multivariate logistic regression model, serum HbA_1c was a most important factor influencing progression. Poor glycemic control raised the risk of progression 10.5-fold; the risk increased 2.5-fold for elevated plasma osteoprotegerin and 2.1-fold for IL-6.

Age, male gender, presence of hypertension, and baseline HbA_1c were predictors of atherosclerosis progression. DR. LAHIRI

SPECT images show progression of atherosclerosis in the right coronary and left circumflex arteries (arrows) of a diabetic patient over 1.7 years. Photos courtesy Dr. Avijit Lahiri

MONTREAL — Suboptimal glycemic control, elevated plasma osteoprotegerin, and presence of serum interleukin-6 were risk factors for progression of coronary artery calcification in a prospective study of asymptomatic patients with type 2 diabetes.

Despite having no known coronary artery disease, a significant proportion (30%) of the 398 patients followed in the study had atherosclerosis progression, Dr. Avijit Lahiri said at the annual meeting of the American Society of Nuclear Cardiology.

The study provides insight into the risk factors for progression of coronary calcification and establishes the role of combining cardiac CT for coronary artery calcium (CAC) imaging with simultaneous single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) in uncomplicated, stable, asymptomatic patients with type 2 diabetes, Dr. Lahiri said.

CAC can be used to identify patients with increased atherosclerotic burden, but it does not identify obstructive coronary artery disease, explained Dr. Lahiri, director of cardiac imaging and research at Wellington Hospital in London. Therefore, there is a need to use combined MPI to detect silent ischemia. “Interestingly, these tests had a synergistic value on prognosis,” he said in an interview. “Thus, it would be cost effective to exclude those without CAC for further testing.”

The original study included 510 patients, of whom 20 went on to have cardiac events, and 402 were willing to participate in the follow-up study. Four scans were technically inadequate, resulting in a cohort of 398 patients. Their mean age was 53 years; 61% were male; and their average serum glycosylated hemoglobin (HbA_1c) was 8%.

All patients underwent CAC imaging, as well as a clinical evaluation—at baseline and about 2.5 years later—that measured HbA_1c; serum interleukin-6 and C-reactive protein; and plasma osteoprotegerin. Those with a CAC score of more than 100 Agatston units at baseline also underwent MPI using a 2-day stress-rest protocol with technetium-99m sestamibi and dipyridamole and maximum treadmill exercise.

At baseline, 211 (53%) of the 398 patients had coronary artery calcification. At follow-up, atherosclerosis progression was observed in 118 (30%) patients, including 22 (5.5%) who had no calcification at baseline, Dr. Lahiri said. Regression was noted in 3 (0.8%), and there was no change in 277 (70%).

At baseline, 24 patients had an abnormal perfusion scan. Progression of ischemia was seen in 14 patients, regression in 8, and no change in 2.

In a univariate analysis, age, male gender, presence of hypertension, and baseline HbA_1c were predictors of atherosclerosis progression. There was no significant association between calcium scores and serum levels of C-reactive protein or IL-6. Surprisingly, statin use was a negative predictor, Dr. Lahiri said.

In a multivariate logistic regression model, serum HbA_1c was a most important factor influencing progression. Poor glycemic control raised the risk of progression 10.5-fold; the risk increased 2.5-fold for elevated plasma osteoprotegerin and 2.1-fold for IL-6.

Age, male gender, presence of hypertension, and baseline HbA_1c were predictors of atherosclerosis progression. DR. LAHIRI

SPECT images show progression of atherosclerosis in the right coronary and left circumflex arteries (arrows) of a diabetic patient over 1.7 years. Photos courtesy Dr. Avijit Lahiri

BARCELONA — Dobutamine echocardiography performed a couple of days after nonrevascularized acute MI reliably distinguishes those patients likely to benefit from percutaneous coronary revascularization prior to hospital discharge from those who don't need PCI, Dr. Gerrit Veen said at a joint meeting of the European Society of Cardiology and the World Heart Federation.

The purpose of the imaging procedure in this situation is to identify patients who have viable—and therefore vulnerable—myocardium in the infarct area. They are the ones at high risk for reinfarction during the next 3–6 months during the post-MI recovery phase. Stenting their infarct-related artery as soon as possible is warranted.

On the other hand, patients without viable myocardium in the infarct zone are at little risk. They can be managed medically, added Dr. Veen of the VU University Medical Center, Amsterdam.

These were the key findings of the Viability-Guided Angioplasty After Acute Myocardial Infarction (VIAMI) trial. The 12-center Dutch randomized trial was the first-ever formal study of viability-guided revascularization in patients not undergoing primary PCI.

VIAMI involved 291 MI patients not treated by primary PCI. About half got thrombolytic therapy, while the remainder experienced spontaneous reperfusion and presented too late to be eligible for thrombolysis. All underwent dobutamine echocardiography when stabilized 2–3 days post MI.

The 216 patients who displayed viability—meaning two or more myocardial segments responded to dobutamine stimulation—were randomized to immediate PCI with stenting of the infarct-related artery, with interhospital transport if needed, or to a more conservative watchful-waiting approach with PCI reserved for those who developed ischemic symptoms. Patients without viability in the infarct zone were followed in a registry.

The primary study end point was the 6-month combined rate of death, recurrent MI, or unstable angina. It was 6.6% in the PCI group, a 59% risk reduction relative to the 15.5% rate in the watchful-waiting arm. The difference resulted from a marked disparity in unstable angina: 2.8% in the PCI group, compared with 11.8% with watchful waiting.

In addition, 17.3% of patients in the watchful-waiting arm underwent elective revascularization in 6 months. None in the PCI group did.

“We believe viability testing should become a standard tool in the clinical evaluation of patients in the first days after thrombolysis in acute MI patients without revascularization. And in patients with viability, revascularization should be considered prior to hospital discharge,” the cardiologist said.

The primary end point rate in registry participants lacking viable infarct-zone myocardium was low, 5.3%. “The message here is that when you don't have viability, it's not necessary to routinely do angioplasty,” Dr. Veen noted.

Discussant Dr. Carlo Di Mario of Royal Brompton Hospital, London, observed that the VIAMI message is out of step with the most recent European Society of Cardiology guidelines on management of acute MI, which call for angiography with an eye toward possible PCI within 24 hours in all patients.

He voiced concern that even a 2- to 3-day delay for viability testing as in VIAMI could be sufficient to lose two-thirds of the benefit provided by a routine early invasive strategy.

But other observers were impressed with the efficiency of the Dutch strategy, which offers a more selective approach than the current popular practice of performing routine PCI in all in order to protect the 20%–30% who would otherwise develop recurrent ischemia during the post-MI recovery phase.

The VIAMI trial was funded by the Netherlands Heart Foundation, Eli Lilly, Boehringer Ingelheim, and Bristol-Myers Squibb.

In acute MI patients with viability, revascularization should be considered prior to hospital discharge. Dr. Veen

BARCELONA — Dobutamine echocardiography performed a couple of days after nonrevascularized acute MI reliably distinguishes those patients likely to benefit from percutaneous coronary revascularization prior to hospital discharge from those who don't need PCI, Dr. Gerrit Veen said at a joint meeting of the European Society of Cardiology and the World Heart Federation.

The purpose of the imaging procedure in this situation is to identify patients who have viable—and therefore vulnerable—myocardium in the infarct area. They are the ones at high risk for reinfarction during the next 3–6 months during the post-MI recovery phase. Stenting their infarct-related artery as soon as possible is warranted.

On the other hand, patients without viable myocardium in the infarct zone are at little risk. They can be managed medically, added Dr. Veen of the VU University Medical Center, Amsterdam.

These were the key findings of the Viability-Guided Angioplasty After Acute Myocardial Infarction (VIAMI) trial. The 12-center Dutch randomized trial was the first-ever formal study of viability-guided revascularization in patients not undergoing primary PCI.

VIAMI involved 291 MI patients not treated by primary PCI. About half got thrombolytic therapy, while the remainder experienced spontaneous reperfusion and presented too late to be eligible for thrombolysis. All underwent dobutamine echocardiography when stabilized 2–3 days post MI.

The 216 patients who displayed viability—meaning two or more myocardial segments responded to dobutamine stimulation—were randomized to immediate PCI with stenting of the infarct-related artery, with interhospital transport if needed, or to a more conservative watchful-waiting approach with PCI reserved for those who developed ischemic symptoms. Patients without viability in the infarct zone were followed in a registry.

The primary study end point was the 6-month combined rate of death, recurrent MI, or unstable angina. It was 6.6% in the PCI group, a 59% risk reduction relative to the 15.5% rate in the watchful-waiting arm. The difference resulted from a marked disparity in unstable angina: 2.8% in the PCI group, compared with 11.8% with watchful waiting.

In addition, 17.3% of patients in the watchful-waiting arm underwent elective revascularization in 6 months. None in the PCI group did.

“We believe viability testing should become a standard tool in the clinical evaluation of patients in the first days after thrombolysis in acute MI patients without revascularization. And in patients with viability, revascularization should be considered prior to hospital discharge,” the cardiologist said.

The primary end point rate in registry participants lacking viable infarct-zone myocardium was low, 5.3%. “The message here is that when you don't have viability, it's not necessary to routinely do angioplasty,” Dr. Veen noted.

Discussant Dr. Carlo Di Mario of Royal Brompton Hospital, London, observed that the VIAMI message is out of step with the most recent European Society of Cardiology guidelines on management of acute MI, which call for angiography with an eye toward possible PCI within 24 hours in all patients.

He voiced concern that even a 2- to 3-day delay for viability testing as in VIAMI could be sufficient to lose two-thirds of the benefit provided by a routine early invasive strategy.

But other observers were impressed with the efficiency of the Dutch strategy, which offers a more selective approach than the current popular practice of performing routine PCI in all in order to protect the 20%–30% who would otherwise develop recurrent ischemia during the post-MI recovery phase.

The VIAMI trial was funded by the Netherlands Heart Foundation, Eli Lilly, Boehringer Ingelheim, and Bristol-Myers Squibb.

In acute MI patients with viability, revascularization should be considered prior to hospital discharge. Dr. Veen

BARCELONA — Dobutamine echocardiography performed a couple of days after nonrevascularized acute MI reliably distinguishes those patients likely to benefit from percutaneous coronary revascularization prior to hospital discharge from those who don't need PCI, Dr. Gerrit Veen said at a joint meeting of the European Society of Cardiology and the World Heart Federation.

The purpose of the imaging procedure in this situation is to identify patients who have viable—and therefore vulnerable—myocardium in the infarct area. They are the ones at high risk for reinfarction during the next 3–6 months during the post-MI recovery phase. Stenting their infarct-related artery as soon as possible is warranted.

On the other hand, patients without viable myocardium in the infarct zone are at little risk. They can be managed medically, added Dr. Veen of the VU University Medical Center, Amsterdam.

These were the key findings of the Viability-Guided Angioplasty After Acute Myocardial Infarction (VIAMI) trial. The 12-center Dutch randomized trial was the first-ever formal study of viability-guided revascularization in patients not undergoing primary PCI.

VIAMI involved 291 MI patients not treated by primary PCI. About half got thrombolytic therapy, while the remainder experienced spontaneous reperfusion and presented too late to be eligible for thrombolysis. All underwent dobutamine echocardiography when stabilized 2–3 days post MI.

The 216 patients who displayed viability—meaning two or more myocardial segments responded to dobutamine stimulation—were randomized to immediate PCI with stenting of the infarct-related artery, with interhospital transport if needed, or to a more conservative watchful-waiting approach with PCI reserved for those who developed ischemic symptoms. Patients without viability in the infarct zone were followed in a registry.

The primary study end point was the 6-month combined rate of death, recurrent MI, or unstable angina. It was 6.6% in the PCI group, a 59% risk reduction relative to the 15.5% rate in the watchful-waiting arm. The difference resulted from a marked disparity in unstable angina: 2.8% in the PCI group, compared with 11.8% with watchful waiting.

In addition, 17.3% of patients in the watchful-waiting arm underwent elective revascularization in 6 months. None in the PCI group did.

“We believe viability testing should become a standard tool in the clinical evaluation of patients in the first days after thrombolysis in acute MI patients without revascularization. And in patients with viability, revascularization should be considered prior to hospital discharge,” the cardiologist said.

The primary end point rate in registry participants lacking viable infarct-zone myocardium was low, 5.3%. “The message here is that when you don't have viability, it's not necessary to routinely do angioplasty,” Dr. Veen noted.

Discussant Dr. Carlo Di Mario of Royal Brompton Hospital, London, observed that the VIAMI message is out of step with the most recent European Society of Cardiology guidelines on management of acute MI, which call for angiography with an eye toward possible PCI within 24 hours in all patients.

He voiced concern that even a 2- to 3-day delay for viability testing as in VIAMI could be sufficient to lose two-thirds of the benefit provided by a routine early invasive strategy.

But other observers were impressed with the efficiency of the Dutch strategy, which offers a more selective approach than the current popular practice of performing routine PCI in all in order to protect the 20%–30% who would otherwise develop recurrent ischemia during the post-MI recovery phase.

The VIAMI trial was funded by the Netherlands Heart Foundation, Eli Lilly, Boehringer Ingelheim, and Bristol-Myers Squibb.

In acute MI patients with viability, revascularization should be considered prior to hospital discharge. Dr. Veen

PHILADELPHIA — Screening patients scheduled to undergo carotid artery stenting by three-dimensional CT angiography led to a change in the planned procedure in 37% of patients in a pilot study with a total of 59 patients.

Screening with computed tomography angiography provides a standardized view of the patient's vascular anatomy and allows exclusion of patients who have clear anatomic contraindications, Dr. Mark C. Wyers said at the Vascular Annual Meeting, sponsored by the Society for Vascular Surgery.

Further study of this screening method is warranted to assess its impact on stroke rates and its cost effectiveness, added Dr. Wyers, a vascular surgeon at Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

“We need to do a better job in selecting patients for carotid artery stenting in order to improve our results,” he said. The anatomic assessments that have been used until now, most often Doppler ultrasound or conventional arteriography, have not provided adequate guidance for patient selection.

The imaging method tested was an orthogonal three-dimensional reconstruction of angiography data collected by CT, using the technique developed for imaging abdominal aortic aneurysms. This imaging was used at the discretion of the carotid stenting operators at Dartmouth-Hitchcock on 59 patients during a 3-year period.

During the same time, another 51 patients underwent carotid artery stenting without first undergoing imaging by CT angiography.

Of the 59 patients reviewed with CT angiography, 37 were approved for carotid stenting. Another 15 of the imaged patients were judged unsuitable for stenting based on the anatomy of their carotid arteries and other vessels, and 5 were considered to have anatomy with borderline suitability. In four of those five borderline patients, the procedure was not attempted, and in one patient, it was attempted but failed.

The number of patients who underwent stenting in the entire series was small (37 who were screened and 51 who weren't screened, for a total group of 88 patients), which makes comparisons between the two subgroups difficult.

The technical success rate of carotid stenting was 100% in the patients who were screened and 98% in those who weren't. The rate of unplanned or nonstandard maneuvers during stenting was 5% (two patients) in the screened subgroup and 12% (six patients) among those who weren't screened.

Screening not only appeared to help operators anticipate potential problems, it also reduced the need to make treatment decisions on the fly and helped reduce the tendency of some physicians to forge ahead with stenting in patients who have suboptimal vascular anatomy, Dr. Wyers said.

A 3-D CT angiogram reveals a heavily diseased aortic arch and carotid artery. The technique may help in appropriate patient selection. Courtesy Dr. Mark C. Wyers

PHILADELPHIA — Screening patients scheduled to undergo carotid artery stenting by three-dimensional CT angiography led to a change in the planned procedure in 37% of patients in a pilot study with a total of 59 patients.

Screening with computed tomography angiography provides a standardized view of the patient's vascular anatomy and allows exclusion of patients who have clear anatomic contraindications, Dr. Mark C. Wyers said at the Vascular Annual Meeting, sponsored by the Society for Vascular Surgery.

Further study of this screening method is warranted to assess its impact on stroke rates and its cost effectiveness, added Dr. Wyers, a vascular surgeon at Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

“We need to do a better job in selecting patients for carotid artery stenting in order to improve our results,” he said. The anatomic assessments that have been used until now, most often Doppler ultrasound or conventional arteriography, have not provided adequate guidance for patient selection.

The imaging method tested was an orthogonal three-dimensional reconstruction of angiography data collected by CT, using the technique developed for imaging abdominal aortic aneurysms. This imaging was used at the discretion of the carotid stenting operators at Dartmouth-Hitchcock on 59 patients during a 3-year period.

During the same time, another 51 patients underwent carotid artery stenting without first undergoing imaging by CT angiography.

Of the 59 patients reviewed with CT angiography, 37 were approved for carotid stenting. Another 15 of the imaged patients were judged unsuitable for stenting based on the anatomy of their carotid arteries and other vessels, and 5 were considered to have anatomy with borderline suitability. In four of those five borderline patients, the procedure was not attempted, and in one patient, it was attempted but failed.

The number of patients who underwent stenting in the entire series was small (37 who were screened and 51 who weren't screened, for a total group of 88 patients), which makes comparisons between the two subgroups difficult.

The technical success rate of carotid stenting was 100% in the patients who were screened and 98% in those who weren't. The rate of unplanned or nonstandard maneuvers during stenting was 5% (two patients) in the screened subgroup and 12% (six patients) among those who weren't screened.

Screening not only appeared to help operators anticipate potential problems, it also reduced the need to make treatment decisions on the fly and helped reduce the tendency of some physicians to forge ahead with stenting in patients who have suboptimal vascular anatomy, Dr. Wyers said.

A 3-D CT angiogram reveals a heavily diseased aortic arch and carotid artery. The technique may help in appropriate patient selection. Courtesy Dr. Mark C. Wyers

PHILADELPHIA — Screening patients scheduled to undergo carotid artery stenting by three-dimensional CT angiography led to a change in the planned procedure in 37% of patients in a pilot study with a total of 59 patients.

Screening with computed tomography angiography provides a standardized view of the patient's vascular anatomy and allows exclusion of patients who have clear anatomic contraindications, Dr. Mark C. Wyers said at the Vascular Annual Meeting, sponsored by the Society for Vascular Surgery.

Further study of this screening method is warranted to assess its impact on stroke rates and its cost effectiveness, added Dr. Wyers, a vascular surgeon at Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

“We need to do a better job in selecting patients for carotid artery stenting in order to improve our results,” he said. The anatomic assessments that have been used until now, most often Doppler ultrasound or conventional arteriography, have not provided adequate guidance for patient selection.

The imaging method tested was an orthogonal three-dimensional reconstruction of angiography data collected by CT, using the technique developed for imaging abdominal aortic aneurysms. This imaging was used at the discretion of the carotid stenting operators at Dartmouth-Hitchcock on 59 patients during a 3-year period.

During the same time, another 51 patients underwent carotid artery stenting without first undergoing imaging by CT angiography.

Of the 59 patients reviewed with CT angiography, 37 were approved for carotid stenting. Another 15 of the imaged patients were judged unsuitable for stenting based on the anatomy of their carotid arteries and other vessels, and 5 were considered to have anatomy with borderline suitability. In four of those five borderline patients, the procedure was not attempted, and in one patient, it was attempted but failed.

The number of patients who underwent stenting in the entire series was small (37 who were screened and 51 who weren't screened, for a total group of 88 patients), which makes comparisons between the two subgroups difficult.

The technical success rate of carotid stenting was 100% in the patients who were screened and 98% in those who weren't. The rate of unplanned or nonstandard maneuvers during stenting was 5% (two patients) in the screened subgroup and 12% (six patients) among those who weren't screened.

Screening not only appeared to help operators anticipate potential problems, it also reduced the need to make treatment decisions on the fly and helped reduce the tendency of some physicians to forge ahead with stenting in patients who have suboptimal vascular anatomy, Dr. Wyers said.

A 3-D CT angiogram reveals a heavily diseased aortic arch and carotid artery. The technique may help in appropriate patient selection. Courtesy Dr. Mark C. Wyers