Predictive value of a positive stress single-photon emission computed tomography or stress cardiac magnetic resonance for ruling in obstructive coronary artery disease in a real-world setting.

INTRODUCTION AND OBJECTIVES: Randomized controlled trials comparing stress cardiac magnetic resonance (CMR) and single-photon emission computed tomography (SPECT) suggest similar diagnostic accuracy for detecting obstructive coronary artery disease (CAD). There are few data on whether this remains true in routine clinical practice. The aim of this study was to assess clinical and angiographic characteristics of patients undergoing invasive coronary angiography (ICA) after stress CMR or SPECT, and to compare their positive predictive value with published results from the CE-MARC trial. METHODS: In this retrospective tertiary-center analysis, we included 429 patients undergoing ICA after a positive stress CMR or positive SPECT performed within the previous 12 months. Obstructive CAD was defined as any coronary artery stenosis ≥50% in a vessel compatible with the ischemic territory on stress testing. RESULTS: Of the total 429 patients, 356 (83%) were referred after a positive SPECT, and 73 (17%) after a positive stress CMR. Patients did not differ according to age, cardiovascular risk factors, previous revascularization or left ventricular dysfunction, but patients with SPECT were more frequently male (p=0.046). The prevalence of obstructive CAD was similar in patients with positive SPECT vs. positive stress CMR (76.1% vs. 80.8%, respectively, p=0.385). The positive predictive values of both techniques were similar to those reported in the CE-MARC trial. CONCLUSION: In this tertiary center analysis, stress CMR and SPECT showed similar positive predictive values, comparable to those reported in the CE-MARC trial. This finding supports the emerging adoption of CMR in clinical practice for the diagnosis and management of CAD.

Five-year morbidity and mortality of patients with ischemia with non-obstructive coronary artery disease and myocardial single-photon emission computed tomography perfusion defects.

INTRODUCTION: Patients with angina and a positive single-photon emission computed tomography (SPECT) scan for reversible ischemia, with no or non-obstructive coronary artery disease (CAD) on invasive coronary angiography (ICA), represent a frequent clinical problem and predicting prognosis is challenging. METHODS: This was a retrospective single-center study on patients who underwent elective ICA with angina and a positive SPECT with no or non-obstructive CAD over a seven-year period. Cardiovascular morbidity, mortality, and major adverse cardiac events were assessed during a follow-up of at least three years after ICA, with the aid of a telephone questionnaire. RESULTS: Data on all patients who underwent ICA in our hospital over a period of seven years (between January 1, 2011 and December 31, 2017) were analyzed. A total of 569 patients fulfilled the pre-specified criteria. In the telephone survey, 285 (50.1%) were successfully contacted and agreed to participate. Mean age was 67.6 (SD 8.8) years (35.4% female) and mean follow-up was 5.53 years (SD 1.85). Mortality was 1.7% (four patients, from non-cardiac causes), 1.7% underwent revascularization, 31 (10.9%) were hospitalized for cardiac reasons and 10.9% reported symptoms of heart failure (no patients with NYHA class>II). Twenty-one had arrhythmic events and only two had mild anginal symptoms. It was also noteworthy that mortality in the uncontacted group (12 out of 284, 4.2%), derived from public social security records, did not differ significantly from the contacted group. CONCLUSIONS: Patients with angina, a positive SPECT for reversible ischemia and no or non-obstructive CAD on ICA have excellent long-term cardiovascular prognosis for at least five years.

Consensus document on chronic coronary syndrome assessment and risk stratification in Portugal: A position paper statement from the [Portuguese Society of Cardiology's] Working Groups on Nuclear Cardiology, Magnetic Resonance and Cardiac Computed Tomography, Echocardiography, and Exercise Physiology and Cardiac Rehabilitation. / Documento de Consenso sobre Estratificação de Risco Cardiovascular e estudo da doença coronária em Portugal: a posição dos Grupos de Estudo de Cardiologia Nuclear, Ressonância Magnética e Tomografia Computorizada Cardíaca, de Ecocardiografia e de Fisiopatologia do Esforço e Reabilitação Cardíaca.

Despite constant medical evolution, the reimbursement policy of Portuguese National Health Service (NHS) for the study and risk stratification of coronary heart disease has remained unchanged for several decades. Lack of adjustment to contemporary clinical practice has long been evident. However, the recent publication of the European Guidelines for diagnosis and treatment of chronic coronary syndromes further highlighted this gap and the urgent need for a change. Prompted by these Guidelines, the Working Group on Nuclear Cardiology, Cardiac Magnetic Resonance and Cardiac CT, the Working Group on Echocardiography and the Working Group on Stress Pathophysiology and Cardiac Rehabilitation of the Portuguese Society of Cardiology, began a process of joint reflection on the current limitations and how these recommendations could be applied in Portugal. To this end, the authors suggest that the new imaging methods (stress echocardiogram, cardiac computed tomography and cardiac magnetic resonance), should be added to exercise treadmill stress test and myocardial perfusion scintigraphy in the available exam portfolio within the Portuguese NHS. This change would allow full adoption of European guidelines and a better use of tests, according to clinical context, availability and local specificities. The adoption of clinical guidance standards, based on these assumptions, would translate into a qualitative improvement in the management of these patients and would promote an effective use of the available resources, with potential health and financial gains.

La gammagrafía de perfusión miocárdica en la cardiopatía isquémica / Myocardial Perfusion Scintigraphy in Ischemic Heart Disease

RESUMEN Fundamento la cardiopatía isquémica presenta una gran prevalencia y mortalidad en Cuba y en países desarrollados. La gammagrafía de perfusión miocárdica es un método diagnóstico no invasivo que facilita el diagnóstico y la toma de decisiones médicas. Objetivo: demostrar el valor de la gammagrafía de perfusión miocárdica en el pronóstico de la cardiopatía isquémica. Método se realizó un estudio descriptivo, de corte longitudinal, prospectivo en un universo de 180 pacientes, que se realizaron estudios de perfusión miocárdica para detectar isquemia, desde enero del 2018 a diciembre del 2019 en el Centro de Investigaciones Médico Quirúrgicas. Las variables estudiadas fueron: características clínico-demográficas (edad, sexo), los factores de riesgo aterogénicos y el dolor torácico. Las variables cualitativas se expresaron en frecuencia y porcentaje y las variables cuantitativas continuas en valores de media y desviación estándar según su distribución y Chi cuadrado. Se tomó como intervalo de confianza el 95 %, con una p < 0,05 para la aceptación e interpretación de los resultados. Resultados el 53,3 % de los pacientes fueron hombres y el 78,3 % padecían hipertensión arterial. Se realizó la prueba de estrés físico para la detección de isquemia al 76,1 %. Predominó el resultado negativo en el 58,9 %; con una evolución clínica al año de solo el 2,8 % con eventos isquémicos. Se demostró isquemia en la perfusión miocárdica al 41,1 %, confirmándose lesiones obstructivas coronarias significativas al 82,4 %. Al año de evolución clínica el 97,3 % desarrolló eventos isquémicos. La caída >10 % de la fracción de eyección ventricular izquierda post-estrés evidenció eventos isquémicos en el 100 % de los pacientes. Conclusiones la gammagrafía de perfusión miocárdica es una técnica no invasiva confiable en el diagnóstico de la cardiopatía isquémica. Aportó seguridad pronóstica a largo plazo tras el resultado negativo de la perfusión miocárdica. La caída de la fracción de eyección ventricular izquierda post-estrés se comportó como una variable predictiva de realizar futuros eventos cardiacos.

ABSTRACT Background: ischemic heart disease has a high prevalence and mortality in Cuba and in developed countries. Myocardial perfusion scintigraphy is a non-invasive diagnostic method that facilitates diagnosis and medical decision-making. Objective: to demonstrate the value of myocardial perfusion scintigraphy in the ischemic heart disease prognosis. Method: a descriptive, prospective longitudinal section study was carried out in 180 patients, in which myocardial perfusion studies were performed to detect ischemia, from January 2018 to December 2019 at the Center for Surgical Medical Research. The variables studied were: clinical-demographic characteristics (age, sex), atherogenic risk factors and chest pain. The qualitative variables were expressed in frequency and percentage and the continuous quantitative variables in mean and standard deviation values according to their distribution and chi square. The 95 % confidence interval was taken, with a p <0.05 for the acceptance and interpretation of the results. Results: the 53.3 % of the patients were men and 78.3 % suffered from arterial hypertension. The physical stress test was performed to detect ischemia at 76.1 %. The negative result predominated in 58.9 %; with a clinical evolution at one year of only 2.8 % with ischemic events. Ischemia was demonstrated in myocardial perfusion in 41.1 %, confirming significant coronary obstructive lesions in 82.4 %. After one year of clinical evolution, 97.3 % developed ischemic events. The drop> 10 % in the post-stress left ventricular ejection fraction showed ischemic events in 100 % of the patients. Conclusions: myocardial perfusion scintigraphy is a reliable non-invasive technique in the ischemic heart disease diagnosis. It provided long-term prognostic security after the negative myocardial perfusion result. The fall in the post-stress left ventricular ejection fraction behaved as a predictive variable of future cardiac events.

Aproximación diagnóstica a la amiloidosis cardiaca por transtiretina en un área no endémica. ¿Qué variables no invasivas orientan a su diagnóstico? / Diagnostic approach to transthyretin amyloidosis in a non-endemic area. Which non-invasive variables could guide the diagnosis?

Al editor: Clásicamente se ha considerado la amiloidosis cardiaca como una afección rara, con un amplio espectro de síntomas que requiere un alto índice de sospecha. Sin embargo, los estudios han demostrado que la amiloidosis cardiaca por transtiretina (TTR) es más común de lo que previamente se creía1,2. Las características clínicas que se han asociado a la amiloidosis cardiaca por TTR son el sexo masculino, la edad avanzada, la hipertrofia concéntrica y la función ventricular izquierda preservada1. Se realizó un análisis descriptivo retrospectivo de las gammagrafías solicitadas en nuestro centro para descartar amiloidosis cardiaca por TTR desde septiembre de 2016 hasta noviembre de 2019. En dicho periodo se realizaron 39 gammagrafías, con una tendencia al alza en los últimos meses. Los objetivos fueron evaluar las gammagrafías solicitadas y conocer el porcentaje de gammagrafías diagnósticas de amiloidosis por TTR, establecer qué características son más frecuentes en los pacientes con amiloidosis por TTR en nuestra población de referencia y analizar las características diferenciales de las distintas posibilidades diagnósticas. Del total de las pruebas, 22 (56.4% de la muestra) mostraron una captación de grado 2-3 de Perugini, diagnóstica de amiloidosis por TTR. De acuerdo con las recomendaciones de diagnóstico no invasivo de amiloidosis cardiaca por TTR3, se descartó la presencia de pico monoclonal. Únicamente se realizó estudio genético a 10 pacientes, en dos de los cuales se detectó una mutación patogénica (Val50Met y variante patogénica c.290C>A en heterocigosis); los ocho restantes no mostraron mutaciones en el estudio molecular del gen TTR.

Exertional chest pain is sometimes more than just coronary atherosclerosis.

CLINICAL CASE: A 64-year-old male, with cardiovascular risk factors and previous history of bilateral carpal tunnel syndrome, presented with exertional retrosternal pain. The resting echocardiogram was unremarkable. A stress echocardiogram with dobutamine revealed hypokinesis of the inferior wall, associated with angina, followed by ventricular tachycardia. The coronary angiography revealed slow flow, a dominant right coronary artery with non-obstructive atherosclerosis and a left anterior descending artery with intermediate lesions in mid and distal segments. The invasive functional evaluation, including fractional flow reserve, thermodilution coronary flow reserve and index of microvascular resistance, led to the diagnosis of microvascular angina, treated with calcium channel blockers and transdermal nitrate, giving symptom relief. EVOLUTION: Three years later he developed complete atrioventricular block and a dual chamber pacemaker was implanted. Shortly after, the patient developed progressive symmetrical tetraparesis, associated with marked muscle atrophy, hand numbness, orthostatic hypotension and dysphagia. The neurology workup led to the diagnosis of familial amyloidotic polyneuropathy, with the Val30Met mutation in the transthyretin gene. The following year he developed congestive heart failure. The echocardiogram showed moderate concentric left ventricular hypertrophy with preserved ejection fraction. A 99mTc-DPD Scintigraphy showed significant myocardial tracer uptake, leading to a diagnosis of TTR amyloid infiltration. DISCUSSION: Patients with exertional angina and microvascular disease should be kept under close surveillance, as they may have systemic disease with cardiac involvement. Carpal tunnel syndrome, in the context of undiagnosed cardiac disease, should trigger suspicion of cardiac amyloidosis.

Concordance between estimated glomerular filtration rate using equations and that measured using an imaging method / Concordancia entre la tasa de filtración glomerular estimada con ecuaciones y aquella medida mediante imágenes

ABSTRACT Background: Guidelines recommend estimating glomerular filtration rate (GFR) using creatinine-based equations (CBE). AIM: To evaluate the agreement between GFR measured using radionuclide imaging and estimated using creatinine-based equations. MATERIAL AND METHODS: In 421 patients aged 54 ± 17 years (47% women) GFR was estimated using the MDRD-4, CKD-EPI and the body surface adjusted Cockroft Gault equation. GFR was also measured using a radionuclide imaging method with 99mTc-DTPA. The concordance between estimated and measured GFR was calculated using Lin's concordance coefficient and Bland and Altman plots. RESULTS: Average GFR values obtained with CKD-EPI, MDRD-4, body surface adjusted Cockroft Gault equation and 99mTc-DTPA imaging were 75.9 ± 26.6, 76.3 ± 28.8, 77.1 ± 31.6 and 77.9 ± 28.4 ml/min/1.73 m2, respectively. There was no significant difference in means and 29% of participants had a GFR < 60 ml/min/1.73 m2 by CKD-EPI. The correlation was good between equations, but acceptable when compared with the 99mTc-DTPA imaging. The weighted kappa between CBEs was good, but low when comparing CBEs with measured GFR. The Lin's concordance coefficient between estimated and measured GFR was low. Conclusions: GFR measured by 99mTc-DTPA radionuclide imaging has a low correlation and poor concordance with estimations using CBE.

ANTECEDENTES: Las guías clínicas recomiendan estimar la tasa de filtración glomerular (TFG) usando ecuaciones basadas en la creatinina sérica. Objetivo: Estudiar la concordancia entre la TFG medida usando un método de imágenes usando radioisótopos y aquella estimada con ecuaciones. MATERIAL Y MÉTODOS: En 421 pacientes de 54 ± 17 años (47% mujeres), la TFG se estimó utilizando las ecuaciones MDRD-4, CKD-EPI y Cockroft Gault ajustada para superficie corporal. La TFG se midió también con una técnica de imágenes usando 99mTc-DTPA. La concordancia entre la estimación y medición se calculó usando el coeficiente de concordancia de Lin y gráficos de Bland y Altman. RESULTADOS: Los promedios de TFG obtenidos con CKD-EPI, MDRD-4, ecuación de Cockroft Gault e imágenes con 99mTc-DTPA fueron 75,9 ± 26,6, 76,3 ± 28,8, 77,1 ± 31,6 y 77,9 ± 28,4 ml/min/1,73 m2, respectivamente. No hubo diferencias significativas en los promedios y el 29% de los participantes tuvo una TFG < 60 ml/min/1,73 m2. La correlación entre las ecuaciones fue buena, pero sólo aceptable cuando se comparó con la medición por imágenes. El kappa ajustado entre las ecuaciones fue adecuado, pero malo cuando se comparó las ecuaciones con la medición por imágenes. El coeficiente de Lin mostró una baja concordancia entre la estimación y medición de TFG. Conclusiones: La concordancia entre la estimación de TFG usando ecuaciones y su medición directa mediante imágenes es baja.

Hiperparatiroidismo primario: reporte de caso clínico / Primary Hyperparathyroidism: Case report

Antecedentes: El hiperparatiroidismo primario, tercer trastorno metabólico más común a nivel mundial, provoca un aumento del calcio sérico y de la hormona paratiroidea, causado por una hiperactividad de las glándulas paratiroideas. En el 85% de los casos, se debe a un adenoma paratiroideo. Es predominantemente asintomático (>80%), pero sus manifestaciones pueden ser musculo-esqueléticas, neurológicas, psiquiátricas, renales, cardiovasculares, y gastrointestinales. Descripción del Caso Clínico: Paciente femenina de 53 años de edad, con antecedente de hipercolesterolemia familiar heterocigoto e hipertensión arterial; presenta insomnio, náuseas, pérdida de peso, mialgias, astenia, relujo gastroesofágico e irritabilidad. Ante indicación de exámenes de labo-ratorio muestra hipercalcemia leve. Se comprueba un adenoma paratiroideo derecho y nódulos tiroideos coloides benignos en lóbulo izquierdo mediante gammagrafía Tc99m MIBI, siendo sometida a su resección con posterior evolución satisfactoria. Conclusiones: Considerando la predilección asintomática del hiperparatiroidismo primario y su preferencia de presentación como adenoma, resulta indispensable su sospecha ante toda hipercalcemia. Requiere entonces una concientización amplia no solo en el ámbito médico sino también en la comunidad, ampliando esfuerzos entre el clínico, cirujano, y patólogo. Se recomienda medir el calcio y fósforo sérico de forma rutinaria en la evaluación clínica cotidiana de cada paciente para su detección...(AU)

Poliartritis asimétrica con distribución en rayo / Asymmetrical arthritis with ray pattern distribution

Resumen Se presenta una imagen gammagráfica que muestra en forma didáctica características típicas de la artritis psoriásica.

Abstract A scintigraphic image is presented that shows the typical characteristics of psoriatic arthritis as a teaching aid.

Amiloidosis cardiaca: estudio de caso y revisión bibliográfica / Cardiac amyloidosis: Case study and bibliographic review

Resumen La amiloidosis es una enfermedad multisistémica, originada por un plegamiento proteico anormal el cual a su vez genera su depósito y acumulación en diferentes tejidos. A nivel cardiovascular, el amiloide se deposita en el tejido miocárdico generando las manifestaciones típicas de la enfermedad. Presenta hallazgos electrocardiográficos y ecocardiográficos distintivos que proporcionan una ayuda invaluable en el diagnóstico de la amiloidosis cardiaca. En el presente artículo se expone un caso de un paciente portador de amiloidosis AL, quien exhibe síntomas de falla cardiaca y en el cual se documenta posteriormente severo compromiso cardiovascular. Además, se presenta una revisión de las manifestaciones cardiovasculares y el diagnóstico de dicha patología.

Abstract Amyloidosis is a multisystemic disease, originated by an abnormal protein folding which in turn generates its deposit and accumulation in different tissues. At a cardiovascular level, amyloid is deposited in the myocardial tissue and thus generating the typical manifestations of the disease. It presents distinctive electrocardiographic and echocardiographic findings that provide invaluable help in the diagnosis of cardiac amyloidosis. In this article, a case of a patient with AL amyloidosis is presented. Said patient developed symptoms of heart failure, which later progressed into severe cardiovascular compromise. Furthermore, a review of the cardiovascular manifestations and the diagnosis of said pathology is presented.

Block resection of lumbar osteoblastoma. presentation of a case and bibliographical update / Ressecção em bloco do osteoblastoma lombar. apresentação de um caso e atualização bibliográfica / Resección en bloque de osteoblastoma lumbar. presentación de un caso y actualización bibliográfica

ABSTRACT Objective: To present the clinical case and update the bibliography. Methods: A male patient, 24 years of age, sought treatment for right lumbosciatalgia of 3 years of evolution with topography L5 and motor deficit (M4). The radiograph showed a radiopaque lesion between the fourth and fifth lumbar vertebrae, with right pedicle effacement of L4. The tomography identified a lytic lesion, partially surrounded by sclerosis with a central nest of 3 centimeters in diameter located in the right pedicle with involvement of the transverse apophysis and reaction of the intertransverse space (Enneking 3). It was complemented by magnetic resonance and bone scintigraphy. The percutaneous biopsy guided by tomography yielded a diagnosis of osteoblastoma and foci of necrosis. A radical block resection was performed with clear tumor margins and instrumented stabilization. Results: After the surgical treatment, the patient evolved favorably, reversing the motor deficit. The anatomopathological study of the specimen confirms the preoperative diagnosis. Discussion: Intralesional resection may be an option in Enneking stage 2. In Enneking stage 3, a percutaneous diagnostic biopsy may be useful, and block resection is the preferred definitive treatment. Conclusions: The management of spinal osteoblastoma requires an exhaustive clinical-imaging analysis. Block resection with clear margins is preferred in advanced cases for management and to decrease the risk of recurrence. Level of Evidence IV; Case seriesh.

RESUMO Objetivo: Apresentar caso clínico e atualizar bibliografia. Material e Método: Masculino, 24 anos de idade, consultado devido a lombociatalgia direita com três anos de evolução, com topografia L5 e déficit motor (M4). A radiografia mostra uma lesão radiopaca entre a quarta e a quinta vértebras lombares, com obliteração do pedículo direito de L4. A tomografia identifica uma lesão lítica parcialmente circundada por esclerose, com um ninho central de três centímetros de diâmetro localizado no pedículo direito com acometimento do processo transverso e reação do espaço intertransversário (Enneking 3). É complementado com ressonância magnética e cintilografia óssea, biópsia percutânea guiada por tomografia diagnóstica: osteoblastoma e focos de necrose. A ressecção radical foi realizada em bloco, com margens livres do tumor e estabilização instrumentada. Resultados: Após o tratamento cirúrgico o paciente evoluiu favoravelmente, revertendo o déficit motor. O estudo anatomopatológico da peça confirma o resultado pré-operatório. Discussão: A ressecção intralesional pode ser uma opção nos estágios de Enneking 2. Nos estágios de Enneking 3, uma biópsia diagnóstica percutânea pode ser útil e a ressecção em bloco é preferida como um tratamento definitivo. Conclusão: O manejo do osteoblastoma espinal requer uma análise clínica e imagética exaustiva. A ressecção de bloco com margens livres é preferida em casos avançados para o gerenciamento e para diminuir o risco de recorrência. Nível de Evidência IV; Série de casosh.

RESUMEN Objetivo: Presentar un caso clínico y actualizar bibliografía. Métodos: Un paciente de sexo masculino, 24 años de edad, buscó tratamiento para lumbociatalgia derecha de 3 años de evolución, con topografía L5 y déficit motor (M4). La radiografía mostró lesión radiopaca entre la cuarta y quinta vértebra lumbar, con borramiento pedicular derecho de L4. La tomografía identificó lesión lítica rodeada parcialmente de esclerosis, con nido central de 3 centímetros de diámetro ubicada en el pedículo derecho con afectación de la apófisis transversa y reacción del espacio intertransversario (Enneking 3). La tomografía fue complementada con resonancia magnética y gammagrafía ósea. La biopsia percutánea guiada por tomografía produjo diagnóstico de osteoblastoma y focos de necrosis. Se llevó a cabo la resección radical en bloque con márgenes libres del tumor y estabilización instrumentada. Resultados: Luego del tratamiento quirúrgico, el paciente ha evolucionado favorablemente, revirtiendo el déficit motor. El estudio anatomopatológico de la pieza confirma el diagnóstico preoperatorio. Discusión: La resección intralesional puede ser una opción en los estadios Enneking 2. En los estadios Enneking 3, puede ser útil la realización de una biopsia percutánea diagnostica, y como tratamiento definitivo se prefiere la resección en bloque. Conclusiones: El manejo del osteoblastoma espinal requiere un exhaustivo análisis clínico-imagenológico. La resección en bloque con márgenes libres es preferida en los casos avanzados para el manejo y disminuir el riesgo de recidivas. Nivel de Evidencia IV; Serie de casosh.

Phase analysis for the assessment of left ventricular dyssynchrony by Gated Myocardial Perfusion SPECT. Importance of clinical and technical parameters / Análisis de fase para la valoración del sincronismo mecánico del ventrículo izquierdo mediante Gated-SPECT de perfusión miocárdica. Importancia de los parámetros clínicos y técnicos

Abstract Introduction: Phase analysis (PA) of the left ventricle is a new tool in nuclear cardiology studies used to assess left ventricular mechanical timing based on different clinical applications. However, the use of this tool is relatively unknown. Objective: To expose the feasibility of the new PA tool in myocardial perfusion (Gated-SPECT) to assess left ventricle mechanical timing, and to verify the differences between values depending on clinical and technical conditions. Materials and methods: The study included consecutive patients evaluated by Gated-SPECT. The main variables were different depending on clinical and technical conditions. PA was assessed using the PHASE tool of the QPS-QGS program (Cedars-Sinai Medical Center, Los Angeles, USA). The following parameters were obtained: histogram bandwith (HB), standard deviation (SD) and entropy (E). A descriptive and analytical analysis of means and/or medians was performed using parametric or non-parametric tests. Statistical significance was p <0.05. IBM-SPSS V21® was used. Results: 300 patients were included in this study with a mean age of 65±12.7. No differences were found in relation to the study phase (stress-rest) [HB (p=0.4), SD (p=0.6), E (p=0.8)], stress type [HB (p=0.38), SD (p=0.8), E (p=0.06), E (p=0.06)], dose used [HB (p=0.19), SD (p=0.05), E (p=0.06)], gamma camera [HB (p=0.02), SD (p=0.06), E (p=0.08)], or history of coronary heart disease [HB (p=0.44), SD (p=0.18), E (p=0.17)]. Furthermore, differences in conduction disorders were observed [HB (p=0.001), SD (p=0.02), E (p=0.001)], ejection fraction < or >35% (p=0.001), E (p=0.001)] normal or necrosis study [HB (p=0.001), SD (p=0.001), E (p=0.001)], and gender [HB (p=0.002), SD (p=0.006), E (p=0.005)]. Conclusions: The new PA tool of nuclear medicine is feasible in our context. The type of stress, the administered dose, the study phase or the gamma camera used did not affect the parameters. However, gender, interventricular conduction disorders, necrosis and systolic dysfunction did have an impact on them.

Resumen Introducción. El análisis de fase (AF) del ventrículo izquierdo es una herramienta de reciente introducción en los estudios de cardiología nuclear, que permite valorar el sincronismo mecánico de la contracción del ventrículo izquierdo con diferentes aplicaciones clínicas, si bien es poco conocida. Objetivo. Mostrar la factibilidad de la nueva herramienta AF por perfusión miocárdica (Gated-SPECT) para valorar el sincronismo mecánico del ventrículo izquierdo y verificar diferencias entre sus valores, según situaciones clínicas y condiciones técnicas. Materiales y métodos. En el estudio participaron pacientes consecutivos con Gated-SPECT. Las variables principales fueron diferentes condiciones clínicas y técnicas. La valoración del AF se realizó mediante la herramienta FASE del programa cardiodedicado (QPS-QGS, Cedars-Sinai Medical Center, Los Angeles, USA). Se obtuvieron los siguientes parámetros: ancho del histograma (AH), desviación estandar de la fase (DE) y entropía (E). Se realizó análisis descriptivo y analítico de medias o medianas a través de test paramétricos o no paramétircos. El límite de significancia estadísitca fue p<0.05. Se utilizó IBM-SPSS V21®. Resultados. Con un total de 300 pacientes y una media de edad de 65±12.7, en el análisis del AF no existieron diferencias según la fase del estudio (estrés-reposo) [AH (p=0.4), DE (p=0.6), E (p=0.7)], tipo de estrés [AH (p=0.38), DE (p=0.8), E (p=0.84)], dosis utilizada [AH(p=0.19), DE (p=0.05), E (p=0.06)], gammacámara [AH (p=0.02), DE (p=0.06), E (p=0.08)] ni entre antecedente de enfermedad coronaria [AH (p=0.44), DE (p=0.18), E (p=0.17)]. Hubo diferencias según trastornos de conducción [AH (p=0.001), DE (p=0.02), E (p=0.001)], fracción de eyección < o >35% [AH (p=0.001), DE (p=0.001), E (p=0.001)], estudio normal o con necrosis [AH (p=0.001), DE (p=0.001), E (p=0.001)] y género [AH (p=0.002), DE (p=0.006), E (p=0.005)]. Conclusiones. El uso de la nueva herramienta del AF de medicina nuclear es factible. Sus parámetros no se afectaron por el tipo de estrés producido, dosis administrada o fase del estudio por la gammacámara empleada. Por su parte, sí fueron afectados por género, trastornos de conducción interventricular, necrosis y disfunción sistólica.

Progression of myocardial sympathetic denervation assessed by 123I-MIBG imaging in familial amyloid polyneuropathy and the effect of liver transplantation. / Progressão da desnervação simpática cardíaca avaliada por cintigrafia com MIBG­I123 na polineuropatia amiloidótica familiar e o impacto da transplantação hepática.

INTRODUCTION: Familial amyloid polyneuropathy (FAP) is a rare disease caused by systemic deposition of amyloidogenic variants of the transthyretin (TTR) protein. The TTR-V30M mutation is caused by the substitution of valine by methionine at position 30 and mainly affects the peripheral and autonomic nervous systems. Cardiovascular manifestations are common and are due to autonomic denervation and to amyloid deposition in the heart. Cardiac sympathetic denervation detected by iodine-123 labeled metaiodobenzylguanidine (MIBG) is an important prognostic marker in TTR-V30M FAP. Liver transplantation, widely used to halt neurological involvement, appears to have a varying effect on the progression of amyloid cardiomyopathy. Its effect on the progression of cardiac denervation remains unknown. METHODS: In this observational study, patients with the TTR-V30M mutation underwent annual cardiac assessment and serial MIBG imaging with quantification of the late heart-to-mediastinum (H/M) ratio. RESULTS: We studied 232 patients (median age 40 years, 54.7% female, 37.9% asymptomatic at the time of inclusion) who were followed for a median of 4.5 years and underwent a total of 558 MIBG scans. During follow-up, 47 patients (20.3%) died. MIBG scintigraphy at inclusion was a strong predictor of prognosis, with the risk of death increasing by 27.8% for each one-tenth reduction in the late H/M ratio. The late H/M ratio decreased with age (0.082/year, p<0.001), but progression of cardiac denervation was so slow that annual repetition of MIBG imaging did not increase its prognostic accuracy. During follow-up, 70 symptomatic patients underwent liver transplantation. The late H/M ratio decreased by 0.19/year until transplantation but no statistically significant differences were detected after the procedure. CONCLUSIONS: Cardiac denervation is common during the progression of TTR-V30M FAP and quantification of the late H/M ratio on MIBG scintigraphy is valuable for prognostic stratification of these patients. Liver transplantation stabilizes cardiac denervation, without recovery or further deterioration in cardiac MIBG uptake after the procedure.

Análisis de fase mediante "Gated-SPECT" de perfusión miocárdica para valorar el sincronismo mecánico del ventrículo / Phase analysis to measure left ventricular dyssynchrony by Gated-SPECT myocardial perfusion imaging showed by two different software

Resumen Introducción y objetivos: El análisis de fase mediante Gated-SPECT de perfusión miocárdica (GS-PMI) es una nueva herramienta para medir la asincronía ventricular izquierda con importantes aplicaciones clínicas futuras en resincronización e insuficiencia cardiaca. Se puede medir mediante dos programas (ECTb o QGS C-S). El objetivo es demostrar su factibilidad y verificar si existen diferencias entre ambos. Metodología: Estudio analítico, observacional y retrospectivo en pacientes con GS-PMI normales. Los parámetros obtenidos fueron: la desviación estándar de la fase (DE) y el ancho de banda de histograma (AH). La evaluación de la diferencia entre los grupos se realizó usando pruebas para muestras independientes después de analizar la distribución de datos. Nivel de significación p<0,05. Se utilizó SPSS IBM V.21®. Resultados: Total pacientes: 193 (104 hombres). Edad media: 64 años (24-89).61/193 procesados con QGS C-S y 132/193 con ECTb. Postestrés: la media de la DE fue 6º±3,7º, con mediana de 5º y rango intercuartílico (IR):3.6º. La media de AH fue 22,7º±10º, con mediana de 18º y IR:11.5º. Postreposo: la media de la DE fue 5,76º±4,82º y la mediana 4,5º con IR: 3.1º. La media de AH fue 21.67º± 14.06º y la mediana 18º, IR:12º. Entre ambos programas se encontraron diferencias significativas en la DE en postestrés (p=0,001) y postreposo (p=0,019), sin diferencias en el AH postestrés (p=0,31) y postreposo (p=0,18). Conclusión: Realizar el análisis fase de análisis por GS-PMI es factible. Sin embargo, la DE mostró diferencias significativas entre los dos programas. Aunque los valores mostrados podrían ser utilizados como valores normales, se recomienda que estos se obtengan y utilicen para cada programa por separado.

Abstract Introduction and objectives:Phase analysis by Gated-SPECT myocardial perfusion imaging (G-MPI) is a new tool to measure left ventricular dyssynchrony with important clinical applications in near future (heart failure and resynchronization) and can be measured by two software (ECTb o QGS C-S). The aim is to show its feasibility and verify whether there is difference between the programs. Methodology: Analytical observational and retrospective study in patients with normal G-MPI. The parameters were the phase standard deviation (SD) and the histogram bandwidth (HB) in post-stress and rest tests. Assessment of the difference between groups was performed using tests for independent samples after analyze the distribution of data. The significance level (p) was 0,05 and the software used was SPSS IBM V.21® Results: Total:193 patients (104 men).64 years old ± (24-89).61/193 processed with QGS C-S and 132/193 with ECTb. Post-stress tests: mean of the SD was 6º±3.7º,the median was 5º,interquartile range (IR):3.6º.The mean of HB was 22.7º±10º and the median was 18º IR:11.5º. Post-rest tests: mean of the SD was 5.76º±4.82º and median was 4.5º IR: 3.1º.The overall mean of HB was 21.67º±14.06º and median was 18º IR: 12º. Between the data from both software, significant differences were found in SD in post-stress(p=0.001)and post-rest tests(p=0.019)and no significant differences were found in HB in post-stress(p= 0.31)or post-rest tests(p=0.18). Conclusion: Phase analysis by G-MPI is feasible. However SD showed significant differences between the two groups. Although the values showed could be used as normal values, it is recommended that these have to be obtained and used for each software separately.

Presentación atípica de una metástasis ósea del pulmón / Présentation atypique d'une métastase osseuse de poumon / Unusual occurrence of osseous metastasis of the lung

Se presenta un paciente masculino de 49 años con antecedentes de Neoplasia de pulmón el cual acude por dolor y aumento de volumen en el miembro inferior izquierdo. Los estudios imaginológicos (radiografías, tomografía computarizada, gammagrafía) sugerían una miositis osificante del tercio medio de la diáfisis femoral izquierda, debido al compromiso de partes blandas, ya que es poco frecuente visualizarlo como una metástasis, pero el diagnóstico histopatológico fue el de una lesión metastásica(AU)

Here is the case of a 49 years-old male patient with a history of lung neoplasia that went to the doctor's because of pain and inflammation of his left leg. Imaging studies including X-rays, CT and scintigraphy indicated ossifying myositis in the medial third of the left femoral diaphysis due to compromised soft tissues, but the histopathological diagnosis showed a metastatic injure(AU)

Un patient âgé de 49 ans, avec des antécédents de néoplasie de poumon, est vu en consultation due à une douleur et à un grossissement du membre inférieur gauche. L'imagerie (radiographie, tomographie axiale informatisée, scintigraphie) a suggéré une myosite ossifiante au niveau du tiers moyen de la diaphyse fémorale gauche due à une lésion des parties molles. Puisque la métastase est difficile à distinguer, un test histologique a confirmé la lésion métastatique(AU)

Presentación atípica de una metástasis ósea del pulmón / Unusual occurrence of osseous metastasis of the lung

Se presenta un paciente masculino de 49 años con antecedentes de Neoplasia de pulmón el cual acude por dolor y aumento de volumen en el miembro inferior izquierdo. Los estudios imaginológicos (radiografías, tomografía computarizada, gammagrafía) sugerían una miositis osificante del tercio medio de la diáfisis femoral izquierda, debido al compromiso de partes blandas, ya que es poco frecuente visualizarlo como una metástasis, pero el diagnóstico histopatológico fue el de una lesión metastásica(AU)

Here is the case of a 49 years-old male patient with a history of lung neoplasia that went to the doctor's because of pain and inflammation of his left leg. Imaging studies including X-rays, CT and scintigraphy indicated ossifying myositis in the medial third of the left femoral diaphysis due to compromised soft tissues, but the histopathological diagnosis showed a metastatic injure(AU)

Is thyroid stunning clinically relevant? A retrospective analysis of 208 patients / O atordoamento da tireoide é clinicamente relevante? Análise retrospectiva de 208 pacientes

Objective : Current guidelines have advised against the performance of 131I-iodide diagnostic whole body scintigraphy (dxWBS) to minimize the occurrence of stunning, and to guarantee the efficiency of radioiodine therapy (RIT). The aim of the study was to evaluate the impact of stunning on the efficacy of RIT and disease outcome.Subjects and methods : This retrospective analysis included 208 patients with differentiated thyroid cancer managed according to a same protocol and followed up for 12-159 months (mean 30 ± 69 months). Patients received RIT in doses ranging from 3,700 to 11,100 MBq (100 mCi to 300 mCi). Post-RIT-whole body scintigraphy images were performed 10 days after RIT in all patients. In addition, images were also performed 24-48 hours after therapy in 22 patients. Outcome was classified as no evidence of disease (NED), stable disease (SD) and progressive disease (PD).Results : Thyroid stunning occurred in 40 patients (19.2%), including 26 patients with NED and 14 patients with SD. A multivariate analysis showed no association between disease outcome and the occurrence of stunning (p = 0.3476).Conclusion : The efficacy of RIT and disease outcome do not seem to be related to thyroid stunning. Arq Bras Endocrinol Metab. 2014;58(3):292-300.

Objetivo : As diretrizes atuais alertam contra a execução da cintigrafia de corpo inteiro com iodo-131 (dxWBS) para minimizar a ocorrência de atordoamento e garantir a eficiência do tratamento com radioiodo (RIT). O objetivo deste estudo foi avaliar o impacto do atordoamento sobre a eficácia do RIT e desfechos da doença.Sujeitos e métodos : Esta análise retrospectiva incluiu 208 pacientes com câncer diferenciado de tireoide submetidos ao mesmo protocolo e acompanhados por 12-159 semanas (média de 30 ± 69 meses). Os pacientes receberam RIT com doses variando de 3.700 a 11.100 MBq (100 mCi a 300 mCi). As imagens da cintigrafia após a RIT foram feitas 10 dias depois da RIT em todos os pacientes. Além disso, as imagens foram também obtidas após 24-48h em 22 pacientes. O desfecho foi classificado como nenhuma evidência de doença (NED), doença estável (SD) e doença progressiva (PD).Resultados : O atordoamento da tireoide ocorreu em 40 pacientes (19,2%), incluindo 26 pacientes com NED e 14 pacientes com SD. A análise multivariada não mostrou associação entre o desfecho da doença e a ocorrência de atordoamento (p = 0,3476).Conclusão : A eficácia da RIT e o desfecho da doença não parecem estar relacionados com o atordoamento da tireoide. Arq Bras Endocrinol Metab. 2014;58(3):292-300.

Hipotiroidismo congénito: aspectos clínicos y ultrasonográficos / Clinical and ultrasound features of congenital hypothyroidism

Congenital hypothyroidism is a condition where a newborn has decreased or absent thyroid function and thyroid hormone production. It is the most common cause of preventable mental retardation and its early diagnosis can only be achieved through systematic neonatal screening because its clinical manifestations are usually late. The etiologic study of this condition relies heavily on nuclear medicine and ultrasound, describing various findings. This research analyzed the characteristics of the ultrasound patterns observed in these children and their correlation with the most common etiologies. The use of ultrasound allows selecting children that require scintigraphic studies, decreasing the use of radiation in neonates.

El hipotiroidismo congénito se define como la condición de déficit de la producción de hormonas tiroideas, que se encuentra presente desde el nacimiento. Corresponde a la causa más común de retardo mental prevenible y su diagnóstico precoz sólo se logra a través de la pesquisa sistemática neonatal, debido a que las manifestaciones clínicas son habitualmente tardías. El estudio etiológico específico se apoya fundamentalmente en la medicina nuclear y el ultrasonido, describiéndose hallazgos variados. Revisamos las características de los patrones ultrasonográficos observados en estos niños y su correlación con las etiologías más frecuentes. El uso de ultrasonografía permite seleccionar los niños que requieren estudio cintigráfico, disminuyendo el uso de radiación en neonatos.

Effective radiation dose of three diagnostic tests in cardiology: single photon emission computed tomography, invasive coronary angiography and cardiac computed tomography angiography.

INTRODUCTION: Diagnostic tests that use ionizing radiation play a central role in cardiology and their use has grown in recent years, leading to increasing concerns about their potential stochastic effects. The aims of this study were to compare the radiation dose of three diagnostic tests: single photon emission computed tomography (SPECT), invasive coronary angiography (ICA) and cardiac computed tomography (cardiac CT) and their evolution over time, and to assess the influence of body mass index on radiation dose. METHODS: We assessed consecutive patients included in three prospective registries (SPECT, ICA and cardiac CT) over a period of two years. Radiation dose was converted to mSv and compared between the three registries. Differences over time were evaluated by comparing the first with the fourth semester. RESULTS: A total of 6196 exams were evaluated: 35% SPECT, 53% ICA and 22% cardiac CT. Mean radiation dose was 10.7±1.2 mSv for SPECT, 8.1±6.4 mSv for ICA, and 5.4±3.8 mSv for cardiac CT (p<0.001 for all). With regard to the radiation dose over time, there was a very small reduction in SPECT (10.7 to 10.5 mSv, p=0.004), a significant increase (25%) in ICA (7.0 to 8.8 mSv; p<0.001), and a significant reduction (29%) in cardiac CT (6.5 to 4.6 mSv, p<0.001). Obesity was associated with a significantly higher radiation dose in all three exams. CONCLUSIONS: Cardiac CT had a lower mean effective radiation dose than invasive coronary angiography, which in turn had a lower mean effective dose than SPECT. There was a significant increase in radiation doses in the ICA registry and a significant decrease in the cardiac CT registry over time.

Iodine-123-metaiodobenzylguanidine scintigraphy in risk stratification of sudden death in heart failure.

Metaiodobenzylguanidine (MIBG) is a false neurotransmitter noradrenaline analogue that is taken up by the 'uptake 1' transporter mechanism in the cell membrane of presynaptic adrenergic neurons and accumulates in catecholamine storage vesicles. Since it is practically unmetabolized, it can be labeled with a radioisotope (iodine-123) in scintigraphic exams to noninvasively assess the functional status of the sympathetic innervation of organs with a significant adrenergic component, including the heart. Studies of its application in nuclear cardiology appear to confirm its value in the assessment of conditions such as coronary artery disease, heart failure, arrhythmias and sudden death. Heart failure is a global problem, with an estimated prevalence of 2% in developed countries. Sudden cardiac death is the main cause of its high mortality. The autonomic nervous system dysfunction, including sympathetic hyperactivity, that accompanies chronic heart failure is associated with progressive myocardial remodeling, declining left ventricular function and worsening symptoms, and contributes to the development of ventricular arrhythmias and sudden death. Since 123I-MIBG cardiac scintigraphy can detect changes in the cardiac adrenergic system, there is considerable interest in its role in obtaining diagnostic and prognostic information in patients with heart failure. In this article we present a literature review on the use of 123I-MIBG scintigraphy for risk stratification of sudden death in patients with heart failure.