CEUS cardiac exam protocols International Contrast Ultrasound Society (ICUS) recommendations.

The present CEUS Cardiac Exam Protocols represent the first effort to promulgate a standard set of protocols for optimal administration of ultrasound enhancing agents (UEAs) in echocardiography, based on more than two decades of experience in the use of UEAs for cardiac imaging. The protocols reflect current clinical CEUS practice in many modern echocardiography laboratories throughout the world. Specific attention is given to preparation and dosing of three UEAs that have been approved by the United States Food and Drug Administration (FDA) and additional regulatory bodies in Europe, the Americas and Asia-Pacific. Consistent with professional society guidelines (J Am Soc Echocardiogr 31:241-274, 2018; J Am Soc Echocardiogr 27:797-810, 2014; Eur Heart J Cardiovasc Imaging 18:1205, 2017), these protocols cover unapproved "off-label" uses of UEAs-including stress echocardiography and myocardial perfusion imaging-in addition to approved uses. Accordingly, these protocols may differ from information provided in product labels, which are generally based on studies performed prior to product approval and may not always reflect state of the art clinical practice or guidelines.

The prognostic value of heart rate response during vasodilator stress myocardial perfusion imaging in patients with end-stage renal disease undergoing renal transplantation.

BACKGROUND: In asymptomatic end-stage renal disease (ESRD) patients undergoing vasodilator stress myocardial perfusion imaging (MPI) prior to renal transplantation (RT), the impact of pre-transplant heart rate response (HRR) to vasodilator stress on post-RT outcomes is unknown. METHODS: We analyzed a retrospective cohort of asymptomatic patients with ESRD who underwent a vasodilator stress SPECT-MPI and subsequently received RT. Blunted HRR was defined as HRR <28% for regadenoson stress and <20% for adenosine stress. The primary endpoint was major adverse cardiac events (MACE), defined as cardiac death or myocardial infarction. Clinical risk was assessed using the sum of risk factors set forth by the AHA/ACCF consensus statement on the assessment of RT candidates. RESULTS: Among 352 subjects, 140 had an abnormal pre-transplant HRR. During a mean follow-up of 3.2 ± 2.0 years, 85 (24%) MACEs were observed. Blunted HRR was associated with increased MACE risk (hazard ratio 1.72; 95% confidence interval 1.12-2.63, P = 0.013), and remained significant after adjustment for gender, sum of AHA/ACCF risk factors, summed stress score, baseline heart rate, and ß-blocker use. HRR was predictive of MACE in patients with normal MPI and irrespective of clinical risk. Blunted HRR was associated with a significant increase in post-operative (30-day) MACE risk (17.9% vs 8.5%; P = 0.009). CONCLUSION: In asymptomatic ESRD patients being evaluated for RT, a blunted pre-transplant HRR was predictive of post-RT MACE. HRR may be a valuable tool in the risk assessment of RT candidates.

Validation of a clinical pathway to assess asymptomatic renal transplant candidates using myocardial perfusion imaging.

BACKGROUND: An AHA/ACCF scientific statement proposed 8 risk factors to assess the need for noninvasive coronary artery disease (CAD) surveillance in asymptomatic patients undergoing evaluation for kidney transplantation. The clinical application of these risk factors and the role of noninvasive testing in this context have not been defined. METHODS AND RESULTS: We retrospectively followed a cohort of 581 consecutive kidney transplant recipients of whom 401 had pre-transplant radionuclide myocardial perfusion imaging (MPI) and 90 had pre-transplant coronary angiography. The sum of pre-transplant AHA/ACCF risk factors (age >60 years, hypertension, diabetes, cardiovascular disease, dyslipidemia, smoking, dialysis >1 year, left ventricular hypertrophy) was calculated. MPI scans were analyzed by a "blinded" reader. Patients were followed for a mean of 3.7 ± 2.3 years post-transplant for major adverse cardiac events (MACE), defined as cardiac death or non-fatal myocardial infarction. The sum of risk factors was associated with modest discriminatory capacity for obstructive angiographic CAD (area under the curve [AUC], 0.70; P = 0.004), 30-day post-operative MACE (AUC, 0.60; P = 0.036), and long-term MACE (AUC, 0.63; P < 0.001). A threshold of ≥3 risk factors was optimal for identifying patients at risk. MPI provided incremental predictive value for obstructive CAD (P = 0.02) and long-term MACE (P = 0.04) but not post-operative MACE (P = 0.56). MPI was best predictive of long-term MACE in intermediate risk (3-4 risk factors) patients. CONCLUSIONS: Asymptomatic kidney transplant candidates with ≥3 AHA/ACCF risk factors are at increased cardiac risk, and should be considered for noninvasive CAD surveillance. Intermediate risk patients (3-4 factors) benefit the most from pre-transplant MPI to define long-term MACE risk.

In-hospital statin underutilization among high-risk patients: delayed uptake of the 2013 cholesterol guidelines in a U.S. cohort.

OBJECTIVES: Clinician utilization of the 2013 cholesterol lowering guidelines remains variable and unknown. We sought to examine statin prescribing patterns and compare rates among specialists who treat high-risk cardiovascular patients admitted to the hospital. METHODS: We retrospectively (via chart review) examined four specialty groups: (i) Cardiology, (ii) Cardiovascular or Vascular (CV) Surgery, (iii) Neurology, and (iv) Internal Medicine. Adult patients were included based on a discharge diagnosis of acute coronary syndrome, coronary artery bypass graft surgery, carotid endarterectomy, acute ischemic stroke, transient ischemic attack, or high-risk chest pain. Prescribing patterns were evaluated 6 months and 18 months after the release of the 2013 guidelines. High-intensity statin was defined as atorvastatin 40-80 mg or rosuvastatin 20-40 mg per day. RESULTS: 632 patients were included in our study. The following percentages of patients were discharged on high-intensity statin (6 months; 18 months): (i) Cardiology (80%; 85%), (ii) CV Surgery (52%, 65%), (iii) Neurology (59%; 66%), and (iv) Internal Medicine (45%; 48%). Among the four groups, Cardiology was the most likely to discharge patients on high-intensity statin (p < 0.001) in 2014 and in 2015. Cardiology, CV Surgery, and Neurology significantly increased the percentage of patients on high-intensity statin from pre-admission to time of discharge in both years. CONCLUSION: High-intensity statin therapy is underutilized among high-risk cardiovascular patients admitted to the hospital. Variations exist in prescribing patterns of different specialties who manage high-risk populations. This data can be used to test quality improvement interventions to improve rates of high-intensity statin utilization among high-risk patients prior to hospital discharge.

Impact of Appropriate Use on the Estimated Radiation Risk to Men and Women Undergoing Radionuclide Myocardial Perfusion Imaging.

UNLABELLED: The impact of appropriate use criteria (AUC) for myocardial perfusion imaging (MPI) with SPECT on the estimated lifetime attributable risk (LAR) of cancer is unknown. METHODS: A cohort of 1,511 consecutive patients who underwent clinically indicated (99m)Tc-setamibi MPI were categorized into appropriate/uncertain (n = 823) versus inappropriate (n = 688) use groups according to the 2009 AUC and were prospectively followed for 27 ± 10 mo. Logistic regression models were used to determine the annualized probability of major adverse cardiac events (MACE) of cardiac death or myocardial infarction and the probability of revascularization within 6 mo of MPI, accounting for relevant covariates. We determined LAR for each subject on the basis of accepted risk estimates. We calculated MPI's benefit-to-risk ratios, defined by the annualized predicted MACE-to-LAR ratio and the predicted 6-mo-revascularization-to-LAR ratio. RESULTS: During follow-up, there were 22 MACE and 29 6-mo revascularizations. The administered radioactivity and effective radiation doses absorbed were similar between the study groups. Patients with inappropriate MPI had significantly higher LAR (median, 0.08% vs. 0.06%, P < 0.001), lower predicted MACE-to-LAR ratio (median, 1.5 vs. 4.3, P < 0.001), and lower predicted 6-mo-revascularization-to-LAR ratio (median, 5.4 vs. 15.5, P < 0.001). Women had higher LAR (median, 0.08% vs. 0.07%, P < 0.001) and lower predicted MACE-to-LAR ratio (median, 1.9 vs. 3.3, P < 0.001) and 6-mo-revascularization-to-LAR ratio (median, 4.4 vs. 17.5, P < 0.001). However, appropriate/uncertain use negated the difference between men and women in LAR (P = 0.94) and the predicted MACE-to-LAR ratio (P = 0.97). CONCLUSION: Inappropriate MPI use is associated with excess cancer risk and lower MPI's benefit-to-risk ratio. Appropriate/uncertain use neutralizes the sex gap in LAR with MPI.

Update on the safety and efficacy of commercial ultrasound contrast agents in cardiac applications.

Ultrasound contrast agents (UCAs) are currently used throughout the world in both clinical and research settings. The concept of contrast-enhanced ultrasound imaging originated in the late 1960s, and the first commercially available agents were initially developed in the 1980s. Today's microbubbles are designed for greater utility and are used for both approved and off-label indications. In October 2007, the US Food and Drug Administration (FDA) imposed additional product label warnings that included serious cardiopulmonary reactions, several new disease-state contraindications, and a mandated 30 min post-procedure monitoring period for the agents Optison and Definity. These additional warnings were prompted by reports of cardiopulmonary reactions that were temporally related but were not clearly attributable to these UCAs. Subsequent published reports over the following months established not only the safety but also the improved efficacy of clinical ultrasound applications with UCAs. The FDA consequently updated the product labeling in June 2008 and reduced contraindications, although it continued to monitor select patients. In addition, a post-marketing program was proposed to the sponsors for a series of safety studies to further assess the risk of UCAs. Then in October 2011, the FDA leadership further downgraded the warnings after hearing the results of the post-marketing data, which revealed continued safety and improved efficacy. The present review focuses on the use of UCAs in today's clinical practice, including the approved indications, a variety of off-label uses, and the most recent data, which affirms the safety and efficacy of UCAs.

Impact of a novel interventional platform and hospital design on the door-to-balloon time in patients presenting with ST-segment elevation myocardial infarction.

INTRODUCTION: Reducing door-to-balloon (DTB) time in ST-segment elevation myocardial infarction improves outcomes. Several hospital factors can delay DTB times and lead to increased morbidity and mortality. The effects of hospital design and an interventional platform (IP) on patient care, particularly on the DTB time, are unknown. METHODS: We performed a retrospective analysis of consecutive patients presenting to the emergency department of a medical center from September 2010 to February 2014 who met criteria for a ST-segment elevation myocardial infarction and underwent primary percutaneous coronary intervention. Patients were divided into 2 groups based on whether they presented before or after the opening of the IP in our new hospital on January 6, 2012. Total DTB time and separate systematic intervals were tabulated. RESULTS: Fifty-two patients met our inclusion criteria, 21 pre-IP and 31 post-IP. Both groups had overall similar baseline characteristics. The mean DTB time significantly improved by 11.7 minutes after the opening of the IP (P = 0.016), and all cases had a DTB time 90 minutes or less as compared with 90.4% prior. Eighty-nine percent of the overall improvement in DTB happened before the patient reached the catheterization table. Important factors were the new emergency department (ED) design that facilitates rapid patient triage and the direct connection between the ED and cath lab. CONCLUSIONS: This study showed that the new hospital design had significant effects on immediate patient care by improving the DTB time at our institution. Further study regarding the long-term impact of hospital designs on patient care is needed.

Cardiac imaging for the assessment of patients being evaluated for kidney or liver transplantation.

Cardiac risk assessment prior to kidney and liver transplantation is controversial. Given the paucity of available organs, selecting appropriate recipients with favorable short- and long-term cardiovascular risk profile is crucial. Using noninvasive cardiac imaging tools to guide cardiovascular risk assessment and management can also be challenging and controversial. In this article, we address the burden of coronary artery disease among kidney and liver transplant candidates and review the literature pertaining to the diagnostic accuracy and the prognostic value of noninvasive cardiac imaging techniques in this population.

Fibrillary glomerulonephritis with hepatitis C viral infection and hypocomplementemia.

Fibrillary glomerulonephritis (FGN) is a relatively rare cause of renal disease, found in only 0.6-1.5% of native renal biopsies. The pathogenesis of FGN is not well described, and very few associations with disease processes other than hepatitis C virus (HCV) have been made. We describe a case that provides evidence in support of the FGN-HCV association, as well as introduces the association of FGN-HCV and hypocomplementemia. The case is a 53-year-old African-American female demonstrating a classical presentation of FGN complicated by a concomitant HCV infection. Treating an HCV infection with alpha-interferon has been shown to result in subsequent improvement in the nephrotic syndrome and renal function. However, this patient is unique in that she is complicated with hypocomplementemia, creating a complex treatment situation.