Incidental Extracardiac Findings of Technetium-99m Pyrophosphate Scintigraphy: A Pictorial Review.

Technetium-99m pyrophosphate (Tc-99m PYP) cardiac imaging is a simple, widely available, noninvasive method to identify patients with transthyretin-type cardiac amyloidosis (ATTR), and it has remarkably high diagnostic accuracy with very high sensitivity and specificity. Visual scores of 0, 1, 2, and 3 indicate non-myocardial uptake, uptake less than rib, equal to rib, and greater than rib uptake, respectively. Semiquantitative assessment using the heart-to-contralateral lung ratio of more than 1.5 at 1 hour accurately distinguishes ATTR from the cardiac amyloid light chain subtype. However, there are several incidental non-cardiac findings that can be seen in planar images, rotating single-photon emission computed tomography (SPECT) images, maximum intensity projection images, or computed tomography images acquired for attenuation correction. These findings may lead to the early detection of a noncardiac condition that may require additional treatment. The intent of this review is to demonstrate several incidental noncardiac abnormalities that have an impact on patient management and follow-up.

The association between low bone mineral density and coronary artery calcification in osteoporotic and non-osteoporotic patients in a tertiary center in Saudi Arabia.

BACKGROUND: Cardiovascular disease (CVD) and osteoporosis are major health-care concerns worldwide. The evidence is contradictory on whether a relationship exists between low bone mineral density (BMD) determined by dual-energy absorptiometry (DXA scan) and coronary artery calcification (CAC) measured by computed tomography. Currently, there are no data on patients from Saudi Arabia. OBJECTIVE: Examine the relationship between CAC and BMD in both genders and study the influence of traditional coronary artery disease (CAD) risk factors and osteoporosis. DESIGN: Retrospective, cross-sectional, analytical. SETTING: Single tertiary care center. PATIENTS AND METHODS: We searched radiology databases for patients who underwent both DXA and CAC score scanning within six months of each other. The inclusion criterion was an absence of any history of CAD. MAIN OUTCOME MEASURE: Association between osteoporosis and CAC. SAMPLE SIZE: 195 (34 osteoporosic, 161 normal BMD or osteopenic) RESULTS: Most of the study population (57.4%) were females. The mean age of all patients was 63.6 (10.1) years. Participants with CAC scores of 0 were significantly younger than those who had CAC scores >0. The presence of diabetes mellitus, hypertension, and hypercholesterolemia was higher in patients with CAC scores >0. CAC score and other CAD risk factors were not significantly different between the osteoporotic and nonosteoporotic groups, except for body mass index. A high CAC score (>100) was present in 28%, 20%, 11%, and 30% of participants with no osteoporosis, osteoporosis of the lumbar spine, osteoporosis of the femoral neck, and participants with osteoporosis of both the lumbar spine and femoral neck, respectively (P=.762), suggesting there is no association between CAC and the presence of osteoporosis. CONCLUSIONS: Osteoporosis is not associated with higher CAC scores in Saudi Arabia and CAD risk factors are not significantly prevalent in osteoporosis. It appears that CAC and osteoporosis are independent age-related diseases that share common risk factors. LIMITATIONS: Single-center, retrospective. CONFLICT OF INTEREST: None.

Breast arterial calcification on mammography does not predict coronary artery disease by invasive coronary angiography.

BACKGROUND: The relationship between breast arterial calcification (BAC) and angiographic coronary artery disease (CAD) is uncertain. Some studies have shown a positive association between BAC and angiographically proven CAD, while other studies have shown no association. OBJECTIVE: Examine the association between visually detected BAC on mammography and CAD found on invasive coronary angiography (ICA) in women and compare the frequency of risk factors for CAD between women with normal and abnormal ICA. DESIGN: Retrospective. SETTING: Single tertiary care center. PATIENTS AND METHODS: A review of the radiology databases was performed for female patients who underwent both ICA and mammography within six months of each other. Cases were excluded if there was a history of CAD, such as coronary artery bypass graft or prior percutaneous coronary intervention. MAIN OUTCOME MEASURES: BAC as a predictor of obstructive CAD on ICA. SAMPLE SIZE: 203 Saudi women RESULTS: The association between age at catheterization and ICA was statistically significant ( P=.01). There was no association between BAC and abnormal ICA ( P=.108). Women with abnormal ICA were older than women with a normal ICA ( P=.01). There was a higher frequency of CAD risk factors among the patients with abnormal ICA, except for smoking. In the multiple logistic regression model, ICA was associated with age, a family history of CAD, diabetes mellitus, hypertension and hypercholesterolemia. BAC-positive women were older than BAC-negative women ( P=.0001). BAC was associated with age, diabetes, hypertension, and chronic kidney disease in the multiple logistic regression model. CONCLUSIONS: BAC on mammography did not predict angiographically proven CAD. There was a strong association between BAC and age and many other conventional CAD risk factors. LIMITATIONS: Relatively small sample, single-center retrospective study. CONFLICT OF INTEREST: None.

Association between breast arterial calcifications found on mammography and coronary artery calcifications in asymptomatic Saudi women.

BACKGROUND: Currently, there are no data on the prevalence of breast arterial calcification (BAC) in Saudi women. Furthermore, there are no data on the relationship between BAC and coronary artery calcium score (CACS) as a coronary artery disease (CAD) risk factor in Saudi women who undergo mammography. OBJECTIVE: Examine the role of BAC as a potential female-specific risk factor for CAD in Saudi women in order to investigate the relationship between BAC and CACS in women who undergo a screening mammography, and study the relationship between BAC and CAD risk factors, including age, diabetes mellitus, hypertension, chronic kidney disease (CKD), dyslipidemia, and family history of CAD. DESIGN: Retrospective, medical records review. SETTING: Single tertiary care center. PATIENTS AND METHODS: The study cohort included women who had mammograms and a CACS scan, and for whom data on CAD risk stratification and CAD risk factors had been collected within one year of each other from 2014 to 2017. Women with CAD were excluded from the study. MAIN OUTCOME MEASURES: Breast arterial calcification as a marker for coronary artery disease. SAMPLE SIZE: 307 Saudi women. RESULTS: BAC was found in 142 (46%) patients in the study population. BAC+ women were significantly older than the BAC- women (P=.001), and a strong association was found between BAC and CACS (P=.0001), diabetes (P=.0001), hypertension (P=.021), and CKD (P=.0031). However, no association was found between BAC and tobacco smoking, dyslipidemia, and family history of CAD. In addition, a strong correlation was found between CACS and the components of the BAC score (P less than .001). Multivariate linear regression analysis revealed that age, CAC, and CKD are the only strong predictors of BAC. CONCLUSIONS: The proportion of BAC in Saudi women is 46%, and there may be a strong association between BAC and CAC, age, hypertension, and CKD. A large-scale prospective research study is necessary to validate the role of BAC on screening mammography as a CAD risk stratification tool and before routine reporting of BAC on a mammography report. LIMITATIONS: Because this was a retrospective study, patient selection bias cannot be excluded. CONFLICT OF INTEREST: None.

Prevalence and predictors of myocardial ischemia by preoperative myocardial perfusion single photon emission computed tomography in patients undergoing noncardiac surgery.

BACKGROUND: The prevalence and predictors of myocardial ischemia before noncardiac surgery are unknown. In addition the predictive value of myocardial perfusion single-photon emission computed tomography (SPECT) before noncardiac in individual patients is uncertain. OBJECTIVE: Evaluate the prevalence and predictors of myocardial ischemia before noncardiac surgery, and determine the postoperative cardiac outcome based on results of myocardial perfusion SPECT. DESIGN: Retrospective. SETTING: Single tertiary care center. PATIENTS AND METHODS: We reviewed the records of adult patients diagnosed with myocardial ischemia by myocardial perfusion SPECT who were undergoing noncardiac surgery. Myocardial perfusion SPECT had been performed within 4 weeks prior to noncardiac surgery requiring general anesthesia. MAIN OUTCOME MEASURES: Prevalence of abnormal myocardial perfusion SPECT results on preoperative evaluation; abnormal myocardial perfusion SPECT results as a predictor for postoperative cardiac events such as cardiac death, nonfatal myocardial infarction, and unstable angina. RESULTS: Of 131 patients who underwent noncardiac surgery from February 2015 to April 2016, 84 (64%) patients were female and the mean (SD) age was 64.1 (13.6) years. The prevalence of abnormal myocardial perfusion SPECT was 18% (24 of 131). Normal myocardial perfusion SPECT was highly predictive (up to 100%), but a positive myocardial perfusion SPECT had low positive predictive value (4%). Variables associated with an abnormal myocardial perfusion SPECT included ischemic heart disease, congestive heart failure, ASA score of 3 or more, limited exercise capacity (less than 4 METs), male sex, hypercholesterolemia, hypertension, smoking, and abnormal ECG. In a multivariable analysis, history of ischemic heart disease and history of smoking were significant predictors of abnormal myocardial perfusion SPECT (P=.001, and .029, respectively). CONCLUSIONS: Because of the low positive predictive value of myocardial perfusion SPECT, utilization of the technique in the workup of cardiac patients undergoing noncardiac surgery has been inappropriate. Myocardial perfusion SPECT should be restricted to only clearly defined appropriate use criteria. LIMITATIONS: Relatively small number of patients and retrospective design.

High prevalence of coronary artery calcification in Saudi patients with normal myocardial perfusion.

BACKGROUND: Normal single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) has a high negative predictive value for ischemic heart disease. Thus, the presence of subclinical coronary atherosclerosis detected by coronary artery calcification (CAC) score in patients who have under-gone SPECT MPI is unknown. OBJECTIVES: Determine the prevalence of coronary artery calcification (CAC) in patients with normal SPECT MPI and examine the association of CAC with conventional coronary artery disease (CAD) risk factors. DESIGN: Cross-sectional analytical study using medical records from February 2010 to April 2016. SETTINGS: Single tertiary-care center. PATIENTS AND METHODS: We studied patients referred from the outpatient clinical services for clinically indicated noninvasive CAD diagnosis with MPI SPECT. CAC scoring was subsequently performed within 3 months after a normal MPI. We excluded patients with chest pain or decompensated heart failure or patients with a history of CAD. The study population was divided into three groups: patients with a CAC score of 0, a CAC score from 1 to 300, and a CAC score more than 300. The groups were analyzed by age and other demographic and clinical characteristics. MAIN OUTCOME MEASURE(S): Prevalence of CAC in patients with normal MPI. RESULTS: The prevalence of CAC was 55% (n=114) in 207 patients with a mean (SD) age of 57.1 (10.4) years. Twelve percent had severe coronary atherosclerosis (CAC score > 300). All patients had a normal MPI SPECT. CAC scores were 0 for 93 patients (45%), 1 to 300 for 89 (43%), and more than 300 for 24 (12%). There was a strong association between CAC score and age (P < .0001), male sex (P < .0001), and diabetes mellitus (P=.042), but no association between CAC score and hypertension (P=.153), family history of CAD (P=.23), obesity (P=.31), hypercholesterolemia (P=.071), or smoking (P=.308). CONCLUSIONS: The prevalence of CAC is high in this study population of patients with normal SPECT MPI. Age, male sex and diabetes were risk factors associated with CAC. LIMITATIONS: Single center and small study population.

Hypoxemia and Right-to-Left-Shunt in Patient with Antiphospholipid Syndrome: A Case Report with Multimodality Imaging Findings and Literature Review.

This is a case report of an extremely rare cause of superior vena cava syndrome with systemic-to-pulmonary venous shunts, illustrated using different imaging modalities with successful SVC and IVC dilatation and stenting.

Noncompaction Cardiomyopathy: Case Presentation with Cardiac Magnetic Resonance Imaging Findings and Literature Review.

Left ventricular noncompaction cardiomyopathy is a very rare condition, yet believed to be often overlooked. It is thought to be caused by the developmental arrest in embryogenesis and characterized by an increase in the noncompacted, trabeculated myocardium adjacent to compacted myocardium in the left ventricular. The clinical presentations of this type of cardiomyopathy are of variable severity. Echocardiography used to be the diagnostic modality, but recent reports suggest that cardiac magnetic resonance imaging has higher sensitivity and specificity by showing a ratio of the noncompacted myocardium to compacted myocardium of >2.3.

Cardiac magnetic resonance imaging: A teaching atlas with emphasizing current clinical indications.

Cardiovascular magnetic resonance (CMR) is an amazing technology that continues to provide new innovative approaches for evaluating the heart and blood vessels. It can assess cardiac morphology, function, perfusion, viability, coronary and peripheral arteries, and metabolism and tissue characterization. The basic pulse sequences of CMR include; Spin Echo, Gradient echo, and Steady stet free precision. Current clinical indications of CMR are multiple and continuously evolving. CMR often works in complementary fashions to other cardiac imaging techniques or to resolve residual diagnostic dilemma. The purpose of this illustrative review is to review current clinical applications of CMR and to provide physicians and technologists with simple, and regular CMR cases form daily practice. Each case discusses briefly the related clinical history, followed by CMR imaging findings, and simple discussion to highlight the role of CMR in a particular cardiovascular disorder.