Nuclear Stress Testing Referrals: Time for a Novel Radiation Sparing Approach?

Background: A Science Advisory from the American Heart Association implores clinicians to always consider equivalent tests which do not use ionizing radiation. Intersocietal guidelines describe only two scenarios where a nuclear stress test is the only option for non-invasive evaluation: left bundle branch block (LBBB) and ventricular-paced rhythm; otherwise, treadmill EKG and stress echocardiography are feasible. This study sought to measure our compliance with appropriate use criteria,6 and then to apply our own Novel Radiation Sparing Approach (NRSA) to measure what percentage could have been evaluated without radiation. Methods: The appropriateness of each referral for nuclear stress testing was evaluated using the AUC. Our NRSA was then applied, reserving a grade of 'appropriate' for patients with LBBB, pacemaker, or known resting wall motion abnormalities. The rate of appropriate referrals was then compared using McNemar's test. Results: We analyzed 423 consecutive referrals between Aug 2010 and Feb 2012. Median age was 64 yr; males comprised 57.2% of all patients; and 64.8% were outpatient. Chest pain and dyspnea were the most common reasons for referral. The rate of appropriate referrals at our facility using the AUC was 93.6%. When applying our NRSA, nuclear stress testing was the required or 'appropriate' test in only 17.7% of our patients (p < 0.001, McNemar's test). Conclusions: According to the current AUC, our facility is referring patients appropriately for nuclear stress testing. However, by reserving nuclear stress testing primarily for patients with LBBB, pacemaker, and baseline wall motion abnormalities, we can reduce radiation exposure to our patients while still providing appropriate evaluation.

Congenital pericardial cyst in a naval special warfare candidate; clearance for diving after resection.

INTRODUCTION: We report the case of a 19-year-old male military recruit who presented for a screening physical for U.S. Naval Special Warfare and Diving Duty. During his screening physical examination, an exophytic pericardial cyst was discovered. Subsequent work-up revealed normal cardiopulmonary function despite this large 7-cm mass, but the candidate was disqualified due to concerns regarding the risk of complications. He underwent successful elective surgical resection without post-operative complications. One year post-operatively, he repeated his cardiopulmonary work-up with normal results and successfully completed training. METHODS: Literature search was conducted using PubMed/Medline. Keywords included pericardial/um, cyst, mediastinum, special operations, military, diving, thoracoscopy/ic resection. Results that included cases of pericardial cysts or other mediastinal tumors were included. RESULTS: Review of the literature reveals that complications are rare and range widely in severity. Analysis of the physiology of diving, together with absence of reported cases, suggest that there is little to no, increased risk in recreational scuba diving for subjects with asymptomatic lesions. While no cases of morbidity or mortality have been reported in elite athletes, the severe and repetitive trauma experienced by Special Operators raises clinical concern for these lesions. CONCLUSION: Because of the increased risk of morbidity and mortality in the Special Operations environment, clearance for duty should not be granted those individuals. However, in the general population, as well as with low-impact activities such as recreational scuba diving, periodic observation without resection seems reasonable.

Aspirin for primary prevention of coronary heart disease: using the Framingham Risk Score to improve utilization in a primary care clinic.

OBJECTIVES: Coronary heart disease (CHD) is the number one cause of death in adults in the industrialized world, and several large studies show that aspirin is helpful for the primary prevention of this disease. Unfortunately, few physicians are aware of its benefit, resulting in the underutilization of aspirin for the primary prevention of CHD. The purpose of this study was to demonstrate the underuse of aspirin for the primary prevention of CHD, and to improve appropriate utilization by implementing an easy-to-use clinic tool that quickly estimates a patient's risk. PATIENTS AND METHODS: This is a retrospective cohort analysis conducted in the Internal Medicine Clinic in the Naval Medical Center in San Diego, California. Random samples of 494 patients before and 593 after intervention who were followed in the Internal Medicine Clinic were screened. Inclusion criteria were a 10-year risk of myocardial infarction or coronary death of more than 10%, or diabetes with one other cardiac risk factor. A poster was placed in each clinic examination room showing the Framingham Risk Score, the indications for aspirin use, and common contraindications to assist physicians in determining if a patient warranted aspirin for primary prevention of CHD. A physician documented regular use of aspirin, 81 to 325 mg per day. RESULTS: Age and sex demographics were similar between the two measurement groups. Diabetics comprised a significantly greater percentage of patients in the postintervention group. There was a trend toward increase in utilization of aspirin from 63.5% to 72.8% (P = 0.054) after our intervention. In subgroup analysis, significant improvement in appropriate aspirin use was found amongst males (P = 0.01) and nondiabetics (P = 0.02). CONCLUSION: Aspirin has proven beneficial in the primary prevention of CHD, but is clearly underutilized in this role. By implementing the Framingham Risk Score to streamline the decision process, appropriate utilization can be improved, and in turn, cardiac events can be reduced and patients can benefit.